Understanding Trichotillomania One Strand at a Time

 

Sit back, relax, and imagine this: You are a Sophomore in High School. You hear the unforgettable sound of the fourth-period bell and just like any other normal day, it’s time to go to Science class. You sit down, unzip your backpack, and start the daily “Do Now” in your notebook. While your teacher instructs a lesson on molecules, you realize that your mind has completely wandered and it’s time to refocus. But, before you can completely snap back to reality, something catches your attention. You see one of your classmates sitting at his desk, pulling out his hair and you wonder: Is my mind playing tricks on me? The scientific community defines this behavior as trichotillomania or TTM. In this article, you will know what is trichotillomania, signs, and symptoms of trichotillomania, comorbidity with other disorders, treatments and much more. 

Trichotillomania

Trichotillomania

What is Trichotillomania?

If you are familiar with the television show My Strange Addiction, you might remember Hayley, a 22-year-old woman addicted to pulling out her hair and eating the follicles. Now that I’ve jogged your memory, I am here to tell you that Hayley suffers from trichotillomania. Trichotillomania is an impulse control disorder characterized by repetitive pulling out of one’s hair, usually from the scalp and/or eyebrows, eyelashes or elsewhere, that results in noticeable hair loss.

Due to the shameful effects of this condition, trichotillomania is an underrecognized neurological- behavioral disorder.

History of Trichotillomania

Hippocrates first described trichotillomania as a “grooming behavior” in his medical literature. He proclaimed that patients grope, scratch and pluck out hair at the height of their grief or depression. Such “grooming behaviors” manipulate an individual into a position where they feel isolated, dependent, and vulnerable to hair pulling.

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In the late 18th century, French dermatologist Francois Hallopeau coined the term trichotillomania. Hallopeau used TTM to describe a condition exhibited by a young male patient who tore out every hair on his body in reaction to an intense itch. This acute case of trichotillomania sparked a breakthrough in Hallopeau’s career and psychological history.

Trichotillomania: Changes in the DSM-5

The Diagnostic and Statistical Manual of Mental Disorders (4th ed) distinguishes those with trichotillomania TTM as individuals who repeatedly engage in hair pulling behaviors to reduce anxiety. The DSM-IV-TR orders five criteria for the diagnosis of trichotillomania:

  1. Recurrent pulling out of one’s own hair that results in noticeable hair loss
  2. Increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior
  3. Pleasure gratification or relief when pulling out the hair
  4. Hair-pulling is not better accounted for by another mental disorder
  5. Significant distress or impairment in social, job stress, occupational, or other important areas of functioning

Discoveries from past and present research launched minor changes in the DSM- 5. “Trichotillomania (hair-pulling disorder)” localizes under an independent chapter for obsessive-compulsive and related disorders in DSM-5. Due to commonalities with obsessive thoughts and repetitive behaviors, trichotillomania no longer fits as an impulse- control disorder. The DSM-5 continues to largely reflect the descriptions, symptoms, and other criteria found in the DSM-IV-TR.

Trichotillomania: Phenomenology

The phenomenology of one’s experience contrasts with that of another based on their so-called “lived experience.” In this section, you will become familiar with the most common hair pulling technique, variances in pull sites among ethnic lines, and the 3 subsets of hair pulling: early onset, automatic, and focused.

Ethnic Variances in Pull Sites:

In most cases, an individual will pull their hair one strand at a time with their fingers, tweezers, combs, or brushes from the scalp. Certain trends and commonalities, among Caucasians and ethnic/ racial minorities, provide scientific insight on ethnic differences in pull sites. Follicular extraction from the eyebrows and eyelashes seems to occur more often in the behaviors of Caucasians but, as for both groups, the number of pull sites increases with age.

3 Subsets of Hair Pulling Behavior:

A professional places an individual into a subset based on age, whether their behavior takes place subconsciously, or if an individual pulls only to satisfy their urges. Are you showing early signs of trichotillomania? Is your behavior focused or automatic? Let’s explore the 3 subsets of hair pulling in trichotillomania:

  1. Early Onset: Children diagnosed with early onset trichotillomania often experience symptoms and receive a proper diagnosis by 8 years old or even younger. Early onset trichotillomania can be self-corrected without therapeutic intervention.
  2. Automatic Hair Pulling: An individual unconsciously participates in hair pulling when they shift their attention onto something else in the environment (e.g., watching television or reading). Automatic hair pulling poses the most health risks.
  3. Focused Hair Pulling: Knowing when and why they are pulling, urges and tension often associated with obsessive-compulsive disorder characterizes focused hair pulling.

