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I Pull My Hair out, Trichotillomania, and a Hypothetical Psychiatric Diagnosis

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Pulling out eyelashes is part of Trichotillomania

Pulling out eyelashes is part of Trichotillomania

Trichotillomania: Psychiatric Diagnosis

Explaining psychological concepts in a potential patient’s presentation of Trichotillomania using professional terminology, an identifying symptoms and behaviors exhibited by the potential patient:

Trichotillomania is a disorder where a person pulls their hair. It is considered a mental disorder that is part of the family of mental disease called obsessive compulsive disorder. The patient who is currently suffering from this disorder has been pulling her hair out from the scalp area, eyebrows, and eyelashes. The patient is aware of the behavior and is trying to cease the practice. The patient has a history of depression and anxiety that has been caused by her parents and also by significant life events, such as beginning college and having a relationship that started off promising but ended up failing. The hair pulling that the patient has suffered from has left areas that are considered patchy and bald, and this can cause stress for the patient's social life as well. The patient, if the situation continues, may start to go through considerable lengths to cover up the hair loss that s caused by the trichotillomania symptoms. The patient attempted to manage her symptoms by being aware, but the breakup of an intimate relationship reignited the symptoms again.

Because she is aware of the situation, she is seeking help. The patient in this scenario is going through a psychological issue that is associated with a mental health disorder. The patient experiences pulling of the hair when she is anxious. The patient feels relief when she pulls. The patient is experiencing stress in her personal and social life due to this issue, and feels personal tension when she considers pulling her hair.

Match the identified symptoms to potential disorders in a diagnostic manual.

The patient is exhibiting symptoms of the condition Trichotillomania. "Trichotillomania (TTM) is characterized as an impulse control disorder in which individuals fail to resist urges to pull out their own hair, and is associated with significant functional impairment and psychiatric comorbidity across the developmental spectrum.”(Franklin, 2011) This condition usually begins when the patient is a child or an adolescent. "The current diagnostic criteria for trichotillomania are: 1) recurrent pulling out of one’s hair, resulting in hair loss; 2) repeated attempts to decrease or stop hair pulling; 3) the hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; 4) the hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition); and 5) 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)." (Grant, 2016) The manual that considers the symptoms says that when one feels tense right before pulling their hair, it is part of the issue of trichotillomania. Also, if one feels relief when they perform the act of pulling on the hair, after feeling the tension of puling, it's part of trichotillomania. At this time, trichotillomania is considered a compulsive obsessive disorder according to the diagnostic manual known as DSM-5.

Proposing a diagnosis based on the patient’s symptoms and the criteria listed for the disorder(s) in the diagnostic manual:

The etiology of the pulling of the hair may be varied in every patient and case. It can be manifested from seizures. It could be manifested from anxiety. It could be part of a tic as a subset of another mental abnormality. The patient has experience recurrent hair pulling that is causing the patient stress that is significant in nature. The patient has made many attempts in the past to stop the behavior. The patient's behavior has brought shame to her, and through her family, which has exacerbated the situation. The patient's behavior started again after a failed personal relationship with someone she cared about. The patient is aware of the feelings of anxiety before pulling. The patient is aware of the pulling while it's happening, and is aware that the pulling of the hair is affecting and negatively impacting her life. It should be known that the patient's symptoms, as she describes it, point to trichotillomania, which is, as mentioned, a compulsive, and repetitive act, of pulling on the hair when the patient is feeling anxiety or tension in their personal life.

Analyzing and explaining how the patient meets criteria for the disorder(s) according to the patient’s symptoms and the criteria outlined in the diagnostic manual:

Trichotillomania is characterized as a disorder where hair-pulling occurs. This action results in hair loss for the patient. A patient often pullshair from their scalp or eyelashes. Also, their eyebrows, beard, and private regions may be affected by hair pulling. Patients who suffer from this condition often feel like they have to wear wigs or unique hair styles and cosmetics to hide their bald patches. (Rothbaum, 1994).

Justifying the use of the chosen diagnostic manual:

The DSM-5 mentions that trichotillomania should not be diagnosed when hair removal is performed for purposes of a cosmetic nature. The DSM-5 mentions that the disorder may be diversified, so it's not justified to determine that someone has this disorder just by comparing it to another that has a similar disorder. The DSM-5 mentions that trichotillomania means that one is pulling the hair as a repetitive behavior, and that they have attempted to stop pulling the hair. There is also tension and anxiety that happens before the hair pulling, or when one attempts to cease the behavior. It's not recognize as an obsessive compulsive disorder. The criteria includes recurrent hair pulling, visible hair loss, several attempts to stop the pulling, stress on the person's social life or family, hair pulling not caused by drug use or other medical condition. "The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) marks the first significant revision of the publication since the DSM-IV in 1994. Changes to the DSM were largely informed by advancements in neuroscience, clinical and public health need, and identified problems with the classification system and criteria put forth in the DSM-IV. Much of the decision-making was also driven by a desire to ensure better alignment with the International Classification of Diseases and its upcoming 11th edition (ICD-11). "(Reiger, 2013)

