Trichotillomania: Identification & Treatments

January 17, 2017

Recent studies point to a high lifetime incidence (78%) of another psychiatric diagnosis among those who suffer from trichotillomania.

Trichotillomania is a hair pulling disorder that can affect individuals of all ages. Commonly associated with anxiety, trichotillomania is recognizable as a 'weird' behavior that stressed out people use as an outlet for overwhelming emotional tension. Pathological hair pulling is even recognized in pop culture and was notably illustrated in the comedy, The Internship, as a youth who was shown to be struggling under crushing parental pressure repetitively pulled out the hairs of his own eyebrows. 

The movie sensitively dramatized some aspects of the disorder, particularly the connection between anxiety and increased hair pulling. Yet in clinical cases, while there is an association between emotional pressure and trichotillomania, it is clear that some individuals are more susceptible to hair pulling than others.

According to psychiatric classification, trichotillomania is largely seen as an impulse control disorder and not as a coping mechanism for stress. Recent studies point to a high lifetime incidence (78%) of another psychiatric diagnosis among those who suffer from trichotillomania. Mood disorders, particularly depression, are prevalent among patients who suffer from trichotillomania. Hair pulling is also highly correlated with severe and disabling psychosocial dysfunction. Trichotillomania is a distressing behavior for those afflicted, and some patients or their parents may seek professional medical attention for the treatment of symptoms. The current treatment approach includes pharmacological treatments as well as cognitive behavioral therapy.

Treatment

The main categories of pharmacological therapies are antidepressants such as SSRIs and antipsychotics such as haloperidol and olanzapine. Pimozide and clomipramine have also been used for symptom control in adults with trichotillomania. SSRIs are the most prescribed pharmacologics for pediatric hair pulling. There is evidence for some efficacy with the use of antidepressants, antipsychotics, clomipramine, and pimozide in adults with this disorder, but data regarding efficacy for either of these pharmacologic categories in the pediatric population is still lacking.

Cognitive behavioral therapy directed at controlling the behavior has been found to be 75% effective in reducing hair pulling in children and adolescents, but there is not strong follow-up data regarding the occurrence of relapse in adulthood or whether children who have temporarily recovered from trichotillomania go on to experience the emergence of similar impulse control issues or bodily harm behaviors, such as skin picking. 

Patient awareness 

A number of neuropsychological disorders have been prevalent for generations, but perhaps were either not given a formal name or were not recognized as defined pathological and treatable disorders by patients and their families. As awareness of behavioral disorders grows, even through pop culture representations that are inherently not thoroughly 'clinical,' some afflicted individuals or their loved ones may take note, recognizing their own distressing symptoms and subsequently take steps to address neuropsychological conditions instead of accepting them as 'just the way I am,' or 'just the way she always has been.' 

Have you ever had a patient who brought up a behavioral condition to you because he or she recognized his or her own condition through fictional entertainment?

References:

Landuyt G, et al. Treatment options for paediatric trichotillomania. Tijdschr Psychiatr. 2016;58(6):463-470.

Houghton DC, et al. Comorbidity and quality of life in adults with hair pulling disorder. Psychiatry Res. 2016 May 30;239:12-19.