Trichotillomania: symptoms and treatment

Trichotillomania is a condition characterised by the recurrent urge to pluck hair or hair. Plucking eyelashes or eyebrows is also part of this disorder

As well as repeated attempts to diminish or stop plucking and significant work, social and interpersonal discomfort or malfunctioning due to the symptom.

Characteristics of trichotillomania

The phenomenology of the disorder appears very simple (the plucking of hair, eyelashes or hair), but recent research has revealed a behavioural and symptomatological heterogeneity.

The tearing behaviour, for instance, can be performed with fingers, tweezers or other cosmetic techniques.

Thus tearing one or two hairs, eyelashes or hairs at a time.

The areas most frequently torn are the scalp, eyebrows, eyelashes and pubis.

The tearing is often anticipated by ritualistic behaviour such as combing the hair, feeling the individual hair between the fingers, pulling it and visually investigating the area. The hair or hairs are not torn at random, but are often chosen on the basis of tactile or visual characteristic.

Post-tear behaviour is also clinically relevant.

Whilst some simply throw the torn hair away, others pinch it between their fingers, inspect it, bite the hair or go so far as to ingest it (a behaviour known as trichophagy).

Environmental and emotional context of trichotillomania

Also under investigation is the environmental and emotional context within which the tearing behaviour occurs.

Environmental context

The situational variables that can fuel the impulse are usually sedentary situations, such as watching TV, reading a book or getting ready in front of the mirror.

The act of plucking one’s hair, eyebrows, etc., may also occur during contemplative activities.

Finally, there may be times of the day when the risk of pulling one’s hair is greater, for example in the evening, during the night, when one is alone, tired or before falling asleep.

Emotional context

The emotional context that can induce tearfulness behaviour is characterised by disturbing emotions such as anxiety/tension, boredom, anger and sadness. It is usually associated with a feeling of increasing tension in the person.

Tearing may bring a momentary sense of relief from tension: some individuals report tingling or itching at the scalp that is relieved only as a result of the tearing behaviour.

Finally, people with trichotillomania repeatedly try to reduce or avoid plucking their eyebrows, hair or hair because of the considerable discomfort associated with such behaviour.

Styles of trichotillomania

Recent studies have also distinguished various styles of trichotillomania, which may correspond to different triggering factors.

Two styles of tearing have been identified, automatic and conscious.

Automatic tearing

Automatic tearing is performed unconsciously, often during sedentary moments.

It does not become conscious until one notices the consequences (e.g. a balled-up pile of hair).

Conscious tearing

In contrast, conscious tearing seems to be a process with various purposes, such as the pleasure derived from tearing.

It can serve to reduce negative emotions, to remove hair that seems out of place or has certain characteristics.

Some research shows us that conscious tearing may be an attempt to regulate negative emotions or thoughts.

Due to the great heterogeneity of this symptomatological condition, great care should be taken when making a diagnosis.

Trichotillomania and differential diagnosis

Obsessive-Compulsive Disorder

The repetitive features of the behaviour and the position within the DSM-5 may lead to confusing this condition with Obsessive-Compulsive Disorder.

However, they are phenomenologically very different from each other, primarily because of the pleasure derived from the ripping behaviour.

This is in fact absent in compulsive rituals.

Also due to the absence of both intrusive thoughts and the multiplicity of ritualistic behaviour, also very different from each other, that we can find in Obsessive-Compulsive Disorder.

Dysmorphic Disorder (Dysmorphophobia)

Another characteristic to be taken into account is the presence of shame and dissatisfaction with one’s appearance.

This could lead to Dysmorphia Disorder, which, however, leads one to focus one’s attention and possible tear only on correcting an alleged aesthetic defect.

Borderline personality disorder

Finally, some suggest similarities with those disorders involving emotional regulation and self-injurious behaviour.

In Borderline Disorder, for example, tearful or self-injurious behaviours may regulate the emotional state.

However, they are explicitly aimed at experiencing pain, whereas in trichotillomania this intentionality is not present.

However, it is known that patients with trichotillomania often report a reduction in anxiety, tension and boredom after episodes of tearfulness.

The role of psychological inflexibility in trichotillomania

A psychological factor that may mediate the relationship between tearing and emotions has been found in the concept of psychological inflexibility.

This has been conceptualised in ACT (Acceptance and Commitment Therapy), which identifies a set of generalised, maladaptive strategies to regulate disturbing emotions and unwanted thoughts.

Various studies show that psychological inflexibility plays a role in controlling maladaptive behaviour triggered by negative emotions and cognitions.

The attempt to control disturbing internal experiences facilitates tearful behaviour.

Cognitive behavioural therapy of trichotillomania

This conceptualisation of the disorder can strengthen the therapeutic strategies available to cognitive behavioural therapy.

Empirical evidence has already demonstrated the good efficacy of certain techniques, such as Habit Reversal Training and stimulus control interventions.

These have been successfully used for the management of repetitive behaviour, together with cognitive techniques for identifying dysfunctional thoughts.

The interventions have shown very good effectiveness in managing the tearing behaviour and in learning alternative and more adaptive behaviours.

They promote awareness of the automatic thoughts that may precede the tearfulness in order to cope adequately with the situation.

Dialectical Behaviour Therapy (DBT) and Acceptance and Commitment Therapy (ACT)

A certain percentage of patients, despite having learned good behavioural management strategies, remain partially disturbed by the emotional experiences that trigger the problem behaviour.

In these cases, Dialectical Behaviour Therapy (DBT) and Acceptance and Commitment Therapy (ACT) come to our aid and have shown excellent effectiveness in learning new emotional management strategies.

Dialectical Behavior Therapy (DBT)

DBT facilitates awareness of emotions such as anger, boredom and frustration.

It addresses maladaptive emotional regulation strategies that reinforce and maintain tearful behaviour.

It helps to replace them with new, more adaptive regulation skills.

Mindfulness exercises train emotional and cognitive awareness and reduce the level of reactivity to disturbing emotions.

Acceptance Commitment Therapy (ACT)

ACT assumes that coping behaviour originates from ‘experiential avoidance’, i.e. the unwillingness to experience certain emotional states.

By means of experiential exercises and learning mindfulness skills, ACT emphasises the concept that the problem does not lie in the impulse to tear itself, but in the reaction to the impulse and the struggle the person engages in with his or her own disturbing emotional experiences.

Also within the cognitive-behavioural therapeutic approaches, ACT techniques, together with DBT techniques, can broaden the therapeutic scope.

They help patients to develop a different view of their internal experiences.

This reduces the need to avoid them, flexibilising the system and directing it towards acceptance, mindfulness skills and committed action towards functional areas of life.

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