Trichotillomania

 

The Greek words thrix (hair) and tillein (to pull) name an impulse disorder in
which people feel mounting tension that can be relieved only by pulling out
their hair. Many people with trichotillomania (TTM) also bite nails, suck their
thumb, chew their tongue, pick scabs, cut themselves, or bang their head.
People with TTM can have obsessive-compulsive disorder or have relatives
with OCD. Both conditions may be related to problems with the
neurotransmitter serotonin. Although stress can aggravate or cause the
first onset of hair pulling, TTM is most likely a biochemical, inherited
disorder.

The following questionnaire supplies information needed prior to starting
treatment for this problem.

HAIR PULLING QUESTIONNAIRE

     1.        Why is hair pulling a problem for you:

• How much time do you spend pulling hair per day?

• What changes have you had to make in your hairstyles because of
  hair pulling?

• What do you avoid because of hair pulling? Does it cause you to be
  dishonest?

• How does it affect your relationships with family, friends, and
  coworkers? How do others react to your hair pulling?

     2.        What “risky” activities are likely to lead to hair pulling:
                  

• Watching TV                        

• Reading                        

• Studying                        

• Talking on the phone

• Class Work                        

• Falling asleep                        

• Driving                        

• Other:

     3.        What behaviors or feelings come just before you start to pull
                your hair:
            

• Touching your face                        

• Looking in the mirror

• Propping your head on your hand                        

• Touching/stroking hair

• Other behavior or feelings:    

     4.        What behaviors would make hair pulling more difficult or
                impossible:

• Doing a craft or playing with clay, Koosh balls, Velcro, or velvet, etc.
  during risky times.

• During class, holding a pen in one hand and a notebook in the other.

• Reading a book until falling asleep.

• Wearing gauze gloves, acrylic nails, or putting gel on affected areas.

• Making tight fists or snapping a rubber band on your wrist until the
  urge to pull has passed.

• Brushing hair when scalp tingles.

• Other:

     5.        What rewards can you give yourself for days or hours when
                you resist urges to pull?
            

• Going out to dinner or the movies                        

• Taking a bubble bath

• Buying myself a gift                        

• Eating a mint

• Adding to my collection of stones, CDs                        

• Other:

TREATMENT PROGRAM

Behavior therapy can be very effective in eliminating hair pulling.
Antidepressant medications that increase serotonin levels may first be
needed if depression, panic disorder, or OCD accompanies TTM. This
helps people gain the motivation and focus needed for behavior treatment.
Beware of tranquilizers and sedatives that can prevent practicing or
learning the following urge-reducing strategies:
    
     1.        Awareness training:

• Record incidents of hair pulling on a chart prior to starting and
  throughout treatment to increase awareness of behavior and
  progress being made.

• Observe hair plucking in a mirror or on videotape to monitor
  movements involved. Describe out loud exactly what you are doing.

• Practice positive grooming after any incidents of pulling: brushing
  hair, repairing eye makeup, or scalp massage.

     2.        Relaxation training. Practice each of the following and decide
                which is most useful:

• Take three calming breaths by breathing in through your nose to the
  count of three and exhaling through your mouth to the count of six.

• Imagine a safe place (the beach, woods) or enjoyable activity
  (swimming, dancing) during your calming breaths. Notice what you
  would see, hear, smell, and feel in each situation to switch from
  thinking to observing.

• Focus on a spot and observe signs of relaxation: becoming still, jaw
  and shoulders dropping, eyes blinking, muscles relaxing, and heavy
  eyelids.

• Repeat a comforting word or phrase during calming breaths,
  imagery, or staring to block thinking that interferes with the (peaceful)
  state of observation.

• Roll your eyes from the floor to the ceiling by holding your head still
  and looking down until your lids are almost shut. Slowly roll your eyes
  up toward your eyebrows. When it is too tiring to look up anymore,
  allow your lids to flutter closed. Take calming breaths, imagine a safe
  place, or repeat a comforting word.

     3.        Competing response (imagery) training: Choose a behavior
                from #4 on the Hair Pulling Questionnaire to substitute for hair
                pulling. Imagine being in a situation in which hair pulling occurs
                and see yourself practicing a competing behavior.

     4.        Exposure training to high-risk situations: Practice substituting a
                competing response (#4 on questionnaire) through imagery
                and then expose yourself to the actual situation. Give yourself
                a reward if you are able to resist any urges to pull. Continue to
                practice deliberate exposure in various situations until urges to
                pull are absent or reduced. Use relapses to clarify high-risk
                situations and practice exposure.

HELPING CHILDREN

When hair pulling starts before the age of 4, it is often outgrown. Parents
need only use simple interventions such as rewards for not pulling and
distractions (competing responses) described above and on the
questionnaire. TTM that starts at 13 or older may need intense intervention
as described above. When young children are still pulling hair by age 6,
they may have the later-onset type of TTM that requires behavior treatment.

RESOURCES

• TTM Learning Center, 1215 Mission St., Suite 2, Santa Cruz, CA
  95060, trichster@aol.com.

• Pioneer Clinic, 2550 University Ave., St. Paul, MN 55114.

Reference

Ideas for the questionnaire and the treatment program are adapted from
Trichotillomania: A Behavioral Approach Video and Manual by Carol Novak
(Pioneer Clinic, 1995) and Trichotillomania: A Guide by Anders and
Jefferson (Dean Foundation, 1994).