Barry can feel the tension building, sometimes for hours, before he yields to his impulse. Although he knows he’s affecting his dark good looks, the anxious feeling doesn’t fade until he’s yanked out another fistful of his own curly black hair. He immediately vows he’ll never do it again, but will readily admit he probably won’t be able to keep that promise.
For Belinda, the tension reliever is pulling out her now-stubby eyelashes. One at a time, slowly, ritualistically she removes the remaining hairs that line her upper and lower lids. She began removing them this way as a child, although she can’t recall exactly why or when. Despite numerous medical exams first by her pediatrician and later by her internist and a dermatologist no physical problems have been found. Her upper and lower eyelids are the only sign of this persistent habit. They have scarcely any hairs at all.
Louisa also tugs at her hair, pulling out a single strand at a time, dozens of times each day. Then she places the strands she’s removed from her scalp into her mouth. She’s seldom seen without a scarf that covers the bald spots this practice has created, but she denies that the patchy appearance of her hair is the result of her own behavior.
Barry, Belinda and Louisa all exhibit the classic symptoms of trichotillomania (pronounced trick-o-till-o-mania), a psychological disorder characterized by an inability to resist the impulse to pull out your hair. Frustrating to those who have it, their family members, and their doctors, the condition often begins in childhood, but can persist for decades sometimes for a lifetime.
But despite the apparent oddity of their hair-related behaviors, the three are not alone.
Millions of Hair Pullers
Before impulse control disorders were widely recognized and understood, trichotillomania was believed to be a rare condition, but that’s no longer the case. The Trichotillomania Learning Center, Inc. (TLC), in Santa Cruz, Calif., provides support to people like Louisa, Barry and Belinda. Since 1991, the organization has responded to some 50,000 requests for information on the disorder from individuals with the condition, their family members and health professionals.
According to TLC, although there have been no scientific studies to identify the exact number of people with this condition, it is estimated that in the United States alone, there are probably between 6 to 8 million sufferers of trichotillomania. A survey of college students in the mid-1990s confirmed this estimate almost two percent of students reported past or current problems with the impulse to pull out their hair.
Some people with trichotillomania pull out just their eyelashes or eyebrows; others focus on removing the hairs of their head, beard, pubic area, or arms and legs. Some pull out hair from all parts of their body.
Gary R. Gaffney, M.D., associate professor in the Department of Psychiatry at the University of Iowa College of Medicine, explains that other, less dramatic features that fall short of hair pulling are associated with trichotillomania, including examining the hair root, twirling it off, and pulling the strand between the teeth.
Behind the Terminology
The term “trichotillomania” was coined in the late 19th century by Hallopeau, a French dermatologist, to describe the compulsive or irresistible urge he saw in some patients to pluck out their hair. It’s composed of three Greek words: thrix, meaning “hair;” tillein, meaning “to pull;” and mania, meaning “madness” or “frenzy.”
TLC points out that the name is not really accurate, because people with trichotillomania are not “mad,” “psychotic” or “crazy” as the name suggests. In psychiatry, trichotillomania is classified as an impulse control disorder, as are conditions such as compulsive gambling, kleptomania (compulsive stealing) and pyromania (compulsive fire-setting).
The Diagnostic and Statistical Manual of the American Psychiatric Association, known as the DSM-IV, lists the five criteria for diagnosing trichotillomania as:
- recurrent pulling out of one’s hair resulting in noticeable hair loss
- an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior
- pleasure, gratification or relief when pulling out the hair
- a disturbance that is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition)
- a disturbance that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
As TLC explains, not all patients who pull out their hair meet every one of these criteria. Nonetheless, they still may have a distressing problem with similar features that might very well benefit from treatment.
Often a physical examination of a person’s scalp, face, extremities, trunk or pubic area is used by psychiatrists and dermatologists to confirm the diagnosis by making sure some other disease isn’t causing the behavior. As Gaffney notes, “All other causes of hair loss, including medical and dermatological ones, must be considered and ruled out before the diagnosis of trichotillomania is confirmed.”
An Inability to Resist Harming Oneself
Trichotillomania is very different from a single incident or two of pulling one’s hair. Gaffney explains that clinically significant hair-pulling “tends to occur in episodes.” It can be made worse by stress, or conversely, by relaxation. For example, he points out, some people with the condition have particular difficulty controlling their impulse to pull out their body hair when reading a book or watching television.
“Nail biting, scratching, gnawing and excoriation may be associated with trichotillomania,” Gaffney explains. “Those with the condition may also have mood disorders, such as depression, anxiety disorders or mental retardation.”
The hallmark of impulse control disorders like trichotillomania is the inability to control or resist the temptation (or impulse) to do something harmful to oneself or someone else. A sufferer sometimes experiences a sense of increasing tension before performing the behavior and can feel a sense of relief or release of tension afterwards. Sometimes people even express a degree of pleasure after having performed the act.
Features of trichotillomania that fit the description of an impulse control disorder include the inability to resist urges to pull out your hair, mounting tension before pulling and feeling of relief afterward.
Course of the Disease and Treatment
In some children, this disorder spontaneously resolves on its own, even after months or years of stereotypical, recurrent hair-pulling. In adults, it may appear and disappear spontaneously in trichotillomanic episodes, or it may be chronic and unrelenting.
Fredrick Penzel, Ph.D., a psychologist at Western Suffolk Psychological Services in Huntington, N.Y., is an expert in trichotillomania. He describes two approaches to treating the condition in adults that are considered helpful medication and behavior therapy, although, he adds, “Neither is a cure.”
Penzel explains the medications typically used include SSRIs and SNRIs such as Prozac, Paxil, Luvox, Zoloft, Celexa, Serzone, Effexor and Anafranil. Occasionally, he says, these drugs may be augmented with a second medication such as Risperdal, Zyprexa, and Seroquel to help them to work better.
The psychologist describes the behavioral therapy used to treat the condition as “Habit Reversal Training (HRT),” an approach developed more than 25 years ago by Dr. Nathan Azrin. HRT typically includes four steps:
- Awareness training keeping detailed records of all hair-pulling episodes and their surrounding circumstances.
- Relaxation training learning to calm one’s nervous system and to focus and center oneself.
- Breathing retraining learning to breathe from the diaphragm to increase relaxation and focus.
- Competing response training a method of tensing the forearms and hands that is incompatible with pulling.
For more information on trichotillomania, consult the following resources:
- The West Suffolk Psychological Services, Huntington, N.Y., Web site at http://www.homestead.com/westsuffolkpsych/index.html.
- The Trichotillomania Learning Center, Inc., Santa Cruz, Calif., Web site at http://www.trich.org.
The TLC, Inc. site also includes links to many personal pages maintained by people with trichotillomania or by family members of those with the disorder.
The value of Web-based support groups has not been evaluated, but anecdotal evidence suggests many people with “trich,” as they themselves commonly call it, have been successful in modifying their hair-pulling behaviors through regular contact online with other “trich”-sters. Such support is not recommended as a substitute for professional diagnosis and treatment, but may be a useful adjunct to such interventions.