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Trichotillomania (TTM) – Compulsive Hair Pulling

INTRODUCTION

Trichotillomania (TTM), a condition of chronic hair pulling resulting in alopecia was first recognised by the Greek physician Hippocrates, the father of modern medicine. However, it was the French dermatologist Franςois Henri Hallopeau, who in 1889 first described the characteristics of this disorder.

TTM is derived from the Greek words Trich (hair), tillo (to pull) and mania (an abnormal love for an object, place or action). Today, TTM is classified as an Impulse Control Disorder affecting up to 3% of the population; sub - clinical forms may affect one in ten. There is, however, uncertainty over these figures, as most remain secretive to their condition. Tragically, for most, TTM is chronic and spontaneous remission rare; most feel guilty, ashamed and believe they alone suffer TTM. The condition has until recently been almost entirely ignored by the medical profession.

TTM may have its onset at any age; middle childhood or early adolescence is however the norm. Males have an earlier age of onset (9.8 + 6.6) than females (12.5 + 5.8) years. When TTM occurs before the age of five, known as baby tricks, spontaneous recovery can occur. In early onset TTM, the condition is more common in males however at puberty there is a ten - fold increase in the prevalence of TTM in females.

THE BEHAVIOUR

The defining features of trichotillomania are:

  • The recurrent pulling of one’s hair from any part of the body that results in noticeable hair loss.
  • Prior to pulling, an increasing sense of tension occurs that is difficult to resist.
  • A sense of pleasure, relief or gratification occurs following the pulling.

Hair pulling is initially restricted to one site; multiple sites subsequently become the norm. Studies show that 38% pull from one site, 62% from two sites and 33% from three or more sites. The most common site is the scalp followed by eyelashes, eyebrows, pubic area, with the least common site being the beard, face, arms and legs. Many select specific hairs to pluck based on hair length, colour or texture; most pluck in secrecy and, some, for hours.

Two patterns of hair plucking have been identified – binge plucking and plucking while undertaking sedentary activities. Those who binge pluck, extract large amounts of hair in a brief period, the plucking driven by the individuals emotional state at the time. They are aware of their plucking but are unable to stop. In contrast, those who pluck while undertaking sedentary activities are unaware of their plucking and pluck less.

Following extraction, which is not painful, the hair may be examined, discarded immediately, hidden or collected. Oral behaviours are acknowledged by 48 - 68%, the plucked hair being touched on the lips, sucked, swirled around the mouth, swallowed or chewed and then swallowed. If the hair is ingested, trichobezoar’s (intestinal hair balls) or trichophytobezoar’s (combination of hair and vegetable matter) may form. Rapunzel syndrome may also occur in which a twisted mass of hair may stretch from the stomach to the colon. Other common physical complications of hair plucking include trauma to the skin and local infection. Re - growth of the hair is often stunted, slow and of a different texture and colour. Chronic plucking may lead to permanent alopecia.

TRICHOTILLOMANIA DOES NOT OCCUR ALONE

Up to 50/% with TTM, suffer a mood disorder – major depression or dysthymia, 30% suffer specific phobia and generalised anxiety disorder (GAD). Twenty percent suffer obsessive - compulsive disorder (OCD) and up to 20% body dysmorphic disorder (BDD). Habitual behaviours are reported by 85%, these include onychophagia (nail biting), tongue chewing, head banging, cheek chewing and skin picking.

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