Trichotillomania (TTM) involves the recurrent pulling out of one’s hair, resulting in noticeable hair loss. In general, it is said that the TTM sufferer experiences tension prior to pulling, and tension if he or she tries to resist the act; and then some form of relief or pleasure once the pulling is completed. It is not thought that there is any pleasure involved in the pain experienced during the act; in fact, many TTM sufferers state that they do not experience pain when pulling.
Current opinion seems to be that TTM is not a form of Obsessive/compulsive Disorder (OCD) as has been assumed for some time, but is an Impulse Control Disorder. This type of disorder is defined by the irresistible tension that is released by performing the act. Some forms of OCD could also be grouped here. Having said that, some TTM sufferers do not seem to experience this irresistible tension, but still have the problem. A minority of TTM sufferers also appear to suffer from OCD, and a majority also suffer from depression and/or an anxiety disorder. For TTM to be classified as a disorder there has to be considerable distress involved and a reduction in everyday functioning.
TTM sufferers typically pull hair from the scalp, often the central part leaving the sides almost untouched. They may also pull from their eyebrows, eyelashes, arms, legs, armpits and pubic region. Men may pull facial hair and if moustaches and beards are shaved there seems to be an increased likelihood with some men to pull from the early re-growth. Among those coming to Anxiety Care, pulling the hair of children or pets has also been mentioned.
Research suggests that most people use their fingers to pull, although some use tweezers, and most pull out one hair at a time and can do this for an hour or more a day, often without being totally aware that they are doing it. TTM sufferers coming to Anxiety Care have confirmed research that suggests that thicker, coarser and more wiry hair is the main target, and that perceived scalp sensations such as pressure or irritation can be eased by pulling. It is also common for TTM sufferers to have other physical habits such as nail biting, tongue or cheek chewing, thumb sucking or nose picking; and many lick, chew or even eat the pulled-out hair. Research suggests that the evening is the worst time for pulling and anecdotally, pulling often seems to occur when the mind is not fully taken up by current activity. One ‘hair twirler’ who did not reach the TTM stage reported to a charity counsellor that his depression and boredom seemed to aggravate the need. Many female TTM sufferers find the pre-menstrual period a particularly unsafe time. It is reported that a quarter of adolescent pullers have Attention Deficit Disorder and a lesser, but still significant percentage, may have an eating disorder.
Who and why?
Estimated prevalence in the general population is difficult to assess and varies between one in two-hundred and one in twenty-five or thirty depending on the criteria used to label the problem. However, OCD used to be thought a minimal problem and less than thirty years ago the estimated community prevalence of OCD was very low indeed. In fact, one charity counsellor used to say that, by then current statistics, he had every OCD sufferer in London in his weekly support group. It seems likely, therefore, that the prevalence of TTM will be seen to be far greater as more and more people come forward for help. Currently, it is estimated that nine out of ten adult pullers are female, while in children there is an even split.
One piece of research suggested that TTM sufferers’ personalities did not differ from that of the general population, and were, in fact, closer to ‘the norm’ than those with anxiety disorders. However, the person with TTM will probably have low self-esteem and suffer from shame and feelings of being of less value than ‘normals’. The simple physical appearance: baldness, particularly with women, is almost certain to generate self-consciousness and feelings of being ‘freakish’. There is some evidence that Body Dysmorphic Disorder (BDD) unrelated to hair, is more common in TTM sufferers than in the general population. Again, it is not difficult to see how a preoccupation with one’s appearance in TTM could make BDD a likely focus of extreme anxiety. Anxiety Care encounters many people whose basic anxiety problem focuses very heavily on their prime worry: mother’s with babies, drivers with roads, teachers with being the focus of attention, etc. The articles ‘Thinking that gets in the way of recovery’, ‘Guilt & Shame’, ‘I know I’ve got to do it myself, but..?’, ‘BDD’, and ‘Social Anxiety Disorder’, all available on this site, might help here.
People generally seem to start pulling around the age of thirteen, although it can start at a much earlier or later time. However, very young children who go through a stage of pulling usually grow out of it. There does not seem to be a ‘typical puller’ although the presence of other pullers in the family makes it more likely. Here it could be a genetic predisposition, possibly aggravated by hormonal changes at puberty. Stress will almost certainly contribute and diet has been mentioned in research. Many people seem to recall a particularly stressful event prior to their first pulling incident. However, as discussed in other literature, we all like good solid reasons for things, particularly when searching for a ‘villain’, so labelling one incident as the full and only cause of TTM might not be useful. Some research suggests that TTM is more of a medical than a psychological problem, like OCD, probably due to malfunctioning brain chemicals.
The ‘irishlace’ site (see references below) describes a nutritional approach that is too complex to detail here. The advice includes avoiding sugar, caffeine and chocolate to see a response within two days; and then beans, peanuts and eggs for a response within ten days. It is obviously up to the individual where diet is concerned, but nobody should undertake a huge realignment of their food intake without first consulting their doctor.
Research findings vary on the value of drug treatments, although use of serotonin reuptake inhibitors, (SRI’s) and clomipramine seem to work best. This tends to suggest again that, like OCD, TTM has a neurochemical basis although the link is not clearcut; and some research suggests that SRI’s are not always effective. However useful the medication, this alone does not seem to be the answer for most people and a variation of cognitive behavioural therapy appears to offer the best results, possibly in conjunction with medication. This treatment will mean the sufferer taking a very active part and learning various techniques to reduce the impact of the disorder. As many TTM sufferers seem to be able to procrastinate broadly where treatment is concerned and to have the ability to be unaware when they are in the midst of a pulling episode, this can take some time and much effort. Doctor Frederick Penzel discusses ‘Habit Reversal Training’ very persuasively (see references below) and is a ‘must read’ for all TTM sufferers.
Recovery maintenance is also a vital area and this can often be achieved via a self-help group. The Anxiety Care, online moderated rooms are available for sufferers to work together, and the charity is always willing to consider setting up a dedicated online support group where there is enough demand.
Cognitive Behavioral Treatment of Trichotillomania, Ferderick Penzel Ph.D,
Grand summary of Things That might Be helpful for Pulling, John R. Kender
Trichotillomania Today: Facts and Myths; dr. C mansueto and Dr. C. Novak
What is Trichotillomania?