Hair Transplant & Hair Restoration in Dallas

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Trichotillomania is a form of traction alopecia caused by the irresistible compulsion to pull or twist one’s hairs out.  The Diagnostic and Statistical Manual of Mental Disorders (DSM) lists the following criteria for diagnosis of trichotillomania:

1. recurrent pulling of one’s hair leading to noticeable hair loss
2. an 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. the condition not attributable to another mental disorder or medical condition
5. the disturbance causing clinically significant distress in social, professional, or personal areas of functioning.

There are two types of trichotillomania:  1)  a benign form that occurs in early childhood (18 months to 4 years) typically with spontaneous resolution or with simple intervention, 2) a more severe form with onset around puberty, predominantly females characterized by a chronic course that can persist into adulthood.  The mean average age for the severe form is 13.1 years and 92.5% are females. 

Single or multiple areas of the scalp can be affected, especially in the parietal and vertex regions.  Also, the peripheral border of the hair is oftentimes left intact (so-called tonsorial distribution) presumably because it is more painful to extract hairs from this region.  Areas where hair has been plucked can assume a bizarre geometric pattern given the erratic behavior.  Scalp hair is the most commonly affected but any body hair may also be subjected to trichotillomania.

No area of plucked hair is uniformly devoid of hair unlike in alopecia areata.  Telogen hairs are easily plucked so they should all be removed already in the affected areas.  Anagen hairs appear broken off and twisted from the difficulty of extracting anagen hairs out.  Therefore, a hair pull test may be negative in the affected area since all telogen hairs would have already been removed.  This stands in distinction to telogen effluvium where there can be a higher percentage of hairs during a pull test.

The affected areas may have abnormal sensations, partly due to the removal of the hairs in that region and partly due to the psychological attention to the affected hairs.  Most oftentimes, hairs are removed during times when the mind is occupied and the hands are idle like lying in bed, reading, watching television, etc.  Extracted hairs are often manipulated, examined and played with prior to discarding or eating.  Eaten hairs can lead to an indigestible mass in the stomach known as a trichobezoar which may necessitate surgical removal of it.  With repeated pulling, hairs may grow out with blunt ends or at odd angles.

On the scalp, there are multiple, broken off hairs in irregular patches in varying lengths.  When the individual complains that the hair just won’t grow, the physician can create what is known as a hair window, shaving a small square in an area that is not accessible to the patient’s view and waiting a month.  At that time, the hair should have grown the typical 1 cm during that interval.  Biopsy can be confirmatory.  In addition, areas of active plucking can convert hairs from anagen over to catagen then to telogen.  Because catagen hairs only account for approximately 1% of hairs on the scalp, the presence of 2 to 3 catagen hairs in a specific biopsy can be suggestive of a diagnosis.  Also, follicular plugs with hair cast remnants can be found in approximately 60% of biopsies with clumps of melanin and keratinaceous debris.  Trichomalacia, with clumped, plicated, corkscrew terminal hairs, is uncommon but considered specific for the condition.

There is increasing evidence that the role of genetics may play a large role in obsessive-compulsive disorder (OCD).  In the 1980s, researchers found that OCDs respond better to serotonin reuptake inhibitors (SSRIs).  There is an association between serotonergic neurons and repetitive motor behaviors.

The Trichotillomania Learning Center can be an important resource in helping both patients and physicians learn more about the disease and how to treat it.  Besides medications, behavior modification strategies can be very important as well, including the following:

1. competitive reaction training- substituting an innocuous behavior like clenching and opening the hands for 3 minutes when hair pulling is likely or has just occurred.
2. awareness training- patients are taught to be aware of the motor movements involved with hair pulling as they examine themselves in the mirror
3. identifying response precursors- patients are asked to evaluate responses that may lead them to engage in hair pulling, e.g., hair touching.
4. identifying habit-prone situations- patients are asked to evaluate situations that may lead them to engage in hair pulling, e.g., driving, watching television.
5. relaxation training- patients are instructed on relaxation methods that include deep breathing and postural adjustment to help minimize the likelihood of hair pulling.
6. prevention training- patients are taught to engage in the competing response whenever they are likely going to engage in hair pulling.
7. habit interruption- patients are taught to immediately engage in the competing response when they engage in hair pulling.
8. positive attention (overcorrection)- patients practice positive hair care behaviors like brushing one’s hair when they have engaged in a negative one like hair pulling.
9. competing reaction- patients are taught to practice the competing reaction daily at home on a scheduled basis and to engage in positive hair care.
10. self-recording- patients record in a diary every time the compulsion or the act of hair pulling occurs.
11. display of improvement- the patient is encouraged to seek out activities that would typically create the desire to hair pull and practice their competing response.
12. social support- significant others are trained to encourage and reinforce the patient to inhibit the habit.
13. annoyance review- patients review all problems associated with hair pulling to enhance motivation.