Preschool- age children exhibit mostly automatic patterns of behavior because their attention span and social awareness are shorter and more limited to that of an adult. If TTM behaviors persist beyond the preschool years, keep a close eye on behavioral progression. Trichotillomania co-occurs with either focused or automatic hair pulling depending on perceived consciousness and other factors that contribute to direct experience.

Trichotillomania

Trichotillomania

Trichotillomania: Prevalence

Previous scientific records show that TTM was once a moderately uncommon disorder with its prevalence assessed as low as 0.05%. Trichotillomania is an established psychopathology but because the number of unreported cases still remains significantly high, TTM remains generally unrecognized. Professionals conclude that the estimated prevalence of TTM ranges from 0.6% to 3.4%. This segment focuses on the prevalence of trichotillomania in race/ethnicity, sex, and age

Race/ Ethnicity

Angela Barnett, a clinical psychologist who specializes in trichotillomania and anxiety among African Americans, studied the relationship between stress, race/ethnicity, and trichotillomania. In an online study of 103 racial/ethnic minorities and 1,290 Caucasians, Barnett found that racial/ethnic minorities reported interference of home management as a result of TTM. Caucasians reported that stress from their academic lives contributed to the onset of their trichotillomania. Even though racial/ ethnic minorities were less likely to participate in a treatment program, there was no significant difference between racial/ethnic minorities and Caucasians with regard to the efficacy of treatment.

Sex

It is seven times more prevalent in females than males, experimental analysis specifies that women disproportionately represented TTM. Here are three possible reasons to better understand this statistic:

(a) Women seek out treatment more often

(b) Men blame TTM on socially acceptable male-pattern balding

(c) Men avoid TTM effects by shaving their heads.

Trichotillomania appears to occur more frequently in women than in men. Men feel less compelled to seek professional help because of the mark of disgrace associated with this disease. They continue to lead a life of denial, blaming their hair pulling behaviors on the natural effects of losing one’s hair. A longing for full societal acceptance motivates their decision to blame the physical consequences of trichotillomania on male- pattern balding. It’s much easier for a man to temporarily destroy the root of their temptation by simply shaving their head.

In individuals with trichotillomania, 3 out of 4 current hair pullers will describe obsessive-compulsive symptoms. In a study and analysis of the distribution and determinants of health and disease conditions in defined populations, a female: male ratio varied from as much as 2:1 to 7:1. Chronic courses associated with other psychopathology in 53% of adults showed that 23% experienced TTM and major depression; 23% experienced TTM and generalized anxiety disorder, and 26%: experienced TTM and OCD.

Age

While signs and symptoms of trichotillomania typically begin in adolescence, onset can take place at any age. Many suggest that TTM equally distributes its symptomatic force between the sexes in early childhood but as age increases, so does the distribution of TTM in women. Seven times more prevalent in children, preschool-aged children diagnosed with TTM undergo a somewhat benign and self-limiting course analogous to nail-biting or thumb-sucking. Those who do not experience early onset trichotillomania consider to be of increased severity, more resistant to treatment and often associated with comorbid psychopathology. In addition, 13.3% of college students participate in behavioral patterns (problematic hair pulling) consistent with some aspects of TTM.

Signs and Symptoms of Trichotillomania

You’ve had a long and stressful day at work. You come home, prepare a snack, and turn on your favorite television show. After an hour, you decide that it’s time to get up from the couch and get ready for another day ahead. As you sit up, you look down and see tiny strands of your own hair dispersed across your chest and on the cushions of your couch. If you find yourself reflecting back to a time in your life where you lived through a similar situation, then you might have trichotillomania.

These are the signs and symptoms:

Low self-esteem

How trichotillomania alters a person’s physical appearance will most likely contribute to their lack of self-confidence. Studies show that improvements in self-esteem increase self- confidence.

