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Trichotillomania is a compulsion to repetitively pull or pluck one's hair, resulting in noticeable hair loss. Many people with trichotillomania feel ashamed and embarrassed by their hair pulling, attempt to hide it from friends, co-workers and family members, and do not seek help. Many who consult their personal physician or a dermatologist because of hair loss never reveal the true cause and doctors often fail to consider this diagnosis.
Some experts feel that trichotillomania is a variant of obsessive compulsive disorder. Both conditions are characterized by compulsive behavior that is usually recognized as senseless, is difficult to resist, and is associated with anxiety. Also, treatment with medications that have similar effects on serotonin, a brain neurotransmitter, may benefit both trichotillomania and OCD. In addition, OCD is more common in people with trichotillomania than in the general population. The observation that a higher-than-expected number of relatives of trichotillomania sufferers have obsessive compulsive disorder suggests a genetic link between the two disorders.
In contrast to OCD, people with trichotillomania tend not to have obsessive thoughts, do not engage in rituals other than hair pulling, and have a different pattern of abnormal brain metabolism. Trichotillomania patients are more likely to be women while OCD has a more even gender distribution; the relationship of trichotillomania to OCD is not fully understood and currently they are thought to be related but distinct disorders.
Incidence; Causes & Development
Researchers estimate that some 1-2% of the U.S. population has trichotillomania. Although trichotillomania can begin in very young children or middle-aged adults, the most common age of onset is during early adolescence. Women seem to be affected more than men with some estimates suggesting a ratio of 3 women to every man.
Trichotillomania is currently categorized as an impulse control disorder in which the urge to pull hair is associated with an increasing sense of tension. The act of pulling itself is presumed to relieve that tension. Trichotillomania has been considered a habit, like nail biting, that can have both a soothing function and potential consequences.
While the actual cause of trichotillomania is not known for certain, several factors appear to play contributing roles:- Yeast infection. Some consider trichotillomania to be an allergic reaction to the Mallesezia-yeast and that certain foods encourage growth of this yeast in the body. This causes an urge with some people to pull out their own hair. Professor John Kender from Columbia University tried a diet which changed his life dramatically, as well as the lives of hundreds of others with trichotillomania.
- Metabolic abnormalities. Alterations in brain metabolism seem to be involved. Investigators have found differences in neuropsychological testing and in special brain scans between people with trichotillomania and people who do not pull out hair. There is some suggestion that abnormalities in the functioning of serotonin, a chemical neurotransmitter in the brain, might be involved. Interestingly, several medications that have shown promise in trichotillomania increase the amount of serotonin available to brain cells.
- Stress. The onset of trichotillomania is sometimes associated with a stressful event and, indeed, stressful life experiences may be important in its development or its continuation. Stressors may include school conflict, abuse, family conflict, threatened loss of a significant other, severe medical illness, or previous scalp trauma or surgery. More often than not, a significant life event cannot be identified that is related to the onset of trichotillomania.
- Family history. There may be some genetic predisposal ion to developing trichotillomania. Relatives of people with the condition have a slightly increased likelihood of developing trichotillomania compared to the general population. In addition, relatives of people with trichotillomania may have a higher prevalence of other psychiatric disorders, particularly depression and obsessive compulsive disorder, than the population at large.
- Unresolved psychological conflicts. Psychoanalysts have suggested that pulling out hair is related to erotic wishes or unresolved life conflicts, or that hair pulling releases unsatisfied sexual tension or substitutes for masturbation. Other theories have suggested that hair pulling is an aggressive reaction against feelings of grief or rage or even against feelings of being deserted or unloved. While all of these ideas are interesting, they are unproven, speculative and have no treatment utility.
Signs & Symptoms
Most people with the condition experience anxiety, embarrassment and diminished self-confidence and self-esteem. Attempts to keep the condition a secret can lead to avoidance of everyday activities such as visits to the hairdresser, sports, exercise, dancing, public showers, swimming, and being in brightly-lit rooms. Some avoid treatment for medical or dental problems because of concern that their hair pulling will be discovered. Many go to great lengths to conceal their hair pulling and try to camouflage hair loss with different hair styles, make-up, clothing, or wigs or other hair pieces. Scalp inflammation, irritation, itchiness and tenderness are common.
Some researchers have found that nearly 20% of hair pullers eat their hair or chew off and swallow the root ends. Called trichophagy, it can lead to hair being lodged between the teeth and more seriously to large accumulations of retained hairs in the stomach and digestive tract called trichobezoars (hair balls).
