The hair-pulling disorder also known as Trichotillomania (TTM) is a psychological condition associated with a compulsive removal of hair from the body. Not only may TTM result in significant hair loss but also cause a marked functional impairment similarly to other types of obsessive-compulsive disorders. Considering that this adverse mental condition can negatively affect one’s quality of life, it is essential to understand which interventions are the most promising in treating TTM and alleviating its symptoms. Thus, the given paper will provide a detailed discussion of the nature of TTM along with existing evidence-based therapies for its elimination.
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TTM was first described in the literature by the end of the 19th century. The term was introduced by the French physician François Hallopeau, and its meaning was derived from the Greek words “thrix” (hair), “tillein” (to pull), and “mania” (madness) (Batten, Schummer, & Selden, 2017). Researchers find positive correlations between TTM and psychological trauma, as well as a wider spectrum of mood and anxiety disorders, such as major depression (Özten et al., 2015; Woods & Houghton, 2014). Gawłowska-Sawosz, Wolski, Kamiński, Albrecht, and Wolańczyk (2016) also note that hair-pulling in the given condition may be regarded as a reaction to stressors. It means that adverse environmental, occupational, and social factors can play a role in the development of TTM. However, until now the exact cause and neurophysiologic basis of the condition remains undefined.
The main characteristic sign of TTM is a feeling of a strong urge to pull hair mainly on the head and the face due to various sensory, cognitive, and emotional triggers. Some patients report pulling hairs automatically and without being aware of the process, while others do it intentionally (Grant & Chamberlain, 2016). As stated by Batten et al. (2017), for those who have this disorder, hair-pulling is “more than a habit:” “it is a compulsive behavior, which means the behavior is irrational and very hard to stop” (p. 2075). Overall, individuals with TTM cannot resist the urge and feel a short-term relief after pulling hairs. However, the sense of alleviation quickly ends, and one starts to feel unhappy and anxious. Considering this, the major psychological sign of the disorder is anxiety, while the physical one is a visible hair loss.
It is observed that the condition is prevalent in younger populations. Grant and Chamberlain (2016) state that the typical age of TTM onset is 10-13 years. According to Woods and Houghton (2014), “up to 11.03% of college-aged individuals pull their hair at least occasionally,” and, moreover, “many young children display hair pulling, although the behavior usually spontaneously remits by the time the child reaches 4 or 5 years of age” (p. 301). Additionally, it is noted that TTM is more common among women than men (Grant & Chamberlain, 2016; Woods & Houghton, 2014). However, the given disparity is observed only in the adult population.
It is reported that individuals with TTM rarely seek treatment. The major reason for that is a common misconception about this disorder and its perception as merely a bad habit (Grant & Chamberlain, 2016). Nevertheless, without the treatment, TTM usually has a poor prognosis because individuals experiencing the disorder symptoms tend to withdraw from the social life and frequently have low self-esteem. Consequently, it negatively affects one’s well-being across the lifespan.
TTM was included as a separate mental condition only in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5). It is present in the chapter on Obsessive-Compulsive and Related Disorders. The main diagnostic criteria for TTM are the recurrent pulling and plucking of one’s own hair and the consequent alopecia, repeated attempts to stop the urge to pull hairs, feeling of severe distress and impaired functioning in social and other spheres of life due to the condition (Grant & Chamberlain, 2016). It is worth noticing that TTM is diagnosed only in case the hair loss cannot be attributed to any other psychological and physiological condition.
TTM Treatment and Relapse Prevention
Age-appropriate cognitive and psychological education may be regarded as a primary element of the TTM intervention. For example, “in children and adolescents psychoeducation should be addressed to family members, and in some cases, members of the immediate environment, who should be involved in the treatment process” (Gawłowska-Sawoszet al., 2016). The curriculum content for both adults and younger individuals should cover the matters related to the nature of the disorder, its risks and effects, as well as available treatment options, support resources, and self-management practices.
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Psychotherapy and different types of cognitive-behavioral therapy (CBT), such as habit-reversal training, are frequently used to treat TTM. The effectiveness and efficacy of the given approaches are verified by multiple studies (Gawłowska-Sawoszet al., 2016). As for habit-reversal training, it showed benefits “in many different frequency formats,” and it is considered that the number of sessions anywhere from 4 to 22 sessions (lasting for 60 minutes) can be helpful (Grant & Chamberlain, 2016, p. 876). The major elements of the given therapy for TTM patients include the development of awareness and mindfulness and implementation of self-monitoring skills. Additionally, the therapy aims to promote greater control over environmental stimuli, which implies the modification of the environment in a way that can reduce one’s exposure to adverse factors (Grant & Chamberlain, 2016). It is possible to say that not only does the latter practice help intervene the existing condition but also largely defines the ability to prevent the relapse.
Currently, there are no pharmacological options that could be used as first-line treatments for TTM. Additionally, research findings indicate the superiority of CBTs regarding their effectiveness in the treatment of the given condition compared to various drugs (Gawłowska-Sawoszet al., 2016). Still, some patients (especially those with polymorbidity) can be prescribed with glutamatergic agents, antipsychotic medications, and cannabinoid agonists (Grant & Chamberlain, 2016). Nevertheless, it is important to note that many of these drugs have multiple mild and severe side-effects. Thus, the conduction of the cost-benefit analysis prior to the administration of pharmacological treatment for TTM is highly recommended.
The results of the literature review demonstrate that TTM falls under the category of obsessive-compulsive disorders and anxiety disorders, yet it differs from them in peculiar ways. For instance, there are no obsessions in TTM, whereas hair-pulling is the only observable compulsion. At the same time, its onset may be closely associated with the progression of other mental disorders such as major depression and general anxiety. Considering that TTM negatively affects one’s functionality and overall welfare, it is important to accurately diagnose and treat it. The primary and the most effective interventions existing at the present moment are behavioral therapies and psychotherapies. The development of essential skills needed for a better self-management of TTM and the achievement of remission as part of the treatment can lead to sustainable positive outcomes.
Batten, D., Schummer, P., & Selden, H. (2017). Trichotillomania. In D. Batten, P. Schummer, & H. Selden (Eds.), Human Diseases and Conditions (3rd ed.) (pp. 2074-2081). Farmington Hills, MI: Charles Scribner’s Sons.
Gawłowska-Sawosz, M., Wolski, M., Kamiński, A., Albrecht, P., & Wolańczyk, T. (2016). Trichotillomania and trichophagia. Diagnosis, treatment, prevention. The attempt to establish guidelines of treatment in Poland. Psychiatria Polska, 50(1), 127-143.
Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania. The American Journal of Psychiatry, 173(9), 868-874.
Özten, E., Sayar, G. H., Eryılmaz, G., Kağan, G., Işık, S., & Karamustafalıoğlu, O. (2015). The relationship of psychological trauma with trichotillomania and skin picking. Neuropsychiatric Disease and Treatment, 11, 1203-1210.
Woods, D. W., & Houghton, D. C. (2014). Diagnosis, evaluation, and management of trichotillomania. The Psychiatric Clinics of North America, 37(3), 301-317.