Irritability

Feelings of frustration or anger may arise in an individual who is unable to pull with ease. It’s completely normal to feel irritable when things don’t go as planned but people with TTM feel ten times more irritable than the average person. Irritability is only an indicator of trichotillomania when feelings become excessive and interfere with daily living.

Depression

Depression can cause significant impairment in the daily lives of those with trichotillomania. If a person has low self-esteem, they most likely have or will develop depression.

Feelings of unattractiveness

If I’m not satisfied with the way that I look in the mirror, how can I possibly be pleasing or appealing to others? This is a constant question that someone with TTM asks themselves every day.

Noticeable hair loss

People with trichotillomania will fit the description of a person whose hair is notably shorter than the standard length. The scalp, as well as other areas of the body, will start to thin out and show patterns of baldness. Eyelash and eyebrow follicles are more scanty and sparse.

Anhedonia

The individual is unable to experience pleasure in activities that they used to find enjoyable because now, the activity that they enjoy most is pulling out their hair.

Feelings of worthlessness

Lack of self-confidence, irritability, depression, and feelings of unattractiveness all result in a belief that they are not worthy of living a life full of happiness.

Hopelessness

They live in a state of despair and the hope that they need to push through and overcome this vicious disease is nonexistent.

Stress

Stress contributes to a never-ending cycle of trichotillomania. In fact, hair pulling becomes more severe when an individual is under a great amount of stress.

Difficulty concentrating

When and where am I going to pull next? Constantly thinking about this question on a daily basis, these individuals find it difficult to direct their attention to work, school or in social situations. In some occurrences, people drop out of school, quit their jobs, or totally isolate themselves from society.

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Shame

Many feel a painful reaction of humiliation or distress caused by their consciousness of wrong or foolish behavior.

An increasing sense of tension before pulling, or when you try to resist pulling

Everyone’s yanked out a piece of their hair at least once in their life. Whether it was by accident or because curiosity got the best of you, you may have felt a little pinch or some tension before you completely removed that strand from your head. Since those with TTM have shorter hair, the tension that they experience before, during, and after pulling is overwhelmingly painful.

A sense of pleasure or relief after the hair is pulled

With each strand comes a heightened sense of satisfaction, enjoyment, and solace in achievement. But if you really think about it, an individual is never satisfied because they return to the same behavior over and over again.

You eat, play, or rub hair follicles across your lips or face

In some cases, some eat, play, or rub their hair follicles across their lips or face to feel a heightened sense of pleasure or relief. This behavior does not happen in every situation but it does exist.

An uncontrollable urge to pick

An uncontrollable urge to pick is the sole reason why it’s difficult to concentrate.

Differential diagnosis involves ruling out other causes of hair loss, including both congenital and acquired causes. An individual undergoes intense medical tests and examinations to see if the high levels of stress and anxiety that they experience are due to other medical conditions. If not, an evaluation takes place to determine if this behavior occurs on a regular basis. Even the slightest possibility of stress and anxiety related hair loss will lead to a trichotillomania diagnosis. If you or anyone you know is experiencing any of these signs or symptoms, contact your healthcare provider immediately. Trichotillomania tends to become more severe if symptoms go unnoticed.

Trichotillomania: Signs and Symptoms
Trichotillomania: Signs and Symptoms

Impairments of Trichotillomania

Unfortunately, those with trichotillomania live a life full of decreased physical,  psychological, social, academic, and occupational functioning. The effects of trichotillomania have long-lasting impairments on its victims.

From skin infections to bleeding and irritation, the most serious physical impairments are a result of the ritualistic behaviors associated with TTM. One ritualistic behavior includes slowly taking the hair and running the follicle over the lips and/or tongue. In people who orally manipulate their hair, forty-eight percent are causing themselves serious dental erosion. Others engage in a ritualistic behavior of ingesting their hair after the completed act of pulling. Hair consumption can cause the development of fatal trichobezoars (hairballs) that results in the development of an intestinal obstruction.

