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Trichotillomania

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Not to be confused with Trichomoniasis.
Trichotillomania
SpecialtyPsychiatry, psychology Edit this on Wikidata

Trichotillomania (TTM, also known as "Trichotillosis"[1]), or "trich" as it is commonly known, is an impulse control disorder characterized by the repeated urge to pull out scalp hair, eyelashes, facial hair, nose hair, pubic hair, eyebrows or other body hair, sometimes resulting in noticeable bald patches.[2]: 645  Trichotillomania is classified in the DSM-IV as an impulse control disorder, but there are still questions about how it should be classified. It may seem, at times, to resemble a habit, an addiction, a tic disorder, an obsessive-compulsive disorder or a response to an external irritant. Trichotillomania often begins during the individual's teenage years. Depression or stress can trigger the trich. Due to social implications the disorder is often unreported and it is difficult to predict accurately prevalence of trichotillomania; 2.5 million in the U.S. may have TTM, with a 1% prevalence rate.[3]

The name derives from Greek: tricho- (hair), till(en) (to pull), and mania.

Characteristics

Individuals with trichotillomania live relatively normal lives; however, they may have bald spots on their head, among their eyelashes, pubic hair, or brows. An additional psychological effect can be low self-esteem, often associated with being shunned by peers and the fear of socializing due to appearance and negative attention they may receive. Some people with TTM wear hats, wigs, wear false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. There seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as 'pulling') whatsoever. This 'pulling' often resumes upon leaving this environment.[4]

Many clinicians classify TTM as a habit behavior, in the same family as nail biting (onychophagia) or compulsive skin picking (dermatillomania). These disorders are a cross between mental disorders, such as obsessive compulsive disorder (OCD), and physical disorders such as stereotypic movement disorder because the person performs repetitive movements without being bothered by or completely aware of them. Some say that pimples on the scalp is all it takes to trigger the pulling in some of those who suffer from TTM. Supposedly, areas that are sore intensify the feeling of pulling. The more the area becomes agitated by pulling, the feeling intensifies, only causing the puller to become obsessed with pulling more. It is also widely believed that individuals with TTM pull because of the sight or feel of a certain area of hair. This theory varies by the individual, as some TTM sufferers say the disorder is not an obsession with looks but rather a habit or an addiction. The current classification of trich as an impulse disorder with pyromania, pathological gambling and kleptomania, has been called into question as inadequate and in need of revision.[5] One study showed that individuals with TTM have decreased cerebellar volume.[6] Anxiety, depression and OCD are more frequently encountered in people with TTM.[7] People with TTM may also eat/chew the hair that they pull, referred to as trichophagia. In extreme cases this can lead to Rapunzel syndrome, and even death.[8][9][10] Some individuals with TTM may feel they are the only person with this problem due to low rates of reporting.[11]

An alternative hypothesis popularized by John Kender is that trichotillomania is a response to an overgrowth of the otherwise common fungus Malassezia furfur in the sebaceous glands. He hypothesizes that individuals with trichotillomania are unusually sensitive to the fungus, and pulling is a response to the irritation caused by it's growth. Kender has proposed a diet to control the growth of the fungus, and some people have found anti-fungal agents such as miconazole to be helpful.[12]

Treatment

Habit Reversal Training or HRT, has been shown to be a successful adjunct to medication as a way to treat TTM.[13] With Habit Reversal Training, doctors train the individual to learn to recognize their impulse to pull and also teach them to redirect this impulse. As a part of the behavioral record-keeping component of HRT, patients are often instructed to keep a journal of their hair-pulling episodes. They may be asked to record the date, time, location, and number of hairs pulled, as well as what they are thinking or feeling at the time. This can help the patient learn to identify situations where they commonly pull out their hair and develop strategies for avoiding episodes.

Treatment with clomipramine, a tricyclic antidepressant, was shown in a small double-blind study to significantly improve symptoms.[14]

Fluoxetine (Prozac) and other similar SSRI drugs have limited usefulness in treating TTM, and can often have significant side effects.[15] According to F. Penzel, antidepressants can even increase the severity of the TTM.[5]

A recent study has shown positive results using a treatment of acetylcysteine[16].

Hypnotherapy has been used to treat it with some success by addressing the symptoms using hypnosis.[citation needed]

Additionally, there are individuals who are applying the 12-step Recovery Model, as created by Alcoholics Anonymous, to recover from Trichotillomania. The 12-step model addresses the spiritual, physical, and emotional components of suffering from a behavioral addiction. This treatment model challenges the idea that Trichotillomania is as an impulse control disorder.[citation needed]

John Kender has proposed a diet to control the growth of the fungus, and some people have found anti-fungal agents such as micanazole to be helpful.[17]

Epidemiology

TTM is diagnosed in all age groups; it is more common during the first two decades of life, with mean age of onset usually reported between 9 and 14 years of age. Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female.[18] Evidence now points to a genetic predisposition.[19][20]

The number of reported trichotillomania cases has increased throughout the years, possibly due to a reduced stigma associated with the condition. Estimates of the number of persons with TTM range from 1–3%[21] up to 5%[20] of the world's population.