Summarizing general views of the diagnosis from multiple theoretical orientations and historical perspectives, and including a discussion on comorbidity if the diagnosis includes more than one disorder:

Patients, when suffering from trichotillomania, may have comorbid disorders. "Results revealed that 38.8% of individuals with HPD had another current psychiatric diagnosis and 78.8% had another lifetime (present and/or past) psychiatric diagnosis. Specifically, HPD showed substantial overlap with depressive, anxiety, addictive, and other body-focused repetitive behavior disorders."(Houghton, 2016)

Evaluating symptoms within the context of an appropriate theoretical orientation for this diagnosis:

"Patients who mentioned their theoretical orientation as "cognitive- behavioral" showed a pointedly superior preference for the proposed DSM-5 personality disorder prototypes when compared to patients who classified their orientation as "psychodynamic/psychoanalytic," while individuals who considered themselves psychodynamic or psychoanalytic rated the PDM as significantly more useful than those who considered themselves cognitive-behavioral." (Paggeot, 2017) "The strongest support exists for CBT of anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Eleven studies compared response rates between CBT and other treatments or control conditions. CBT showed higher response rates than the comparison conditions in 7 of these reviews and only one review reported that CBT had lower response rates than comparison treatments." (Hofmann, 2012)

Utilizing at least two peer-reviewed articles to assess the validity of this diagnosis, and describing who is most likely to have the diagnosis with regard to age, gender, socioeconomic status, sexual orientation, and ethnicity. This section will provide a brief evaluation of the scientific merit of these peer-reviewed sources in the validity assessment:

"The disorder is present in 0.6% of college students. The majority of sufferers who seek treatment are female, with usual age of onset between 11 and 16 years. “(Minichiello, 2008)

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Reference: Minichiello, W. (2008) Trichotillomania: clinical aspects and treatment strategies. Harv Rev Psychiatry. 1994 Mar-Apr; 1(6):336-44.

"Clinical studies suggest that the prevalence of TTM varies from 0.6% to 3% and is more common in female patients. Differential diagnoses include more common alopecia’s such as alopecia areata (AA). TTM may be associated with depression, bipolar disorder, and obsessive-compulsive disorder." (Pinto, 2017)

Reference: Pinto, A. C. V. D., de Andrade, T. C. P. C., de Brito, F. F., da Silva, G. V., Cavalcante, M. L. L. L., & Martelli, A. C. C. (2017). Trichotillomania: a case report with clinical and dermatoscopic differential diagnosis with alopecia areata . Anais Brasileiros de Dermatologic, 92(1), 118–120.

Summarize the risk factors (i.e., biological, psychological, and/or social) for the diagnosis. If one of the categories is not relevant, address this within the summary.

Usually trichotillomania begins in childhood or the early teen years, around ten to thirteen years old. If there is a family history of trichotillomania, it may affect offspring. It can develop if one is enveloped in stressful situations. The individual may be suffering from another mental disorder as well.

Comparing evidence-based and non-evidence-based treatment options for the diagnosis of Trichotillomania:

Regular treatment includes habit several training, cognitive therapy, and acceptance and commitment therapy. There are not medications specifically for this diagnosis, but sometimes a doctor may prescribe an antidepressant like Anafranil or N-acetylcysteine, or Zyprexa. A non-alternative therapy is meditation or the use of essential oils.

Evidence-based treatment:

One evidence-based treatment is habit reversal training. What is habit reversal training? Habit reversal training makes sure that the patient is aware of what's going on. The patient has to go through response training and contingency management. They have to learn techniques on relaxing, and it not only helps with trichotillomania, but it also helps with biting of the nails, sucking one's thumb, issues with a stutter, and disorders of the TMJ area. A study found that Habit Reversal therapy is extremely effective. Compared to control conditions, HRT showed a large effect size pre-treatment to final post-treatment assessment. Moderator analyses revealed significant treatment effects for HRT for most moderator levels, indicating that HRT is efficacious in some variations for a variety of types of maladaptive behaviors, across a wide range of sample characteristics. The findings provide substantial support for the efficacy of HRT for disorders it is commonly used to treat. (Bate, 2011)

Non Evidence-based treatment:

A non-evidence based treatment is mindfulness-based cognitive therapy. This treatment appeared to be quite effective. The goal of this treatment is to have the patient accept that the experience they are going through is uncomfortable. The problem is not the discomfort itself. The goal of those who suffer from trichotillomania is to gain the ability to be able to deal with their negative feelings but without the act of pulling out the hair. Mindfulness is a somewhat new trend where individuals face their thoughts and use forms of meditation to become present. When someone is mindful, they are more aware of their present moment in time and in a way that is not judgmental towards themselves. The therapy known as mindfulness based cognitive therapy marries the cognitive therapy concepts with practices that are considered more of the meditation realm. Once the patient is aware of their thoughts, they learn to have a different kind of relationship with these particularly thoughts that trigger their trichotillomania. The patient does homework to begin to train their brain to think differently and uses meditation, breathing exercises and yoga.