The repercussion of trichotillomania generates a decrease in psychological, social, academic, and occupational functioning. Some avoid going to social or recreational events that may expose their hair loss (e.g., swimming, being outside in the wind) which unintentionally puts their relationships with family, friends, and lovers on the line. A behavioral analysis of TTM hypothesizes that people who describe their hair pulling as focused and automatic also reported severe psychological and functional impact than those with lower levels of hair pulling. TTM destroys an individual’s ability to focus, which ultimately affects their academic performance or success in their careers.

Sleep- Isolated Trichotillomania (SITTM)

Sleep- isolated trichotillomania is a relatively underreported condition. SITTM is defined as the plucking of body hairs during sleep with no recollection of the event while awake. An individual with SIITM wakes up in a state of confusion and wonders why their body hair is either thinning or balding.

There are two cases of sleep- isolated trichotillomania. Hair pulling at night may be a nonrapid eye movement (NREM) sleep parasomnia that occurs during nightmares, night terrors, sleepwalking, confusional arousals, and many others. In patients who have nonepileptic seizures, TTM may be a symptom of a sleep-related dissociative disorder. Like a standard case of trichotillomania, the severity and frequency of hair pulling during sleep is greater when an individual is highly anxious.

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Because SITTM is an underreported condition, the number of reported cases of sleep- induced trichotillomania is insufficient to determine underlying etiology and specific treatment recommendations. Medical and psychological professionals suggest pursuing polysomnography to rule out sleep-disordered breathing, confusional arousals, other NREM parasomnias, and REM behavior disorders to ensure that the patient is experiencing SITTM. Once notable causes of SITTM come to surface, then a true treatment plan should be devised and used for future reference.

Sleep- Isolated Trichotillomania (SITTM)
Sleep- Isolated Trichotillomania (SITTM)

Etiology of Trichotillomania

Environmental and biological factors are considered for a feasible etiology. One possibility is that an individual’s environment classically conditions the body into associating stress with the body’s automatic or focused hair pulling. Under other conditions, biological explanations focus mainly on an imbalance of neurotransmitters.

Environmental Etiology

Various studies have reported a genetic and familial basis for a diagnostic predisposition. Diefenbach, Reitman, and Williamson suggest that TTM may be modeled and learned from peers and family members although it is unlikely that all the theories proposed are evident in an individual. People who’ve seen this behavior first hand has an increased chance of developing the same reactions to stress as those in their environment. Genetically speaking, people that are genetically susceptible to an emotional attack on the mind and body are able to function in highly stressful situations. Genetic influences impose a vulnerability to emotional dysregulation through biological processes.

Past trauma and posttraumatic stress disorder (PTSD) are proposed to have a role in the etiology of TTM, but research is limited on this potential etiology. Deeply disturbing or distressing experiences incline certain manifestations of TTM, combining the biological, psychological, and social factors that can potentially open doors for future research. Early work suggests that childhood trauma might predispose people to develop trichotillomania but there is little evidence to support this claim.

Biological Etiology

Abnormalities related to the structures and overall function of the brain play a major part in the development of trichotillomania. Subtle changes in the putamen, cerebellum and cortical regions tell us how prone we are in developing habitual behaviors or our ability to suppress inappropriate or unwanted habits once they occur. More research is required to better understand if biological etiology contributes to distinct structural or functional brain abnormalities and the development of trichotillomania.

As we reach new conclusions and discover another underlying mechanism through systematic and research-based investigations, we’ll obtain a better understanding about trichotillomania and its unknown etiology.

Trichotillomania: Familial Etiology
Trichotillomania: Familial Etiology

Differentiation Between Trichotillomania and Other Disorders

Before we can cover the topic of comorbidity, we must establish factual- based statements on the differentiation between TTM and other diseases. While recognizing that trichotillomania has similar signs and symptoms of other body-focused repetitive behaviors, TTM is not a habit, tic, OCD or pathological skin picking.

TTM is a body-focused repetitive behavior (BFRB). A BFRB is an umbrella term for impulse control behaviors that trigger a person to repeatedly cause damage to their physical body. Tics are involuntary compulsions driven by sensory urges, somatic discomfort, physical pain or tension where TTM behaviors are voluntary and rooted in anxiety.

Over time, there has been much debate on whether scientists should include trichotillomania in the spectrum of obsessive-compulsive disorders (OCD). Due to the similar neurobiological and clinical features, many argue that invasive cognitions motivate the desires and drives of OCD, whereas intrusive thoughts are not a part of the criteria for TTM.

