Trichotillomania: Overview

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.

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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 and 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 Malassezia-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 and 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:

Symptoms - Hair

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Recommendations for Trichotillomania:

Amino Acid / Protein

Cysteine / N-Acetylcysteine (NAC)

In 2009 it was reported that a 12-week trial with 50 patients indicated that 56% were "much or very much improved" with N-acetylcysteine use compared with only 16% of those taking placebo.


Sugar Avoidance / Reduction

For those who are interested in seeing if their hair pulling is food-related, there is a simple test that can be done: eat as much of a snack such as peanut 'M&M's (containing sugar, chocolate and legumes) 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).  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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