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Trichotillomania
A look at the causes and the psychology behind Trichotillomania,
a condition characterized by incessant pulling or plucking of one's
own hair.
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If you or a loved one is suffering from Trichotillomania, it is
important that you educate yourself on the condition. We have all the
important information here.
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Trichotillomania
The name of a psychological condition which results in an
obsession with plucking or pulling on one's own body or scalp
hair. There are several problems that can result from this
activity, and the psychology behind it can be confusing. Commonly
treatable in children, adults with this condition rarely recover. |
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What exactly
is Trichotillomania?
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Trichotillomania is now recognized as being neither so rare nor
so benign as previously believed. Patients with Trichotillomania seen
in dermatological clinics appear normal in their daily behavior, at least
as viewed by laypersons, except for the habit causing the Alopecia. Young
patients and their parents regard the Alopecia. as a dermatological condition.
In fact, these patients are largely treated by dermatologists, specialists
who have sufficient training and knowledge to make the correct diagnosis.
The prognosis of Trichotillomania is guarded or fairly good. In a smaller
group of adult-aged patients with years of Trichotillomania, the Alopecia.
is usually extensive and hard to treat in spite of psychiatric intervention.
This condition occurs as a result of a person's compulsive hair-pulling/plucking
behavior. According to Mehregan (1970), 100 practicing dermatologists
evaluated 2-3 cases per year. According to Muller (1990), the condition
was far from rare, although not common, both in children and adults. According
to a report in 1978, it was estimated that up to 8 million Americans might
be affected. Considering its benign self-limited course
in most patients, the real incidence in the general population should
be much higher than the numbers seen by physicians. In South Korea, practicing
dermatologists see approximately 1 case per year.
In children, males most commonly display this activity. In adolescence,
it is more common in females. In adulthood, most patients are females.
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The Psychology
of Trichotillomania
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The patient often appears to be indifferent or to have poor insight
as to the cause of the illness. During interviews, the patient's responses
are ambiguous and could baffle an inexperienced physician. It is worthwhile
to remember that hair manipulations frequently occur while patients are
engaged in sedentary activities, such as reading, writing, or watching
television. For some reason, many patients claim that their hairs do not
grow longer than 1.5cm, and frequently comment of itching scalp skin.
The compulsive behavior causing and perpetuating the Alopecia. has not
been fully explained yet, but it may be included in a category of impulse
control disorders. To continue the repetitive behavior of hair manipulation,
a certain mental state characterized by tension with gratification or
relief from the hair pulling may be needed. However, it is not sufficient
to call the hair pulling a purely compulsive reaction. The initial impulse
can be caused by varied cues in the patient's mind (internal) and environment
(external).
The internal cues include various emotions, such as anger, frustration,
and loneliness. The external cues might include an environment where the
patient is prone to manipulate the hairs without being interrupted. Although
no universal cause of these cues is known, an unsatisfying family relationship
or loss of maternal love, especially in children, most often is found.
Also, it may be possible that once the behavior is established, it becomes
habitual, regardless of the initial causative emotional problem.
The kinds of manipulations to which hairs can be subjected include rubbing,
twisting, breaking, pulling (not forcible plucking), and plucking. Although
the name Trichotillomania suggests the act of plucking (tillein is Greek
for "to pluck, pull out"), actual plucking seems to be a minor
component of the total hair manipulations. If the force of pulling (versus
plucking) induces premature entry of the follicles into the catagen phase,
this would subsequently lead to increased hair shedding.
Likewise, breaking of hairs may not be accomplished by only a single manipulation
of the hair shaft. Repeated trauma of the hair would make the already
manipulated hair more vulnerable to the subsequent injury, resulting in
hair that is more easily broken. For all these reasons, patients may believe
the Alopecia. is due to a disease of the hair itself.
These behaviors can occur deliberately, semiconsciously, or often unconsciously.
Therefore, a patient's ambiguous answers to the physician's questions
are not surprising, and they do not represent intentional malingering.
To understand Trichotillomania, understanding both the biology of hair
and the patient's psychological state are needed.
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Diagnosing
Trichotillomania
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Clinical diagnosis with inspection of the lesion and history
is sufficient in many cases. A trichogram can be helpful. Quite often,
biopsy is needed to differentiate Trichotillomania from Alopecia. areata.
Multiple sections, either vertically or transversely oriented, are recommended
to observe characteristic findings. In general, the biopsy should be
taken from a new lesion. The most frequent findings are empty anagen
follicles (especially in transverse sections), increased numbers of
noninflamed catagen follicles, and pigment casts in hair canals. Distorted
or torn away follicles are found infrequently.
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Treating Trichotillomania
For patients seen in
dermatology clinics, good results can be obtained by confronting
both the patient and the parents with the diagnosis. Supportive
care by the dermatologist may be sufficient.
Shaving or clipping hairs close to the scalp may be helpful
to stop the behavior and to assure the parents of the nature
of the Alopecia. Shaving a circumscribed area on a weekly
basis (the "hair growth window") can have the same
diagnostic and reassuring benefits. It should be remembered
that the shaved (clipped) hairs are not all in the actively
growing anagen stage, and several weeks may be required before
total regrowth is noted.
In adult groups, the treatment is difficult and disappointing
and is performed best in psychiatric clinics.
It is unclear how well antidepressants and tranquilizers work
for Trichotillomania Well-documented reports in the psychiatric
literature show that clomipramine causes short-term improvement
in adult patients who are severely affected with Trichotillomania
and whose disease interferes with their daily life. |
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In very young children, the prognosis is excellent. In late childhood
and adolescence, the prognosis is usually good but is more guarded than
in young children. The Alopecia. quite often recurs after a variable
time. In adult patients, the prognosis is poor, and permanent recovery
is uncommon.
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Trichotillomania
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