The essence of impulsivity and compulsivity are the basic and inherent features that differentiate trichotillomania from OCD. Consequently, compulsions bring pleasure to those with TTM but in an obsessive-compulsive hair puller, an irresistible urge goes against conscious wishes and does not result in a pleasurable outcome.

Trichotillomania: Comorbidity

Comorbidity, the simultaneous presence of two chronic diseases or conditions, is important in understanding the nature of any health condition. TTM can exist independently or simultaneously with other medical conditions.

Trichotillomania and OCD

OCD is highly comorbid with trichotillomania especially in women and early-onset OCD patients. Both OCD and TTM patients describe ritualistic behaviors and compulsive urges.

Trichotillomania and Major Depression

In a study of 303 adult patients receiving psychological treatment for major depression, 5% endorsed symptoms of hair pulling disorder.  Hair pulling co-occurs in the medical nature of both diagnoses because of the intense feelings of helplessness, hopelessness, and despair. With the presence of the physical characteristics of trichotillomania and the anxious and depressive symptoms exhibited by the patient, it is possible that they have a case of trichotillomania comorbid with major depression.

Trichotillomania and Pathological Skin Picking

Trichotillomania and pathological skin picking share similarities in phenomenology and clinical symptoms but did you know that pathological skin picking is more common than TTM? Or that TTM occurs more frequently in adolescence whereas pathological skin picking has a bimodal onset? Nevertheless, there’s higher comorbidity between trichotillomania and pathological skin picking.

On behalf of the small number of reported case- studies, there are limitations on the comorbidity between trichotillomania and other disorders.

Treatment of Trichotillomania

Trichotilllomania

Trichotillomania

Formulating a treatment plan is one of the most difficult tasks for clinicians because the exact causes of TTM are still unknown. Rates of trichotillomania are continuing to grow at alarming speeds and with limited approaches to treatment, rates are starting to match or exceed those of more commonly researched disorders. In this section, we will touch on the various treatments of trichotillomania in terms of psychological and pharmacological approaches.

Cognitive Behavior Therapy (CBT)

Patients will come to terms with the thoughts and feelings that influence their behaviors through a hands-on practical approach to problem-solving. CBT is commonly used to treat anxiety and depression, two common symptoms of trichotillomania.

Habit Reversal Training (HRT)

HRT is a type of psychotherapeutic approach in which the person learns to attend to hair-pulling desires and engage in behaviors that prevent hair pulling. A physically incompatible “competing response” (clenching of the fist for 60 seconds instead of pulling hair) physically blocks the behavior that is responsible for their feelings of unattractiveness. Those treated under habit reversal training find relief in relaxation exercises and therapeutic tasks in which they learn how to monitor the self.

Function-Based Intervention

For children who are too young for HRT, function-based interventions (or stimulus control interventions), seem to be the most beneficial. Function-based interventions involve changing the client’s environment to make the pulling behavior more effortful or less rewarding. An intervention specifically fit the needs of the child based on a thorough examination of familial background, the nature of pulling episodes, and the aftermath of an episode.

Social Support

Above all, social support plays a vital role in the successful treatment of any disease, disorder, or medical condition but in trichotillomania, the role of social support could not be stressed enough. Social support identifies hair pulling while encouraging and redirecting the client to participate in the competing response training.

Acceptance and Commitment Therapy

Acceptance and commitment therapy is a form of counseling and a branch of clinical behavior analysis where a patient will learn how to accept their thoughts instead of diminishing or eliminating them. During a four stage process, an individual will learn how to accept and become aware of thoughts, urges, and feelings that cause discomfort, reject the emotional control that prevents growth toward life goals, address the behaviors that prevent growth toward life goals, and cognitively defuse the situation.

Pharmacological Treatment

Currently, there are no treatments approved by the US Food and Drug Administration which creates a huge problem in selecting appropriate pharmacology. Without clear direction on which medications are the best fit for treatment, a determinant of medication decides upon the severity of the disorder, psychiatric comorbidity, and timing of the onset of TTM.

