Trichotillomania is hair loss from compulsive pulling or twisting of the hair until it breaks off. Trichotillomania is a type of compulsive behavior. Its causes are not clearly understood. It may affect as much as four percent of the population. Women are four times more likely to be affected than men.
Symptoms usually begin before age seventeen. The hair may come out in round patches or across the scalp. The effect is an uneven appearance. The person may pluck other hairy areas, such as the eyebrows, eyelashes, or body hair.
- These symptoms are usually seen in children.
- An uneven appearance to the hair
- Bare patches or all around (diffuse) loss of hair
- Bowel blockage (obstruction) if people eat the hair they pull out
- Constant tugging, pulling, or twisting of hair
- Denying the hair pulling
- Hair regrowth that feels like stubble in the bare spots
- Increasing sense of tension before the hair pulling
- Other self-injury behaviors
- Sense of relief, pleasure, or gratification after the hair pulling
Trichotillomania is usually confined to one or two sites, but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, legs, and pubic hairs. The classic presentation is the "Friar Tuck" look with crown alopecia (sudden loss of hair). Children are less likely to pull from areas other than the scalp.
Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, overall hair density is normal, and a hair pull test is negative (the hair does not pull out easily). Hair is often pulled out leaving an unusual shape; individuals with trichotillomania may be secretive or shameful of the hair pulling behavior.
An additional psychological effect can be low self-esteem, often associated with being shunned by peers and the fear of socializing due to appearance and negative attention they may receive. Some people with TTM wear hats, wigs, wear false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. There seems to be a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as "pulling") whatsoever. This "pulling" often resumes upon leaving this environment. Some individuals with TTM may feel they are the only person with this problem due to low rates of reporting.
Other medical complications include infection, permanent loss of hair, repetitive stress injury, carpal tunnel syndrome, and gastrointestinal obstruction as a result of trichophagia. In trichophagia, people with trichotillomania also ingest the hair that they pull; in extreme (and rare) cases this can lead to a hair ball (trichobezoar). Rapunzel syndrome, an extreme form of trichobezoar in which the "tail" of the hair ball extends into the intestines, can be fatal if misdiagnosed.
Environment is a large factor which affects hair pulling. Sedentary activities such as being in a relaxed environment are conducive to hair pulling. A common example of a sedentary activity promoting hair pulling is lying in a bed while trying to rest or fall asleep. An extreme example of automatic TTM is found when some patients have been observed to pull their hair out while asleep. This is called sleep-isolated trichotillomania.
Signs and tests
People with this disorder often will first seek the help of a doctor who treats skin problems (dermatologist). A piece of tissue may be removed (biopsy) to rule out other causes, such as a scalp infection, and to explain the hair loss.
Causes and pathophysiology
Anxiety, depression and obsessive–compulsive disorder are more frequently encountered in people with TTM. Trichotillomania has a high overlap with post traumatic stress disorder, and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hair pulling as addictive or positively reinforcing as it is associated with rising tension beforehand and relief afterward. A neurocognitive model — the notion that the basal ganglia plays a role in habit formation and that the frontal lobes are critical for normally suppressing or inhibiting such habits —sees trichotillomania as a habit disorder.
Abnormalities in the caudate nucleus are noted in OCD, but there is no evidence to support that these abnormalities can also be linked to trichotillomania. One study has shown that individuals with TTM have decreased cerebellar volume. These findings suggest some differences between OCD and trichotillomania. There is a lack of structural MRI studies on trichotillomania.
It is likely that multiple genes confer vulnerability to trichotillomania. One study identified mutations in the SLITRK1 gene, another identified differences in the serotonin 2A receptor genes, and mice with a mutation on the HOXB8 gene showed abnormal behaviors including hair pulling. These data are preliminary, but could indicate a genetic component in trichotillomania.
TTM is diagnosed in all age groups; onset is more common during preadolescence and young adulthood, with mean age of onset between 9 and 13 years of age, and a notable peak at 12–13. Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between (70-93) percent of patients being female. Among adults, females typically outnumber males by 3 to 1.
"Automatic" pulling occurs in approximately three-quarters of adult patients with trichotillomania.
Hair pulling was first described in the literature in 1885, and the term trichotillomania was coined by the French dermatologist François Henri Hallopeau in 1889.
Early detection is the best form of prevention because it leads to early treatment. Decreasing stress can help, because stress may increase compulsive behavior.
Habit Reversal Training (HRT) has the highest rate of success in treating trichotillomania. HRT has shown to be a successful adjunct to medication as a way to treat TTM. With HRT, doctors train the individual to learn to recognize their impulse to pull and also teach them to redirect this impulse. In comparisons of behavioral versus pharmacologic treatment, cognitive behavioral therapy (including HRT) have shown significant improvement over medication alone. It has also proven effective in treating children. Biofeedback, cognitive-behavioral methods, and hypnosis may improve symptoms.
