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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Minding Your Mind Minding Your Mind

Hair-Pulling Disorder -- Is It Taken Too Lightly?

July 10, 2012

By Michael Craig Miller M.D.

Harvard Medical School

Hair pulling carries a tongue-twisting name: trichotillomania. The disorder is not widely recognized by the public or by mental health professionals. People with hair-pulling disorder suffer in silence. They tend to avoid getting help because they feel ashamed. Many have had the problem since childhood or adolescence.

What is Hair-Pulling Disorder (Trichotillomania)?

Trichotillomania has been considered an impulse control disorder, but in the next edition of psychiatry's diagnostic manual, it is likely to be re-classified with obsessive-compulsive disorders. Under this new organization, the name should also be simplified to hair-pulling disorder.

People pull hair from their scalp, eyebrows, eyelashes or pubic area, which can leave noticeable bald spots. As with other compulsions, trichotillomania sufferers feel mount-ing tension beforehand. Then they may feel a sense of relief from uncomfortable feelings or even pleasure when pulling their hair.

Hair-pulling disorder ranges in severity from very mild to incapacitating and affects up to 3 in every 100 people. A more conservative estimate is that 1.2% (approximately 3.7 million Americans) have the symptoms to a significant degree. There is evidence that the disorder can be inherited. The genetics of the disorder are not well known, however.

At the most severe end of the spectrum, a person pulls hair most or all of the time. The disorder often begins in childhood and women seem twice as likely as men to have the disorder. But the sex-related imbalance may be overestimated because men could be half as likely as women to get treatment.

The symptoms of hair-pulling disorder may come and go. There can be long periods where the disorder is quiet, only to return when a person is under stress.

Some people with hair-pulling disorder report hard-to-describe sensations just from the area they are pulling from, while others say the sensation is more like an overall feeling of physical or mental anxiety. A significant number of people with hair-pulling disorder pull all of the hair from the area they have targeted, causing total hair loss.

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Hair-pulling can be terrible to live with. Since it affects appearance, hair-pullers often feel very embarrassed. Some avoid close relationships, refuse to take vacations or go out in public. The illness can interfere with school and work performance. People with hair-pulling disorder tend to have low self-esteem and feel less satisfied with their lives. Many become anxious or depressed, or they turn to cigarettes, alcohol or drugs for relief. All of these problems can be eased by treatment, but all too often people who pull their hair suffer alone.

To compound the shame problem, many health practitioners have limited awareness of the problem, which can make it harder to get help.

Besides the obvious hair loss and skin or scalp irritation, people with hair-pulling disorder can experience other physical problems:

  • Carpal tunnel syndrome from repetitive hand and wrist motions
  • Dental problems resulting from eating pulled hair
  • A build-up of swallowed hair called a trichobezoar, which causes pain, nausea, vomiting, or — if it grows large enough — a dangerous obstruction requiring surgery; death, though very rare, can occur

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What Causes Hair-Pulling Disorder?

Researchers don't know what causes hair-pulling disorder, but many think it's related to obsessive compulsive disorder (OCD). Neuroscientists have suggested that people with hair-pulling disorder have trouble putting the brakes on motor behavior. They also may have more trouble than average shifting from one task to another — a capacity of the brain called "cognitive flexibility." These observations suggest that there's a problem in the connection between the frontal lobe — the part of the brain involved in planning and reasoning — and the striatum, which is involved in regulating action. Abnormalities in the cerebellum may also be involved. This part of the brain, which sits behind the brainstem, helps regulate movement.

These findings are preliminary, but lend hope that we can better understand the biology of this behavior and develop effective treatments.

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Does Treatment Work?

According to research, a form of cognitive behavior therapy called habit reversal training (HRT) is the most effective treatment available for hair-pulling disorder. An HRT therapist trains the individual to pay close attention to the symptom, noting sit-uations when hair-pulling is most likely to occur. The person then tries to replace the habit with a competing motion that makes the hair-pulling impossible, such as clenching the fist and pressing it against the side of the body. HRT can be supplemented by relaxation techniques, support and encouragement. Unfortunately, symptoms often come back after treatment ends.

Most psychiatrists treat hair-pulling disorder with medications for OCD. They often start with selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft), or with the older tricyclic antidepressant, clomipramine. If one drug alone is not helpful, then the psychiatrist will usually try a combination of drugs, such as an SSRI plus clomipramine or an SSRI with an antianxiety drug, a mood stabilizer, an antipsychotic or even a stimulant.

Right now there is no evidence that one medication is better than another, or that any medication is better than a placebo (dummy pill). One recent article showed that a combination of psychotherapy and medication provided the most relief.

Psychiatrists may be pulling whatever they can out of their medicine bag to treat hair-pulling disorder. But when the disorder is severe, the suffering can be so great and the barriers to living a productive or satisfying life so significant that, even as neuroscientists work to learn more about the causes of the disorder, doctors and patients need to keep trying things that offer the possibility of relief, keeping in mind the risks or side effects.

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Living With the Disorder

It is important not to underestimate the suffering this disorder causes.

Even if the hair-pulling itself is not significantly improved with treatment, the anxiety and depression that go along with it can be effectively treated. Psychotherapy can lend support and help a person cope with shame. And in the age of the Internet, support groups, such as Trichotillomania Learning Center and other resources are easier to find.

Despite the limits of our knowledge about the causes and the treatment of hair-pulling disorder, there does seem to be growing awareness of the problem, which brings hope that better treatments are on the way. In the meantime, getting past the shame and living a full life with the disorder may be the best treatment of all.

Michael Craig Miller, M.D. is Editor in Chief of the Harvard Mental Health Letter. He is also associate physician at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School. He has been practicing psychiatry for more than 25 years and teaches in the Harvard Longwood Psychiatry Residency Program.

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