Earlier intervention leads to better prognosis and prevents from serious setbacks that can negatively affect the patient’s health. Mental health counselors should start by attempting to decrease or manage levels of stress, anxiety, and depression.

Trichotillomania: Pharmacology
Trichotillomania: Pharmacology

Trichotillomania: Adjunct and Emerging Approaches

Some research indicates that current treatments resulted in limited success and failure to address symptom presentation in different types of hair pullers. A combination approach, acceptance- enhanced behavioral therapy, and decoupling will maximize the effectiveness of existing CBT, HRT, function-based interventions, acceptance and commitment therapy, and pharmacological treatments.

Combination Approach

A combination approach integrates the therapeutic techniques of pharmacotherapy and CBT. As opposed to monotherapy, a combination of psychotherapy and pharmacotherapy constitutes a reduction in the symptoms of trichotillomania and trichophagia over time. The positive outcomes of a combination approach are not reachable without a daily dose of quetiapine (a supplemental antidepressant prescribed to those with trichotillomania), familial support, and enrollment into a psychiatric program where they attend regular meetings to talk, interact, and discuss their experiences with each other and a group leader. Because case studies are not generalizable, combination approaches are presented as emerging approaches.

Acceptance-Enhanced Behavioral Therapy (ACT)

Instead of teaching an individual how to better control their urges, they will learn how to notice and accept the unwanted feelings, thoughts, and sensations that serve as the driving forces of physically attending to their behaviors. As a subdivision of a combination approach, ACT combines habit reversal training, psychoeducation, and acceptance and commitment therapy with various relaxation exercises and coping mechanism.

Decoupling

In 2011, Moritz and Rufer added decoupling as an emerging therapeutic intervention. The basic idea is that the individual shifts the behavioral movement of pulling to another movement. Presented as a self- help technique, the psychological effects of decoupling departs from the established therapeutic outcomes of habit reversal training. HRT terminates the behavior while decoupling allows for the patient to participate in urge satisfying responses that reverse the unhealthy upshots of trichotillomania (e.g., instead of pulling at the scalp, massage the scalp). Moritz and Rufer substitute habit reversal training for decoupling when the client may be unwilling or not ready to seek professional help.

Trichotillomania, Perfectionism, and Shame

Nonclinical and clinical samples were created to look at the relationship between multidimensional perfectionism, behavioral shame, and trichotillomania. 125 individuals were recruited to a clinical sample according to specifications found in Criteria A of the DSM-IV-TR. A determination of participant engagement was dictated based on their own personal accounts of hair pulling and noticeable hair loss posted on social networking sites, online message boards and forums, support groups for OC spectrum disorders, and a national conference for individuals with TTM. In an urban southeastern university, online recruitment from an undergraduate course took place to fill the 284 spots in a non- clinical sample. The following hypothesis was considered:

  • Perfectionistic concerns will be positively associated with the three subtypes of shame that will be positively associated with TTM in both samples.
  • Perfectionistic strivings will be negatively associated with the three subtypes of shame that will be positively associated with TTM in both samples.
  • The three dimensions of shame (characterological, behavioral, and bodily shame) will mediate the relationships between both perfectionistic concerns and strivings and TTM in both samples.

Trichotillomania and Perfectionism

Participants in the clinical sample reported higher levels of maladaptive perfectionism than the nonclinical sample. While there were various critical connections made between shame, strivings for flawlessness, and trichotillomania in both samples, higher maladaptive perfectionism showed a positive correlation with characterological, behavioral, and bodily shame in trichotillomania. Maladaptive perfectionists resorted to behaviors that were more severe and frequent, focus- based, and intensely distressing and impairing when they failed to meet unrealistic standards.Trichotillomania: Perfectionism and Shame

Trichotillomania and Shame

Behavioral shame arbitrates a positive relationship between maladaptive perfectionism and the severity of self- injurious behaviors. Recent findings suggest that individuals with TTM may not experience more severe hairpulling behaviors or impairment because of shame around their physical appearance but they may experience more severe hair-pulling because of shame around the behavior itself. All three dimensions of shame do not explain symptom severity or mediate the relationships between maladaptive and adaptive perfectionism and TTM.