See also

Notes

  1. ^ James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0721629210.
  2. ^ Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. ISBN 0071380760.
  3. ^ Diefenbach, G.J., Reitman, D. & Williamson, D.A., (2000). "Trichotillomania: A challenge to research and practice". Clinical Psychology Review. 20 (20): 289–309. doi:10.1016/S0272-7358(98)00083-X.{{cite journal}}: CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link)
  4. ^ Christenson GA, Mackenzie TB, Mitchell JE (1991). "Characteristics of 60 adult chronic hair pullers". The American journal of psychiatry. 148 (3): 365–70. PMID 1992841.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  5. ^ a b Penzel (2003) The Hair-Pulling Problem: A Complete Guide to Trichotillomania; Oxford University Press, p. 3. ISBN 0-19-514942-4
  6. ^ Keuthen NJ, Makris N, Schlerf JE; et al. (2007). "Evidence for reduced cerebellar volumes in trichotillomania". Biol. Psychiatry. 61 (3): 374–81. doi:10.1016/j.biopsych.2006.06.013. PMID 16945351. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  7. ^ Christenson GA, Crow SJ (1996). "The characterization and treatment of trichotillomania". The Journal of clinical psychiatry. 57 Suppl 8: 42–7, discussion 48–9. PMID 8698680.
  8. ^ Ventura DE, Herbella FA, Schettini ST, Delmonte C (2005). "Rapunzel syndrome with a fatal outcome in a neglected child". J. Pediatr. Surg. 40 (10): 1665–7. doi:10.1016/j.jpedsurg.2005.06.038. PMID 16227005.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ^ Pul N, Pul M (1996). "The Rapunzel syndrome (trichobezoar) causing gastric perforation in a child: a case report". Eur. J. Pediatr. 155 (1): 18–9. PMID 8750804.
  10. ^ "Hairball kills teenager". hairgrowthnews.com. Retrieved 2007-08-11.
  11. ^ Christenson GA, MacKenzie TB, Mitchell JE (1994). "Adult men and women with trichotillomania. A comparison of male and female characteristics". Psychosomatics. 35 (2): 142–9. PMID 8171173.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ^ http://home.intekom.com/jly2/ttmdiettheory.htm. {{cite web}}: Missing or empty |title= (help)>
  13. ^ Woods DW, Wetterneck CT, Flessner CA (2006). "A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania". Behaviour research and therapy. 44 (5): 639–56. doi:10.1016/j.brat.2005.05.006. PMID 16039603.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL (1989). "A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling)". N. Engl. J. Med. 321 (8): 497–501. PMID 2761586.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ^ Christenson GA, Mackenzie TB, Mitchell JE, Callies AL (1991). "A placebo-controlled, double-blind crossover study of fluoxetine in trichotillomania". Am J Psychiatry. 148 (11): 1566–71. PMID 1928474. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  16. ^ Grant J; et al. (2009). "N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania". Archives of General Psychiatry. 66: 756–63. {{cite journal}}: Explicit use of et al. in: |author= (help)
  17. ^ http://home.intekom.com/jly2/ttmdiettheory.htm. {{cite web}}: Missing or empty |title= (help)>
  18. ^ Sah DE, Koo J, Price VH (2008). "Trichotillomania". Dermatol Ther. 21 (1): 13–21. doi:10.1111/j.1529-8019.2008.00165.x. PMID 18318881.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ "Entrez Gene: HOXB8 homeobox B8 [ Homo sapiens ]". National Center for Biotechnology Information. August 12 2006. Retrieved 2007-11-13. {{cite web}}: Check date values in: |date= (help)
  20. ^ a b "Hair pulling disorder gene found". BBC News. 29 September 2006. Retrieved 2007-05-01. {{cite web}}: Check date values in: |date= (help)
  21. ^ Christenson GA, Mackenzie TB, Mitchell JE (1991). "Characteristics of 60 adult chronic hair pullers". Am J Psychiatry. 148 (3): 365–70.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Further reading

  • Hennerberg, Gary (2009) Urges: Hope and Inspiration for People with Trichotillomania and Other Mysterious Compulsive Disorders; Doses of Comfort Publishing, ISBN 978-144-8690-831
  • Keuthen, Stein, Christensen & Christenson (2001) Help for Hair Pullers: Understanding and Coping With Trichotillomania; New Harbinger Publications, ISBN 1-57224-232-9
  • Parker (Ed.) (2004) Trichotillomania - A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References ; Icon Health Publications, ISBN 0-597-84664-2
  • Stein (Ed.), Christenson (Ed.) & Hollander (Ed.) (1999) Trichotillomania; American Psychiatric Press, ISBN 0-88048-759-3
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