Symptoms of trichobezoars include abdominal pain, nausea, vomiting, and sometimes blood and/or visible hairs in the stool. Trichobezoars can also cause foul breath, poor appetite, constipation, diarrhea, excessive gas, bowel obstruction, and even bowel perforation. Liver and pancreas functions can be adversely altered. Sometimes a physician can feel a trichobezoar by gently pushing in the mid or left upper area of a patient's abdomen. Trichobezoars can be diagnosed by using special upper gastrointestinal X-rays, looking into the stomach with an endoscope, or using ultrasound. Surgical removal is the most common treatment.
Prognosis; Complications
Hair pulling very rarely causes irreversible baldness. However, when the behavior stops, hair occasionally grows back gray or white and it may be finer, coarser or curlier. These changes may normalize over time.
Some researchers have described early onset (childhood) and later onset (adolescent) types of trichotillomania. There is no clear evidence that children with this form of the disorder are at increased risk for developing future psychiatric problems. However, children who are four, five or six and are still pulling their hair may begin to overlap with the later onset type trichotillomania which has a less favorable prognosis.
The trauma of hair pulling also increases the risk for scalp infection. Sometimes repetitive hair pulling can cause problems such as carpal tunnel syndrome, tendonitis, and neck/back strain. Perhaps the most common serious medical complication of trichotillomania is avoiding medical care for other illnesses because of the shame associated with hair pulling and the fear of its discovery.
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Signs, symptoms & indicators of Trichotillomania:
Recommendations and treatments for Trichotillomania: | | | | | Diet |  Sugars Avoidance / Reduction | If people are interested in seeing if their hair pulling is food-related, there is a simple test that can be done. Simply eating a snack such as peanut M&Ms (containing sugar, chocolate and legumes) - as many as you can stand at one sitting, washing them down with Coca-Cola (cola, caffeine and more sugar or aspartame, which is just as bad) is all that it takes. If in 2 days there is a noticeable increase in hair pulling urges, then you could consider abstaining from "bad" foods.
Unfortunately, it appears to take from 30-40 days to purge the gut and skin of their bad effects fully, and it also seems to take several attempts and about a year of trying for most pullers to achieve the desired results. People report that avoiding sugar and caffeine - which act more quickly - is the most rewarding way to start.
The list of foods that aggravate this condition includes concentrated natural sugars, tomato seeds, soy products, yams, MSG, and ibuprofen. However, there are a few "good" foods, which partially counteract the "bad" ones, including garlic, most acidic fruits, dry red wine, unsweetened yogurt, and a chemical family called gluconates. |
Caffeine/Coffee Avoidance| | See the link between Trichotillomania and Sugar Avoidance. |
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KEY | | Proven definite or direct link | | | Likely to help |
GLOSSARY
Abdomen (Abdominal)
That part of the body between the chest and the hips that contains the stomach, intestines, liver, bladder, pancreas and other organs.
Anxiety
Apprehension of danger, or dread, accompanied by nervous restlessness, tension, increased heart rate, and shortness of breath unrelated to a clearly identifiable stimulus.
Aspartame
A low-calorie sweetener used in a variety of foods and drinks and as a tabletop sweetener. It is about 200 times sweeter than sugar and is commonly known by names such as NutraSweet, Equal, Spoonful or Equal-Measure.
Carpal Tunnel Syndrome
A common, painful defect of the wrist and hand. It is caused by pressure on the middle nerve in the carpal tunnel. The syndrome is seen more often in women, especially in pregnant and in menopausal women. Symptoms may result from a blow, swelling, a tumor, rheumatoid arthritis, or a small carpal tunnel that squeezes the nerve. Pain may be infrequent or constant and is often most intense at night.
Constipation (Constipated)
Difficult, incomplete, or infrequent evacuation of dry, hardened feces from the bowels.
Diarrhea
Excessive discharge of contents of bowel.
Endoscope
Instrument for examining the interior of a hollow organ.
Gastrointestinal (GI, GI Tract)
Pertaining to the stomach, small and large intestines, colon, rectum, liver, pancreas, and gallbladder.
Liver (Hepatic)
The largest and one of the most complex organs of the body, the liver is responsible for much of the metabolism of fats, proteins and carbohydrates. It is the site of much of the body's detoxification. It is connected very closely with digestion and the regulation of blood sugar, among many other functions. Found behind the ribs on the right side of the abdomen, it has many important functions such as removing harmful material from the blood, making enzymes and bile that help digest food, and converting food into substances needed for life and growth. Hepatic: Pertaining to the liver.