Measuring Perfectionism and Shame in Trichotillomania

With approximately 4% engaging in levels of TTM behaviors consistent with a clinical diagnosis, roughly 12% reported nonclinical levels of hairpulling behaviors. An insufficient record of statistical data, in the nonclinical population, is due to an absence of directly observable symptoms. The Almost Perfect- Scale, The Massachusetts General Hospital Hairpulling Scale (MGH), and The Experience of Shame Scale (ESS) silences a demand for continued research and assesses an individual based on the psychological aspects of TTM.

Almost Perfect Scale-Revised: Created to measure people’s attitudes towards themselves and their performance, this 23-item inventory measures the adaptive and maladaptive dimensions of perfectionism. Individuals will place in either an adaptive or maladaptive dimension based on performance standards and discrepancies.

Massachusetts General Hospital Hairpulling Scale (MGH): MGH determines a diagnosis of trichotillomania using a first- hand self- report. Participants rate 7 questions using a 5- point Likert scale on matters of frequency, intensity, and ability to control their urges, the number of attempts made to resist hair pulling, the frequency of hair pulling, perceived control over hair pulling, and associated distress. MGH demonstrates acceptable validity in measuring current symptom severity as well as symptom change, strong test-retest reliability, and strong internal consistency.

Experience of Shame Scale (ESS): The Experience of Shame Scale estimates the nature, power, and degree of shame on experiential, cognitive, and behavioral levels. The ESS yields a total score, as well as three subscale scores of the degree of characterological, behavioral, and bodily shame, felt within the past year. This method exhibits high internal consistency and test-retest reliability.

Future Research on Trichotillomania

Today, longitudinal designs are being used to study the effects of elevated levels of shame on well-being outcomes and mental health issues. As opposed to a cross-sectional design, vigorous long-term research assesses the relationships between shame, perfectionism, and trichotillomania, establishes an unknown etiology and reliable treatment plan, and reduces the number of unreported cases.

Implications for Counselors

Competence in recognizing all signs and symptoms of TTM will allow for an accurate and easy assessment, diagnosis, and treatment. With just 6 easy suggestions, you can improve your level of competence in no time!

First and foremost, tackle your clients’ feelings of shame

Are their feelings surrounded by characterological, behavioral, or bodily shame? Is an incapacity to “just stop pulling” affecting their emotional state? 99% of the time, behavioral shame will explain the austerity of TTM behaviors.

Talk to your client about any shameful experiences related to their behavior

Therapeutic intervention uncovers any traumatic events that may contribute to the start of their trichotillomania. A patient-therapist interaction improves rates of frequent hair pulling behaviors and episode severity.

Explain that their behaviors have a function

Empathize with your client and show that you understand why they are engaging in this type of behavior. This can help reduce clients’ feelings of shame, establish trust, decrease secrecy, and promote new coping skills and healthier behaviors.

Regularly ask your clients about compulsive hairpulling and other BFRBs

Those who experience compulsive hair pulling, or meet criteria for TTM, may not know that their behaviors are classified as an impulse control disorder. Gathering background information about your patient’s medical history will improve your degree of competence for future directions.

Remember that all forms of perfectionism are not universal

Research has shown that perfectionism is characterized by maladaptive traits but when a client suspects that they have trichotillomania, do not assume that their perfectionism is maladaptive. Assess a client’s type of perfectionism before concluding that their perfectionism is pathological, maladaptive or adaptive.

Take caution when assessing, diagnosing, and treating each patient

Considering that there is no standard treatment for trichotillomania keep ethical considerations in mind in the three stages of treatment.

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Tips on Trichotillomania

Feeling trapped by your own conscious or unconscious behaviors? Well, what if I told you that you can escape from your own living nightmare? What if I told you that you are capable of living a “normal” life full of happiness just like everyone else? Instead of looking in the mirror and resenting yourself, follow these helpful tips to win back every ounce of self- love that has been lost in the crossfire we call trichotillomania.

Create a personalized reward system

Purchase a sticker chart at your local crafts store and add a sticker for every day that you go without pulling. After you accumulate 7 stickers in a row, reward yourself with that new pair of shoes that you’ve had your eye on for a couple of weeks. After all, you deserve it after all your hard work and dedication!

