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Trichotillomania is an impulse control disorder that affects between 1-2% of the general public, although few are aware of this. The Victoria Secret model, Sara Sampaio, is one of the most famous stars that suffer from this condition.
Compulsive hair pulling is a complex matter that impacts the lives of the affected and their emotional state in a big way. Here we explain what trichotillomania is, its diagnosis, main symptoms, and treatment methods recommended for this disorder.
In the DSM-5 -the Diagnostic and Statistical Manual of Mental Disorders- (APA, 2013) trichotillomania is classified as an obsessive-compulsive spectrum disorder.
Those that suffer from this disorder experience recurring hair-pulling episodes, which can focus on different areas of the body. These lead to hair loss even, and the affected person usually tries to stop this behavior unsuccessfully. Stress, anxiety, and a lack of control over impulses is directly related to this syndrome.
Thirty percent of people that suffer from trichotillomania also commit trichophagia -or eating one's own hair. When the bezoar that forms in the stomach extends beyond the duodenum, this is known as Rapunzel syndrome.
When this begins during adolescence, it can become chronic and usually happens in conjunction with other psychiatric disorders.
It's worth noting that this behavior can affect any area of the body where hair grows. Eyebrows, the scalp, and eyelashes are the most common areas. While pubic hair, facial hair, underarm hair, and hair in the area surrounding the anus are other less common targets.
Likewise, people that suffer from this hair pulling disorder tend to experience short episodes throughout the day, and this kind of behavior tends to last for months or even years.
For diagnosis, those affected by this syndrome need to meet specific DSM-5 criteria, as described on the list below:
Constantly pulling out hair
Attempting to stop pulling hair
Significant deterioration of important areas of one's life due to this issue
The behavior of the syndrome is not the result of any other medical condition or mental disorder
Both trichotillomania and excoriation -another type of syndrome where the person compulsively damages their skin- are obsessive-compulsive disorders where the affected party has repetitive behaviors that focus mainly on their body in a seemingly controlled way.
However, in the case of excoriation, the person compulsively scratches their skin, eventually leading to multiple wounds. Both of these disorders are generally associated with feelings of anxiety and even boredom, and not any kind of obsession.
The most common sign of trichotillomania is alopecia or hair loss. Of course, this varies in each case. However, some people try to pull out the hairs in a specific pattern, while others don't try to do it symmetrically.
On this note, this disorder is linked to symptoms on an emotional level, socially and even at the workplace. Embarrassment, lack of control, anxiety, and guilt are all emotions experienced in conjunction with this syndrome.
Likewise, irreversible capillary damage can take place, and the person with this disorder may experience permanent hair loss in places -alopecia- or otherwise, there can be severe harm done to the hair. Besides, this could lead to medical conditions such as thrombotic thrombocytopenic purpura (TTP), musculoskeletal injuries, blepharitis, and dental damage.
Scalp infections can occur as well as carpal tunnel syndrome. If the person commits trichophagia, this can cause anemia, abdominal pain, hematemesis, nausea, vomit, obstruction, and abdominal perforation.
Trichotillomania also shares comorbidities with anxious-depressive and addictive disorders, as well as Tourette's syndrome and others related to obsessive-compulsive disorder. Some people also have repetitive body-focused behaviors like nail biting, skin picking, and lip biting.
Treating trichotillomania starts with a proper diagnosis to choose the best therapies to help the person and to avoid relapses in the future. Generally speaking, the preferred treatment -always keeping each case in mind- tends to be a model that uses a mix of psychological and pharmaceutical therapies.
Serotonin reuptake inhibitors (SSRIs) are usually prescribed since they have had the best results in cases of compulsive behaviors.
Regarding psychological treatment, behavioral and cognitive behavioral therapies tend to be the most effective in treating trichotillomania. These help the person to desensitize the behavior and become more conscious of their actions, by finding a behavioral alternative to hair pulling.
Group therapy has also had positive results since it can help to improve social interaction and hear other cases of people that have experienced the same issues.
Topical antibiotics and corticosteroids are two types of medications that are used to control the infections that can arise as a result of hair pulling. If there is an excessive loss of eyelashes and eyebrows -madarosis- tattoos or hair transplants may also need to be done.
Finally, in the most severe trichophagia cases, surgery may be necessary. It's also important to treat anemia, digestive problems, and malnutrition that are all associated with this syndrome.
American Psychiatric Association (APA). (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), fifth edition. Madrid: Panamerican.
França, K., Kumar, A., Castillo, D., Jafferany, M., Hyczy da Costa Neto, M., Damevska, K., Wollina, U., & Lotti, T. (2018). Trichotillomania (hair pulling disorder): Clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations. Dermatologic Therapy, e12622.
Jaramillo-Borges, Y. M. (2007). Trichotillomania, Tricophagia and Rapunzel Syndroms. Acta Médica Costarricense, 49(1) 4-5.