Metabolism (Metabolic, Metabolize, Metabolizes, Metabolizing)
The chemical processes of living cells in which energy is produced in order to replace and repair tissues and maintain a healthy body. Responsible for the production of energy, biosynthesis of important substances, and degradation of various compounds. Also defined as the sum total of changes in an organism in order to achieve a balance (homeostasis): Catabolic burns up, anabolic stores and builds up; the sum of their work is metabolism.
Monosodium Glutamate (MSG)
Used as a flavor enhancer and preservative in many foods, especially Asian (Chinese). Once banned, it is now permitted in small amounts because no health risks have been found in older children and adults.
Multiple Sclerosis (MS)
Demyelinating disorder of the central nervous system, causing patches of sclerosis (plaques) in the brain and spinal cord, manifested by loss of normal neurological functions, e.g. muscle weakness, loss of vision, and mood alterations.
Nausea
Symptoms resulting from an inclination to vomit.
Neurotransmitters (Neurotransmitter)
Chemicals in the brain that aid in the transmission of nerve impulses. Various Neurotransmitters are responsible for different functions including controlling mood and muscle movement and inhibiting or causing the sensation of pain.
Obsessive-Compulsive Disorder (Obsessive Compulsive, Obsessive-Compulsive, OCD)
Those suffering from OCD have obsessions and/or compulsions. Obsessions refer to recurrent and persistent thoughts, impulses, or images that are intrusive and cause severe anxiety or distress. Compulsions refer to repetitive behaviors and rituals (such as hand washing, hoarding, ordering, checking) or mental acts (like counting, repeating words silently, avoiding). These obsessions and compulsions significantly interfere with normal routine, functioning, social activities and relationships.
Pancreas (Pancreatic)
Opposite the liver and behind the stomach, the pancreas has two main functions - to manufacture various enzymes for digestion, and to release hormones to help control the body's use of carbohydrates. It releases insulin to help each cell absorb glucose to burn as energy. In this way, insulin controls the amount of sugar (glucose) in the blood. Proper pancreatic function is very important: too much, too little, or no insulin production can be life-threatening. Some of the chemicals released by the pancreas are not hormones, but stimulate other glands to make hormones. Once again, balance is necessary. Nutritional requirements for the pancreas are many. Research indicates that chromium vitamins C, E, B-complex, calcium, magnesium and potassium are especially important.
Prognosis
A prediction (estimate) of the future course and outcome of a disease and an indication of the likelihood of recovery from that disease.
Self-Esteem
The extent to which and ways in which people view themselves. People who view themselves favorably have good self-esteems whereas people who view themselves negatively have poor self-esteems. Self-esteem affects a person's behavior dramatically.
Serotonin
A phenolic amine neurotransmitter (C10H12N2O) that is a powerful vasoconstrictor and is found especially in the brain, blood serum and gastric membranes of mammals. Considered essential for relaxation, sleep, and concentration.
Stomach
A hollow, muscular, J-shaped pouch located in the upper part of the abdomen to the left of the midline. The upper end (fundus) is large and dome-shaped; the area just below the fundus is called the body of the stomach. The fundus and the body are often referred to as the cardiac portion of the stomach. The lower (pyloric) portion curves downward and to the right and includes the antrum and the pylorus. The function of the stomach is to begin digestion by physically breaking down food received from the esophagus. The tissues of the stomach wall are composed of three types of muscle fibers: circular, longitudinal and oblique. These fibers create structural elasticity and contractibility, both of which are needed for digestion. The stomach mucosa contains cells which secrete hydrochloric acid and this in turn activates the other gastric enzymes pepsin and rennin. To protect itself from being destroyed by its own enzymes, the stomach’s mucous lining must constantly regenerate itself.
Tendonitis
Inflammation of the tendons (structures that attach muscles to bones).
Ultrasound
Ultrasound testing uses sound waves projected into the body to produce an image of internal organs, structures, tumors, etc. In this procedure, a gel is applied to the patient's skin, and a small device that emits ultrasonic pulses is slowly passed over the area. The sonic image produced is viewed on a monitor.
X-rays (X-ray)
High-energy radiation used to take pictures of areas inside the body.
Yeast
A single-cell organism that may cause infection in the mouth, vagina, gastrointestinal tract, and any or all bodily parts. Common yeast infections include candidiasis and thrush.
Last updated: May 18, 2008
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