Trichotillomania (TTM) – Compulsive Hair Pulling
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 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.
sense of pleasure, relief or gratification occurs following the
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.
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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