Be patient

It’s impossible for any type of change to happen overnight especially when a behavior has become part of your daily routine. So what if you’ve had one bad day? Look at how far you’ve come and celebrated gradual success.

Be active

Physical activity is an essential component of a healthy lifestyle especially for those with TTM. So instead of binge watching all 6 seasons of Gossip Girl, go for a hike or take a spontaneous trip to the beach. Occupying time outside of the home will distract you from your temptations.

Incorporate hats and/or bandanas into your daily wardrobe

Not only will you make a fashion statement, but you will feel confident, beautiful, and comfortable in your own skin. Hats and bandanas conceal what your fingers are fiending for.

Educate yourself about trichotillomania through shows and documentaries

Seeing personal accounts of TTM through the eyes of others may put your world into perspective. You might even say to yourself, “Wow, is that really what I have been doing to myself?”

Dear diary

Exert your feelings of anxiety through your words rather than your actions. Journaling clears your mind, reduces stress, and increases emotional self-awareness. Writing daily journal entries can draw a link between your behaviors and emotions.

Keep those fidgeting fingers busy

Whether it is simply playing with silly putty or snapping a rubber band against your wrist, countless websites are offering fidget toys to help increase tactile awareness of your fingers and soothe your emotions in highly stressful situations.

Seek out professional help

Depending on the severity of your TTM symptomatology, you might need some extra guidance. Forget the social and personal stigma associated with mental health, you are a strong and courageous individual who is making a decision to better your life. A professional addresses your needs through a personalized treatment plan.

So, do you have trichotillomania? Let us know what you think in the comments below!

References

GOYAL, D., SURYA, S., ELDER, J., MCCALL, W. V., & GRAHAM, K. (2016). Sleep-isolated Trichotillomania (SITTM): A Case Report.Innovations In Clinical Neuroscience, 13(1/2), 40-42.

GRZESIAK, M., REICH, A., SZEPIETOWSKI, J. C., HADRYŚ, T., & PACAN, P. (2017). Trichotillomania Among Young Adults: Prevalence and Comorbidity. Acta Dermato-Venereologica, 97(4), 509-512. doi:10.2340/00015555-2565

Isaac, T., Telang, A., & Chandra, S. (2018). Trichotillomania ranging from “ritual to illness” and as a rare clinical manifestation of frontotemporal dementia: Review of literature and case report.International Journal Of Trichology, 10(2), 84-88. doi:10.4103/ijt.ijt_100_17

McDonald, K. E. (2012). Trichotillomania: Identification and Treatment. Journal Of Counseling & Development, 90(4), 421-426. doi:10.1002/j.1556-6676.2012.00053.x

Montvilo, R. P. (2014). Trichotillomania. Salem Press Encyclopedia Of Health,

Noble, C. M., Gnilka, P. p., Ashby, J. S., & McLaulin, S. E. (2017). Perfectionism, Shame, and Trichotillomania Symptoms in Clinical and Nonclinical Samples. Journal Of Mental Health Counseling, 39(4), 335-350. doi:10.17744/mehc.39.4.05

Sharma, V. (2017). Pharmacotherapy of trichotillomania. Journal Of Psychiatry & Neuroscience, 42(3), E5-E6. doi:10.1503/jpn.160223

Snorrason, I., Walther, M. R., Elkin, T. D., & Woods, D. W. (2016). Treating Trichotillomania (Hair-Pulling Disorder) in a Child. Journal Of Clinical Psychology, 72(11), 1200-1208. doi:10.1002/jclp.22399

Trichotillomania (hair-pulling disorder). (2016, November 17). Retrieved from https://www.mayoclinic.org/diseases-conditions/trichotillomania/symptoms-causes/syc-20355188

Trichotillomania. (n.d.). Retrieved from https://rarediseases.org/rare-diseases/trichotillomania/

What is Trichotillomania (aka Trichotillosis). (n.d.). Retrieved from https://www.trichstop.com/info/general/definition

Linda is currently a student at Stony Brook University, studying a Bachelors in Psychology. Through her writing, she hopes that she will be able to expand her own knowledge on the motivation behind human behavior and how the brain works. She hopes that she will be able to inform others about psychology- related topics in a fun, easy, and creative way.