Evaluating well-established treatments for the diagnosis, and describing the likelihood of success or possible outcomes for each treatment:

"Efficacious treatments have been developed, in particular cognitive–behavioral interventions involving procedures collectively known as habit reversal training, yet relapse in adults appears to be common. Recent developments in pharmacotherapies for TTM and in combining cognitive–behavioral therapy approaches with medication hold promise, and efforts to examine their relative and combined efficacy are needed." (Franklin, 2011)

For reference, including an annotated bibliography of five peer-reviewed references published within the last ten years to inform the diagnosis and treatment recommendations, with a small evaluation of the scientific merit of each of these references.

1. Franklin, M. E., Zagrabbe, K., & Benavides, K. L. (2011). Trichotillomania and its treatment: a review and recommendations. Expert Review of Neurotherapeutics, 11(8), 1165–1174.

This article outlines the Trichotillomania Diagnostic interview that gives a three point clinician rating in regards to Trichotillomania a mental disorders. The focus is on Trichotillomania as an Obsessive Compulsive abnormality, and a semi-structured interview known as the Yale-Brown Obsessive Compulsive Scale, also known as the Y-BOCS. The severity of the manifestation of trichotillomania is photographed for comparison for after treatment, even though hair may not grow back immediately.

2. Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania. The American Journal of Psychiatry, 173(9), 868–874.

This article provides a case of a woman known as Mr. G. It goes into details as to how she pulled her eyebrows at age fourteen, but then shifted the attention to her head. She pulled during stress. The article mentions this disorder of Trichotillomania with being associated with psychosocial dysfunction, low self-esteem and social anxiety. The article mentions how Trichotillomania occurs with depression, anxiety, and substance use.

3. McGuire, J. F., Ung, D., Selles, R. R., Rahman, O., Lewin, A. B., Murphy, T. K., & Storch, E. A. (2014). Treating

Trichotillomania: A Meta-Analysis of Treatment Effects and Moderators for Behavior Therapy and Serotonin Reuptake Inhibitors. Journal of Psychiatric Research, 0, 76–83.

This article shares some of the history of the Diagnostic Criteria for Trichotillomania. It mentions Criterion A, B, C, D, and E and goes into some detail as to how Trichotillomania is diagnosed. The article also goes into detail about comorbidities and offers clinician samples within treatment studies. Interestingly, animals have been used to study this phenomenon. Neuroimaging was also discussed to find out with differences were found with patients who have a case of Trichotillomania. Behavioral assessments are also discussed.

4. Sharma, V. (2017). Pharmacotherapy of trichotillomania. Journal of Psychiatry & Neuroscience? JPN, 42(3), E5–E6.

This article mentioned a twenty seven year old woman that had a bipolar disorder. She mentioned pulling hair from her eyebrows since her child was born. She attempted to cease the behavior, but was unable to. The article mentions that trichotillomania used to be classified as an impulse disorder. The article discusses the lack of pharmacotherapy that is available for trichotillomania. It goes into detail as to the many different kinds of drugs, like stimulants and neuroleptics, have been studied. Lithium was used successfully for a patient, but presents many issues, and also helped treat the patient's bipolar disorder.

5. Woods, D. W., & Houghton, D. C. (2014). Diagnosis, Evaluation, and Management of Trichotillomania. The Psychiatric Clinics of North America, 37(3), 301–317.

This article stressed that trichotillomania has a lot do with the patient's environment. The article mentioned that some people pull while being aware and part of the process. Others who pull hair are not aware of what they are doing until they see a pile of hair or find a bald spot. This was called as either automatic, or focused. When a person is focused, sometimes they focus on the texture of the hair, or even ingest the hair by purposely biting the root. The article mentioned that the patient's neural circuitry was studied to find out if there are any differences within the brain's grey matter. A test called the Massachusetts General Hospital Hair pulling Scale was also discussed.


Bate, K. (2011) the efficacy of habit reversal therapy for tics, habit disorders, and stuttering: a meta-analytic review. Clin Psychol Rev. 2011 Jul;31(5):865-71. doi: 10.1016/j.cpr.2011.03.013. Epub 2011 Apr 5.

Franklin, M. E., Zagrabbe, K., & Benavides, K. L. (2011). Trichotillomania and its treatment: a review and recommendations. Expert Review of Neurotherapeutics, 11(8), 1165– 1174

Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania. The American Journal of Psychiatry, 173(9), 868–874.

Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36(5), 427–440.

Paggeot, A. (2017) the Impact of Theoretical Orientation and Training on Preference for Diagnostic Models of Personality Pathology. Psychopathology. 2017; 50(5):304-320. doi: 10.1159/000479284. Epub 2017 Oct 12.

Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013). The DSM-5: Classification and criteria changes. World Psychiatry, 12(2), 92–98.

Rothbaum, B. (1994) The assessment of trichotillomania. Department of Psychiatry, Emory University School of Medicine, 1365 Clifton Road, Atlanta, GA 30322, U.S.A.

Woods, D. W. (2016). Comorbidity and Quality of Life in Adults with Hair Pulling Disorder. Psychiatry Research, 239, 12–19.

© 2018 Charlotte Doyle


Liz Westwood from UK on September 27, 2018:

You give detailed analysis in this article.

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