What is Trichotillomania?
Trichotillomania (TTM) is a chronic mental disorder that manifests as irresistible urges (compulsions) to pull out one’s hair. The impulses are recurrent and span an extended period. A person with TTM may want to stop the hair-pulling behaviors, but they cannot resist. The behaviors and their consequences cause significant distress and often impair the person’s ability to function socially.
Symptoms of Trichotillomania
TTM compulsions are most commonly focused on hair on the head, but they can also be directed toward hair on other parts of the body, such as the eyebrows, eyelashes, and beard.
Symptoms of the disorder include:
- Repeated hair pulling
- Feeling of tension in anticipation of hair pulling (or when trying to resist)
- Feeling of relief or pleasure after hair pulling
- Rituals or habits associated with hair pulling
- Hair loss in the affected areas
- Playing with, chewing, or eating pulled hair
- Unsuccessfully trying to stop pulling behaviors
- Distress at school, work, or home associated with pulling behaviors
Variation of TTM Symptoms
The severity of TTM symptoms varies widely from case to case. Some people experience only mild symptoms, but others are significantly impaired by their behaviors. Some recognize that the behaviors are problematic, while others deny the existence of a problem.
TTM also varies in terms of the person’s awareness of their behaviors. For example, some people pull their hair without realizing that they’re doing it (automatic behavior). Others pull their hair intentionally to relieve stress (focused behavior) and may develop elaborate rituals around the hair-pulling behaviors.
What Causes Trichotillomania?
Doctors and researchers have not yet determined precisely what causes TTM, but they have identified several risk factors that increase an individual’s likelihood of developing the disorder.
- Genetic Predisposition. Having a parent, sibling, or child who has been diagnosed with TTM may increase the chance that you will also be diagnosed with the disorder. Researchers have made some progress in identifying the genes that may play a role in the development of OCD-related disorders. Still, more research is necessary to determine the precise genetic connections.
- Environmental Factors. Symptoms of TTM often seem to be triggered by stress. Childhood traumas may also be a risk factor for the development of the disorder.
- Age. TTM usually develops in late childhood or early adolescence.
Women are more likely than men to seek treatment for TTM, but studies suggest the disorder is equally prevalent in boys and girls.
Is Trichotillomania Hereditary?
Researchers have long suspected that biological factors rather than environmental factors primarily cause OCD, and some scientists believe that TTM is a sub-type of OCD. Studies of families in which OCD occurs strongly suggest that a genetic component may be responsible.
Studies of people with TTM suggest that those with a close relative who also has the disorder are at increased risk. However, most people with a family history of TTM do not develop the disorder.
How Is Trichotillomania Detected?
Because the onset of TTM often occurs in childhood or adolescence, detecting the early signs of the disorder often falls on parents. Eventually, the compulsive symptoms will become so severe that they interfere with the child’s functioning, but they may be subtle at first.
Potential warning signs of TTM include:
- Avoidance of social situations
- Wearing hats, wigs, or clothing that covers areas of hair loss
- Avoidance of close relationships
- Poor performance at school
- Use of alcohol or drugs
How Is Trichotillomania Diagnosed?
To diagnose TTM, a doctor will first rule out other potential medical causes of the symptoms. If the symptoms seem to meet the diagnostic criteria for TTM, the patient will likely be referred to a mental health professional for further assessment.
Diagnostic steps may include:
- A physical exam. This exam is aimed at ruling out physical conditions that could be causing the symptoms.
- Blood tests. These tests will look at the patient’s blood chemistry for issues such as thyroid function. Screenings for drugs and alcohol may also be conducted to rule out symptoms that may be caused by substance abuse.
- Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.
The psychological assessments will be compared to the diagnostic criteria for TTM in the Diagnostic and Statistical Manual of Mental Disorders. Comparing these criteria will help a mental health professional decide whether the symptoms indicate TTM or another psychiatric problem (obsessive-compulsive personality disorder, anxiety disorders, or depression).
The diagnostic criteria for TTM include:
- Chronic hair-pulling behavior that causes hair loss
- Unsuccessful attempts to stop hair-pulling behavior
- Another mental or medical disorder doesn’t better explain hair-pulling behavior
- Symptoms cause significant distress or impairment in social, occupational, or other daily functioning
How Is Trichotillomania Treated?
TTM currently has no cure, but a combination of medications and psychotherapy may effectively reduce the severity of symptoms in many patients. Unfortunately, many sufferers will need to continue treatment for the rest of their lives to manage their symptoms, and some patients may not respond to treatment at all.
Several different medications may be used to treat and manage the symptoms of TTM, and individual medication plans depend on the patient’s age, the patient’s responsiveness to treatments, and the severity of their symptoms.
- Antidepressants. Clomipramine may be prescribed to treat TTM symptoms in adults and children over 10.
- Antipsychotics. When TTM patients do not respond to treatment with antidepressants, doctors sometimes prescribe an antipsychotic such as olanzapine.
- Other Medications. The amino acid N-acetylcysteine may have some benefit for people with TTM.
The most commonly used therapeutic approach is cognitive behavioral therapy (CBT). This process focuses on helping the patient identify a pattern of harmful thoughts and construct strategies and solutions for dealing with them that don’t interfere with functionality.
Other types of therapy sometimes used to treat TTM include habit reversal training and acceptance and commitment therapy.
How Does Trichotillomania Progress?