Treatment is based on a person's age. Most pre-school age children outgrow it if the condition is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including behavior modification programs, may be considered; referrals to psychologists or psychiatrists are considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other psychiatric disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hair pulling may resolve when other conditions are treated
Experts do not agree on the use of medication for treatment. However, naltrexone and selective serotonin reuptake inhibitors (SSRIs) have shown effective in reducing some symptoms. Behavioral therapy and habit reversal may also be effective.
Medications can be used. Treatment with clomipramine (Anafranil), a tricyclic antidepressant, was shown in a small double-blind study to significantly improve symptoms, but results of other studies on clomipramine for treating trichotillomania have been inconsistent. Fluoxetine (Prozac) and other selective serotonin reuptake inhibitors (SSRIs) have limited usefulness in treating TTM, and can often have significant side effects. Behavioral therapy has proven more effective when compared to fluoxetine or control groups. Dual treatment (behavioral therapy and medication) may provide an advantage in some cases, but robust evidence from high-quality studies is lacking. Acetylcysteine treatment stemmed from an understanding of glutamate's roll in regulation of impulse control.
When it occurs in early childhood (before five years of age), the condition is typically self-limiting and intervention is not required. In adults, the onset of trichotillomania may be secondary to underlying psychiatric disturbances and symptoms are generally more long-term.
Secondary infections may occur due to picking and scratching, but other complications are rare. Individuals with trichotillomania often find that support groups are helpful in living with and overcoming the disorder.
Typically, trichotillomania is limited to younger children who tend to outgrow the behavior. For most, the hair pulling ends within twelve months. Children who start pulling hair early (before age 6) tend to do better than those who start later.
People can have complications when they eat the pulled-out hair (trichophagia). This can cause a blockage in the intestines or lead to poor nutrition.
How do cannabinoids help relieve symptoms of TTM?
Trichotillomania fall under a psychiatric diagnosis bunched together with Impulse Control Disorders (along with pathological gambling, kleptomania and pyromania). For many patients it is associated with significant depression, anxiety and social phobias. Many times it presents in childhood but for many patients it presents in adulthood. Children commonly outgrow it but adults have difficulty and it can persist for many years if not for a lifetime.
Patients explain that marijuana relaxes them, reduces their anxiety and reduces their urge to pull their hair out. They still struggle but their symptoms are largely reduced to the point where they see hair growth. They also feel less social anxiety and feel more comfortable in public. Many patients try medications such as SSRI’s (like prozac) but have to discontinue them due to side effects. There is a drug clomipramine (a tricyclic anti-depressant) which is often used with minimal success.
Science: THC effective in trichotillomania symptoms in a pilot study:
An open clinical study with patients suffering from trichotillomania, who received oral dronabinol (THC), was conducted at the Department of Psychiatry of the University of Minnesota in Minneapolis, USA. Trichotillomania is an impulse control disorder and characterized by the compulsive urge to pull out one's own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat. Fourteen female subjects with a mean age of 33 years with trichotillomania were enrolled in the 12-week study. Doses ranged from 2.5-15 mg THC daily. The primary outcome measure was change from baseline to study endpoint on the so-called MGH-HP Scale, which measures the intensity of symptoms in trichotillomania. In order to evaluate effects on cognition, subjects underwent pre- and post-treatment assessments using objective computerized neurocognitive tests.
The mean effective dose was 11.6 mg per day. The medication was well-tolerated, with no significant deleterious effects on cognition. Authors concluded that "pharmacological modulation of the cannabinoid system may prove useful in controlling a range of compulsive behaviors." OBJECTIVE: Dronabinol appears to reduce the exocitotoxic damage caused by glutamate release in the striatum and offers promise in reducing compulsive behavior. . Data were collected from November 2009 to December 2010.
Twelve of the 14 subjects (85.7%) completed the 12-week study. The medication was well-tolerated, with no significant deleterious effects on cognition.
This study, the first to examine a cannabinoid agonist in the treatment of trichotillomania, found that dronabinol demonstrated statistically significant reductions in trichotillomania symptoms, in the absence of negative cognitive effects. Pharmacological modulation of the cannabinoid system may prove useful in controlling a range of compulsive behaviors. Given the small sample and open-label design, however larger placebo-controlled studies incorporating cognitive measures are warranted.
(Source: Grant JE, Odlaug BL, Chamberlain SR, Kim SW. Dronabinol, a cannabinoid agonist, reduces hair pulling in trichotillomania: a pilot study. Psychopharmacology (Berl). 2011 May 19. [in press])
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Department of Psychiatry, University of Minnesota School of Medicine, 2450 Riverside Avenue, Minneapolis, MN, 55454, USA, firstname.lastname@example.org.
(Source: Grant JE, Odlaug BL, Chamberlain SR, Kim SW. Dronabinol, a
cannabinoid agonist, reduces hair pulling in trichotillomania: apilot study.
Psychopharmacology (Berl). 2011 May 19. [in press]) Department of Psychiatry, University of Minnesota School of Medicine, 2450 Riverside Avenue, Minneapolis, MN, 55454, USA, email@example.com.