Trichotillomania: Causes and Treatment
... and hair balls from eating it. Noticeable hair thinning and baldness is common as is scalp bleeding and irritation. Complications to the hands, elbows, and arms are due to the prolonged repetitive nature of the disorder. (Begotka, Woods, & Wetterneck 2004) One of the most destructive consequences of TTM is the prolonged experience of loss of control over one’s own actions. The sufferer feels like both the victim and the perpetrator. The ability to maintain a sense of integrity, control and meaning is lost and the inner struggle becomes a chronic trauma. Deep feelings of inadequacy, self doubt and unbearable shame become the only coherent way of seeing oneself (Grubb, 1996). Causes While thirteen years is the general age of onset, TTM has been known to occur in infants and toddlers, as well as middle-aged and older individuals. What sets it off seems to determine the onset of the disorder. For example in one case, a college aged women was brutally beaten and raped by three men who, among other things, cut off her hair with a knife. Subsequently she developed the disorder. In the case of a middle aged woman, her symptoms began right after the Northridge earthquake of which she and her family were victims. In the case of infants and toddlers, the streptococcal virus has been known to provoke hair pulling, as well as oral fixation. In yet another case, the onset of the disorder occurred subsequent to a traumatic episode in early childhood that included physical punishment involving the patient’s hair, and sexual exposure. This patient also had family members with mood disorders and schizophrenia. In addition, there was prolonged family chaos. The patient also developed comorbid disorders. The question then becomes, what predisposes certain people to this particular disorder? Very little research has been done on the subject of TTM and as a result, there is no clear cause for the disorder. (Kress, et al., 2004) However, there are some interesting hypotheses such as: biological causes; genetic predisposition; clinical depression; trauma during childhood and subsequent; fixation during the oral stage; and mere habit development. It is most likely that some combination of the above could result in TTM. Biological and Genetic Causes It is believed by certain clinicians that TTM has neurobiological roots. Studies have shown that there is a link between lack of serotonin in the brain and grooming behaviors (Kress, Kelly, McCormick, 2004). Tourette’s syndrome and trichotillomania have related dynamics in that both are repetitive behaviors that are dictated by internal and external cues Tourette’s syndrome is a genetic, neurological disorder involving the abnormal metabolism of transmitters in the brain. Both disorders involve lack of serotonin, and irresistible urges to perform tic behaviors. (Kress, et al., 2004). Genetically, there is reason to believe that nervous, grooming like behaviors, which seem to be done by most people to some degree, are permanently wired into the brain’s circuitry. Examples would be; picking at skin, nail biting, cuticle picking, and hair twirling and fondling. Grooming behaviors have been developed and preserved on an instinctual level in order to detect body and hair abnormalities as well as for self preservation (even animals groom themselves). Since TTM is associated with nervous grooming and negative self image, further genetic research may possibly reveal that a series of linked gene defects might be affecting a certain set of linked receptors in the brain. http://www.geocites.com/`modularforms/trich/definitions.html Since virtually all TTM sufferers have comorbid disorders, it is logical that heredity may play an important factor. It seems unlikely, that without a genetic and/or biological cause, TTM would not exist as a disorder. Clinical Depression Another theory is that TTM serves as a way of working out real or imagined threats of object loss. Some victims of TTM report that the behavior is often triggered by overwhelming emotional suffering or negative affective cues. The act of hair pulling eases tension and can serve to “reduce psychological numbness”. (Kress, et al., 2004) It seems to serve the purpose of regulating their emotional states. It may also function to avoid aversive, private experiences. In one study, results showed a significant correlation between the severity of TTM and experiential avoidance (escape from unwanted thoughts or emotions) (Begotka, et al. 2004). Oral Fixation While not a direct cause of TTM, oral fixation seems to set the stage for it. When babies are going through the oral stage, (identifying with objects through the sensations in their mouths) and they are prevented from doing so, their instinctual energy becomes trapped in that stage (Sue, Sue, & Sue, 2003). This most likely happens when babies have their hands slapped every time they attempt to grab something and put it in their mouths, or some other more severe form of trauma occurs. Another way it happens is when babies are prevented from enjoying their suckling instincts through thumb sucking or a pacifier. Consequently, when they become adults they will retain strong features of the oral stage. Passivity, helplessness, obesity, chronic smoking, and alcoholism are all characteristics of oral fixation. When the mouth becomes part of the focus for TTM sufferers, it is easy to conclude that oral fixation may be at the root of it. Trauma The likelihood that there is a link between psychological disorders and childhood trauma has been confirmed in studies on anxiety disorder patients. (Lochner, duToit, Zungu-Dirwayi, Marais, Kradenburg, Curr, Seedat, Niehuas, and Stein 2002) There is also a clear familial component linking disorders such as, panic disorder, agoraphobia, OCD, and social anxiety disorder to a history of childhood physical and sexual abuse. (Lochner, et al., 2002) Freud contended that obesessional neurosis was a manifestation of premature sexual experience. (Freud, 1909) Yet little empirical research has been done in this area. Another study conducted to examine the relationship between violence at any age and TTM, revealed that TTM patients experience a disproportional number of traumatic or violent events and family chaos. The number of violent experiences in this study exceeded numbers reported in the general population. (Boughn & Holdom, 2003) Habit A body of tests suggests that there are similarities to early onset hair pulling (18 months to 4 years old) and other benign habits such as thumb sucking, and attachment to an object. Some clinicians have argued that early onset of hair pulling is fundamentally different from TTM (Byrd, Richards, Hove, and Friman 2002). In studying early onset, it was discovered that the relative simplicity of treatment contrasted with the complexity of the clinical response to the same treatment. Another factor to consider is that many early onset conditions are subsequent reactions to having the streptococcal virus. In any event, treatment seems to be successful when hair pulling is merely habitual. Assessment In order to give accurate treatment, therapists are obligated to become educated about the assessment and diagnosis of TTM. They should consider all aspects of TTM together with the patient’s past and current life events as they pertain to the disorder. (Kress, et al., 2004) When a patient seeks treatment for TTM, a specific interview pertaining to the patient’s background should be given. After getting a history on the onset; the course of the behavior; the lifetime and frequency of hair pulling; changes ...