Trichotillomania (Hair-Pulling Disorder) DSM-5 312. 39 (F63.2)

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DSM-5 Category: Obsessive-Compulsive and Related Disorders

Introduction

Trichotillomania (TTM) is classified as an obsessive-compulsive disorder under DSM-5. More commonly known as hair-pulling disorder, it involves an individual recurrently pulling hair from any part of his/her body – the head, eyelashes, eyebrows, beard, underarms, chest, legs, or other area. The scalp is the most common area. Similar to other OCDs, the person feels a compulsion to pull hair and feelings of satisfaction from the act. Pulling hair can be an avoidance or coping mechanism. The hair-pulling often creates bald patches, which can encourage social withdrawal in an attempt to hide the patches. Social and work life can be disrupted by the disorder.

TTM is sub-classified under body-focused repetitive behaviors (BFRBs). TTM is one of four disorders under body focused, impulse control disorders. Under DSM-5, BFRB becomes a specifier of absent/delusional beliefs. BFRB is a delusional disorder in which a person is convinced that they have abnormal defects or flaws.

Symptoms of Trichotillomania

Trichotillomania involves a person engaging in persistent fiddling with his/her hair, which results in the creation of bald spots. The trichotillomaniac will wear hats, wigs and other items to hide the bald spots. According to the DSM-5, the condition can develop in childhood or adulthood but onset is usually around 9 to 13 years of age. Many people who have TTM experience a high level of anxiety and/or depression, although happy people also engage in hair-pulling activity.

DSM-5 criteria include (APA, 2013):

  • Recurrent pulling out of one's hair, resulting in hair loss.
  • Repeated attempts to decrease or stop hair pulling.
  • The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
  • The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).

The hair pulling usually takes place in private and the trichotillomaniac will make attempts to cover it up. The hair-puller may be only partly aware of his/her behavior, and pull hair while watching TV or talking on the phone. The person may also pull hair from animals and dolls. Related obsessive disorders of a body-focused nature are common, such as nail biting or picking skin.

Trichotillomania in Daily Life

TTM can create social stigma. The person may avoid social situations due to his/her appearance. Shame and embarrassment may lead to low self-esteem. Hair may be cut short and restyled. Hat, wigs and other items are used to hide the hair loss. The condition is often hidden not only from family and friends but also from doctors. Health and safety issues include infection and permanent hair loss. Those who eat the hair can become ill or experience intestinal problems.

A person with TTM experiences a cycle of distress and then relief. As noted above, the DSM-5 criteria requires that repeated attempts be made to stop the behavior, indicating an awareness of the self-harm. A feeling of tension builds up before the act, followed by satisfaction, and then shame and distress. To relieve the negative feelings, the hair-pulling cycle begins again. Therapy can help identify the emotions behind the impulsive actions and distress (Keuthen & Sprich, 2012).

The act of hair pulling typically involves pulling the hair out strand-by-strand. The trichotillomaniac may often twirl his/her hair in public but begin pulling in private. TTM can lead to trichophagia, which is the eating of hair. This act may be part of the effort to hide any evidence of the TTM behavior. As the physical symptoms worsen, the person will avoid social situations. Job performance and relationships may suffer.

Trichotillomania Therapy

Treatment choices depend on the stage of life. TTM in childhood often self-resolves and no treatment needs to be pursued. In adults, the condition is often long term and treatment should be sought. Treatment options for TTM include psychotherapy to address habits, behavior therapy, cognitive behavioral therapy, medication, and alternative therapy. Medication may be used to treat the symptoms of TTM, including anxiety and depression. Multicomponent treatments have shown promise in the treatment of this disorder, whose causes have not been fully explained.

Behavioral therapy (BT) and cognitive behavioral therapy (CBT) are becoming popular approaches for treating TTM. In studies, they are being compared with alternative approaches. BT has been found to be more effective than minimal attention control (MAC), and the positive effects were maintained. CBT on its own has not always been effective in the treatment of TTM. Dialectical behavior therapy (DBT)-enhanced cognitive behavioral treatment produced positive outcomes across all measures – TTM severity, emotion regulation, anxiety and depression and experiential avoidance (Keuthen et al., 2012). DBT combines CBT with emotion regulation and mindful meditation practices derived from Buddhist meditation.

Acceptance and Commitment therapy (ACT) has produced positive results. ACT is a form of psychotherapy combining acceptance, mindfulness and behavioral change strategies. One study employing Acceptance Enhanced Behavior Therapy (AEBT) in adolescents resulted in participants stopping hair-pulling behavior for a 2-week period (Fine et al., 2011). The distress level was also reduced. While some do not consider TTM to be a habit, a habit-based therapy has produced positive effects. A study combining ACT with habit reversal training (HRT) produced an 88.7% reduction in hair pulling was produced (Crosby, Dehli, Mitchell, & Twohig, 2012).

Group therapy is also considered to be helpful by those with TTM. Complete abstinence from hair pulling is a strong predictor of long-term abstinence from the disorder (Falknstein, 2014).


References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Crosby, J. M., Dehlin, J. P., Mitchell, P. R., & Twohig, M. P. (2012). Acceptance and commitment therapy and habit reversal training for the treatment of trichotillomania. Cognitive and Behavioral Practice, 19(4), 595-605.

Falkenstein, M. J. (2014). Predictors of Relapse Following Treatment of Trichotillomania.

Fine, K. M., Walther, M. R., Joseph, J. M., Robinson, J., Ricketts, E. J., Bowe, W. E., & Woods, D. W. (2012). Acceptance-enhanced behavior therapy for trichotillomania in adolescents. Cognitive and Behavioral Practice, 19(3), 463-471.

Keuthen, N. J., & Sprich, S. E. (2012). Utilizing DBT skills to augment traditional CBT for trichotillomania: An adult case study. Cognitive and Behavioral Practice, 19(2), 372-380.


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