This fearful sounding name is the label for a problem that few people are aware of and yet paradoxically its sufferers are all around us. There may even be members of your own family in the early stages of this compulsive disorder, but its early manifestation may appear reasonably harmless. What is this behaviour that can pass so unnoticed in its early stages yet be so difficult to ignore once it has taken hold?
Hair pulling. The true Trichotillomania sufferer feels a need to pull at and even pull out, strands of their hair. In prolonged cases this can be so severe that noticeable hair loss takes place even to the point of patchy baldness. This condition is not as rare as one might think and as far back as 1978 research by Azrin & Nunn concluded that this ‘chronic habit disorder’ could affect up to 8 million people.
What causes Trichotillomania?
One view is that trichotillomania is an obsessive-compulsive disorder (sometimes called an impulse-control disorder) and as such is a form of ‘nervous’ illness. Another, that it is entirely a behavioral disorder learned as a reaction to prolonged stress. Another possibility is that the root of this pernicious activity, which seems to begin as a form of self-grooming, is linked to regressive (instinctive) behavior patterns, as it has been observed in other animals under certain conditions. Interestingly many infants hold onto, or pull their mothers hair when being nursed – so perhaps subsequent personal hair pulling is an attempt to key into this early comfort state?
Some theories link this problem with stress but while it may be that high stress levels exacerbate the situation this may not be the originating cause. It is interesting to note the common phrase I was so angry/worried/frustrated I was, “pulling my hair out!” As if this was a normal reaction to unpleasant life situations. For many people it is more than a metaphor.
Many sufferers report that changes to diet can make the impulse to pull hair seem stronger, especially bouts of ‘junk food’ consumption. In this regard a small number of researchers are pursuing the possibility that trichotillomania is linked to a potassium shortage but this research is far from conclusive and finding few adherents. More likely A poor diet simply increases the perceived level of stress.
Many sufferers report that they get a certain feeling of satisfaction/pleasure or relief by the act of pulling hair from their scalp. As such this has some similarity with the pleasure response of the masochist. Here the patient has become classically conditioned to experience pleasure from a certain amount of pain. Perhaps more accurately the trichotillomania sufferer seeks a feeling of deferred relief, exchanging the sense of pain/relief obtained from uprooting hair for the scratching/relief of a more concealed psychological itch.
It seems likely that the causes of this malady will be a proportionate mixture of some or all of these theories.
Signs and Symptoms
The seeds of trichotillomania might be sown innocently enough. The sufferer begins the habit by playing with or ‘toying’ with their hair. This usually seems to occur when distracted (watching television for example) or perhaps daydreaming. It’s almost as though the unconscious mind plays with or comforts itself while the conscious mind is otherwise absorbed. There is some evidence that this behaviour can be learned from peers and parents.
Many sufferers explain that they are unaware that they are pulling out their hair until the act is accomplished. It should also be mentioned that most do not actually mind the act of hair pulling (because it is a source of perverse satisfaction) and would find no problem with this activity if it did not lead to unsightly bald patches on the scalp.
In extreme cases a situation can arise which has been named Tonsure Trichotillomania where the patient has become almost completely bald, save for the hairs that are fine and most painful to remove, such as at the nape of the neck.
It seems from medical reports that young females are more likely to fall prey to this problem than their counterparts. This may be explained by the fact that females traditionally wear their hair much longer than males and so it is more available to the fingers. Similarly, young females are perhaps more likely to strongly associate behavioural patterns with hair grooming as this is a more important part of parental contact to them. However this observation is not statistically proven and males do suffer from this complaint too.
It seems that sufferers, once they are aware that they have formed an addiction to the act of pulling out hair, might well begin to hide this practice. They might even take steps to hide or disguise the subsequent hair loss in various ways, so parents should be vigilant. I should also mention that while the focus of this problem is usually the scalp it can also generalize in time, until the sufferer pulls hair from the eyebrows, eye lashes, nasal hair, arms, hands, armpits, chest, breasts, nipples, legs, pubic areas and so on. There are even cases on record of people so severely afflicted that hair has also been pulled from wigs, soft toys and pets!
Mention should be made of the fact that some sufferers actually consume the hair that they remove (a condition named Trichophagia), which can form undigested masses of hair in the stomach called Trichobezoars and require hospital treatment.
It’s sad to report that most conventional treatments for trichotillomania have been found largely ineffective. High doses of mood altering medication have been tried and so has various dietary regimes. Another common reaction is to attempt to control the problem by shaving the head of the sufferer but evidence shows that the problem remains and merely waits until the hair returns to reassert itself.
Treatment with Hypnotherapy
The direct / indirect script based method seems to have little impact on this problem so alternative methods have been used. The general consensus is that trichotillomania is fundamentally a habitual/stress based disorder so a strategy utilising distraction and relaxation is possible. First the patient is induced into a very relaxed state and this state is associated with a ‘favourite place of relaxation/safe place’. The patient might also be taught self hypnosis and be given the homework of going into deep relaxation and developing this as a place of comfort (between visits to the clinic). Once the patient can access a relaxed comfort zone on command one can give suggestions to the patient (in hypnosis) that whenever they feel a tug on their hair they will immediately go into their prepared relaxed calm state and their hands will become very relaxed (and if it is safe – fall into their laps). At the next session they can be given the cue / suggestion that whenever they feel / notice their hand rising to pull hair, they immediately cue this deep relaxation and abort the behaviour. This action can be intentionally rehearsed over and over in the clinic to establish this pattern until the original action is de-linked. One can suggest relief and happiness when the impulse to pull hair is noticed and abandoned and even instigate some form of reward (small piece of candy etc). Similarly one can attempt to link and aversive response to the act of pulling out hair (though one might not expect too much from this aversive approach).
Trichotillomania comes in many stages of severity and it may be that symptom transference is initially needed. Here the patient is hypnotised and the ‘part’ causing the obsession is negotiated with and, for example, pulling hair from the scalp is traded down for pulling hair from the arm or leg, etc. It might even be possible to transfer the hair pulling ‘off site’ onto a doll / wig/ or piece of material. Bubble wrap has been used with associated types of problem. It is possible to substitute a similar (though less destructive) stimulus response by having the patient wear an elastic band around the arm or leg (or perhaps even the forehead) which can be pulled and released with a snap, in place of the ‘satisfaction pain’ of haired being pulled out.
One might also attempt to establish a initiating cause using regression. Here one regresses the patient to a point in time when hair pulling as a problem was absent and move forward in time-stages until the problem is encountered – then it is a case of establishing and event or fundamental misconception which set up the errant behavioural pattern and reviewing it in the light of conscious attention. This particular OCD requires patience and may require 6 to 12 sessions for serious improvements to be experienced and consolidated.