People with TTM often feel shame and embarrassment due to their compulsions, and their self-esteem generally suffers. Attempts to avoid embarrassing or humiliating situations can lead to social isolation, which may feed feelings of depression or anxiety. These negative feelings, in turn, may make the symptoms of TTM worse.
Left untreated, TTM may eventually lead to long-term mental and physical complications, including:
- Lack of close relationships
- Emotional distress
- School or work problems
- Damage to hair or skin
- Digestive problems caused by eating hair
- Substance abuse
How Is Trichotillomania Prevented?
TTM cannot be prevented, but early diagnosis and a consistent treatment plan can help manage symptoms and prevent them from becoming as disruptive as they would be if they were left untreated. Faithful adherence to a treatment plan, especially if it’s working well, can also help to prevent a relapse into a state of severe symptoms. Therefore, it’s essential for those diagnosed with TTM to seek regular evaluation from their mental health providers and stick to any prescribed medication plan.
Trichotillomania Caregiver Tips
Caregivers for someone with TTM should consider these tips to help the sufferer and themselves to cope with the disorder:
- First, learn as much as possible about the condition.
- Seek out appropriate professional treatment for the sufferer.
- Do everything possible to support the affected person in the pursuit of treatment.
- Find ways to have positive experiences with the afflicted that don’t focus on the disorder.
- Finally, find a support group for caregivers.
Most people with TTM also suffer from other brain and mental health-related issues, a situation called co-morbidity. Here are a few of the disorders commonly associated with TTM:
Trichotillomania Brain Science
Researchers are currently working on studies to find the source of TTM behaviors. Some studies have found differences in the brains of people with TTM compared to healthy brains. These differences include structural changes in the putamen, cerebellum, anterior cingulate cortex, and right inferior frontal gyri.
These diverse parts of the brain are responsible for varied functions, but a common thread among them is control of movement. Some researchers believe that interaction between these brain areas regulates how susceptible we are to developing habitual behaviors and how good we are at suppressing habits when they’re inappropriate. So it’s possible that impaired function in these parts of the brain could make someone with TTM more prone to ritualistic hair-pulling behavior and less able to control that behavior.
Title: Leveraging Technological Advancements to Improve the Treatment of Trichotillomania
Principal investigator: Joseph McGuire, PhD
Johns Hopkins University
This project will examine the effect of using the Keen 2 on hair pulling styles (automatic and focused), the severity of hair-pulling behaviors, and related psychiatric symptoms. Given that the Keen2 is anticipated to increase awareness of pulling behavior (but not necessarily change pulling behavior), the investigators hypothesize that the Keen 2 will elevate awareness of pulling behaviors and reduce automatic pulling behavior. In addition, the investigators will explore reductions in overall hair pulling severity and related psychiatric symptoms.
Novel technologies present one solution to help identify and reduce automatic pulling behaviors associated with trichotillomania (TTM). The Keen 2 is one such novel technology, a bracelet that gives the user alerts in the form of a vibration when engaging in hair-pulling behavior. Thus, using the Keen 2 could positively increase the awareness of automatic pulling behaviors, which is largely unaffected by existing evidence-based treatments like HRT. This information would be advantageous for the scientific community to determine the possible benefit of this approach to help individuals with TTM.
This project will examine the effect of using the Keen 2 on hair pulling styles (automatic and focused), the severity of hair-pulling behaviors, and related psychiatric symptoms. Given that the Keen2 is anticipated to increase awareness of pulling behavior (but not necessarily change pulling behavior), the investigators hypothesize that the Keen 2 will increase awareness of pulling behaviors and reduce automatic pulling behavior. The investigators will explore reductions in overall hair pulling severity and related psychiatric symptoms.
Title: Memantine in Body-Focused Repetitive Behaviors
Principal investigator: Jon E. Grant, MD, JD, MPH
University of Chicago
This study is eight weeks long and involves subjects taking memantine or a placebo. If they are randomly assigned to the memantine arm and are eligible to participate in the study, they will begin by taking 10mg once daily of memantine for two weeks, then 20mg for the remaining six weeks. Efficacy and safety measures will be performed at each visit. Participants will be randomized to receive either memantine or a placebo on a 1:1 basis. This blinding will be maintained by the IDS pharmacy at the University of Chicago.
The proposed study aims to evaluate the efficacy and safety of memantine in 80 subjects with DSM-5 trichotillomania (TTM) or skin picking disorder (SPD).
The hypothesis to be tested is that memantine will be more effective and well-tolerated in adults with trichotillomania or skin picking disorder compared to placebo. The proposed study will provide needed data on treating a disabling disorder with no current treatments options.
This will be one of few studies assessing the use of pharmacotherapy to treat TTM and SPD in adults. Assessing the efficacy and safety of memantine will help inform clinicians about additional treatment options for adults suffering from this disorder.
Title: Technology Assisted Treatment for Trichotillomania
Stage: Not Yet Recruiting
Contact: Sameer Kumar, BS
Trichotillomania is characterized by recurrent hair pulling resulting in hair loss causing significant distress and impairment, which persists despite repeated attempts to stop. Behavioral-based therapies focused on increasing awareness of hair pulling followed by the use of an incompatible behavior have proven effective. In an effort to enhance awareness, a wrist-worn motion detection device and a companion mobile application were created. In this study, we will test the initial efficacy of the HabitAware device and accompanying app as a system for delivering self-administered habit reversal training (HRT).