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Symptoms and warning signs of trichotillomania

Trichotillomania, also known as “the hair pulling disorder,” is a self-destructive disorder defined by a victim’s uncontrollable or sometimes unconscious urge to pull his or her hair from its roots. Trichotillomania can vary in intensity. Some patients claim they can control the action while others are faced with the overpowering urge to incessantly pull out hair. This type of behavior is rather uncommon and can interfere with normal life functioning, it is not well publicized which leads victims to feel alone and sometimes confused. This paper will define trichotillomania, explain the symptoms, and describe possible causes. Also, this report will discuss treatment options for persons afflicted with this ailment. By the end of this report, the reader will have a better understanding of this disorder.

Trichotillomania can be found under “impulse control disorders” in the DSM-IV, though there is debate as to where exactly it should be placed. Victims of trichotillomania may pull hair from a variety of bodily locations. Hair may be torn from legs, arms, armpits, scalps, pubic regions, feet, even eyelashes and eyebrows. Inevitably, bald patches will appear. The average age group that Trichotillomania effects is 9-13. A study done by a group researches based in Florida found the average age of diagnoses to be 13.57. This leads researchers to believe that trichotillomania can be attributed to puberty and the stress associated with it (Duke,Keely, Richetts, Geffken,& Storch, 2009). Occurrences of trichotillomania after age 17 are rare, though this late onset of Trichotillomania can be chronic, and the recovery process may become more difficult than those who develop it earlier in life (Mancini, Ameringen, Patterson, Simpson, & Truong, 2009).

The average victim of Trichotillomania pulls from one to two locations. For example, one may pull hair from a certain area of the scalp and arm. However, it is not limited to one or two regions. In some instances, the hair pulling pattern occurs randomly throughout the body. This could be purely because the puller is tired of pulling from one spot or it is an attempt to stunt the thinning of hair. Currently, there are two types of hair pulling, focused and automatic. Focused hair pulling involves much thought. It can involve rituals and the desire to pull out particular hairs. Approximately 31.3% of hair pullers report themselves as focused hair pullers. In contrast, automatic hair pulling appears to be unconscious. Some victims claim to not even remember pulling the hair. The remaining 68.7% of hair pullers identify themselves as automatic hair pullers (Duke,Keely, Richetts, Geffken,& Storch, 2009).

The prevalence of trichotillomania in the United States may be as high as 4%. However, this 4% is actually quite giving. Many hair pullers only experience the urge a couple times throughout their life. Another important consideration is the under-reporting of hair pulling. Many with trichotillomania may feel ashamed and are commonly co-diagnosed with depression. They might feel as though they are the only persons in the world who do such a thing. Thus, in shame, they are less likely to report. Women are four times as likely to be affected by this disorder than men. Once again, this high contrast could be due to the male ego and the embarrassment of reporting. Trichotillomania is likely to come with a co morbid diagnosis of a mood or anxiety disorder, e.g., depression, bipolar disorder, among others.

Symptoms and Warning Signs of Trichotillomania

There are many symptoms and signs of trichotillomania. Those with trichotillomania may feel ostracized. They may be wary when it comes to appearing in social environments out of fear of ridicule. When they do decide to go out, they are likely to wear some sort of cover, a hat, a wig, or long sleeve shirts to hide the thinning or bald patches. Some of the other symptoms include noticeable hair loss or thinning and uneven patches of hair. Many of those diagnosed also perform other self harm activities such as cutting, or stabbing. Others may tug and twist their hair. Intriguingly, a warning sign of trichotillomania, is the denial of hair-pulling for the reason stated above. Prior to the act, those who suffer from this ailment may exhibit signs of great stress. Once hair is pulled, the victim may feel gratification and relief. Leading the victim to rely on the pulling to relieve stress.

Other Concerns

Many of those afflicted with trichotillomania are at risk for other problems. One of interest is Trichophagia, even more rare that trichotillomania, victims of Trichophagia often digest the hair or the root that has been pulled. Since the body cannot digest the hair, it can build up in the stomach and In rare cases, this build up can be fatal when the hair ball extends into the intestines or causes a gastrointestinal blockage (Grant & Odlaug, 2008).

Other problems include infection. In some instances, hair pulling can become aggressive and out of control. When this happens, the puller may begin to bleed and these open wounds make them prone to bacterial infections. Sometimes the torn out hair does not grow back, leaving the afflicted with permanent hair loss. In other cases the victim may develop carpal tunnel syndrome from the repetitive use of their hands.

Causes of Trichotillomania

The causes of trichotillomania are not well understood. There appears to be a link between stress, anxiety, and anger levels and the frequency of pulling. For instance, research shows that while studying for a test or reading, 75% of hair pullers will become more active in their ritual (Duke,Keely, Richetts, Geffken,& Storch, 2009). This could come from the stress sometimes involved with studying or just because the mind is focused on other activities, the unconscious act takes over. Known factors involved in tricotillomania include: genetics, environment, and brain chemistry. It is unclear if depression and anxiety lead to the tricotillomania or if trichotillomania leads to depression and anxiety, or both.

In searching for the causes of trichotillomania, scientists have begun examining an unlikely subject, parrots. Captive parrots will sometimes take part in what is known as “feather plucking.” During feather plucking, a parrot will tear at its feathers, much like a human with trichotillomania will tear at his or her own hair. Scientists have concluded that the causes of feather plucking can range from genetic, socio-environmental, and neurobiological factors. It is likely that the results taking from feather plucking studies can be applied to humans. However, the researchers want their readers to understand that feather plucking may not be related to trichotillomania at all. It could just be a grooming fetish that is stimulated when parrots are faced with anxiety (Zeeland, Spruit, Rodenburg, Riedstra, Hierden, & Buitenhuis, 2009).


Currently, there exists no universal effective treatment for trichotillomania. What works for some patients may not work for others. Common treatments include the use of anti-depressants, anti-psychotics, bupropion, lithium, and topiramate (Woods, Adcock, & Conelea, 2008). Another treatment involves the use of cognitive behavioral training. The aim of cognitive behavioral training (CBT) is to boost the client’s awareness of when these urges occur. CBT also helps clients through self-monitoring, habit reversal training, competing response training, and stimulus control techniques (Flessner, Penzel, & Keuthen, 2010). Other therapy options considered are support groups or alternative medicine, e.g.,prayer, hypnosis, meditation, diet change, or yoga.

In a recent case study, researchers used the drug Oxcarbazepine on a patient with trichotillomania and binge eating disorder. After nine months, the client’s condition improved without relapse. However, this research is inconclusive as it was only tested on a single individual. The researchers recognize the need to broaden their study. Despite the limited results, a glimmer of hope remains (Leombruni & Gastaldi, 2010).

Many with hair pulling disorders may describe their urges similar to scratching an itch. Cleverly, a researcher suggested that numbing cream be used on the scalp and other areas of problem hair picking. This method, in addition to CBT, has shown great effectiveness in several single-subject experiments. However, follow up research on the subjects has not been conducted (Dia, 2008).

In closing, trichotillomania is a misunderstood and under-studied disorder. Research on this disorder is limited, creating great gaps in our understanding of it. Scientists need to increase their knowledge base with additional conclusive studies. Causes of trichotillomania must be determined so that it can be prevented. In addition, the treatments for this disorder should be further analyzed to provide relief for the victims. Finally, the public should be more aware and involved with this disorder. People with trichotillomania, especially children, should not be socially isolated and teased for something that is beyond their control.

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