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I Pull My Hair Out: Trichotillomania Symptoms and Socio-Cultural Perspectives

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Hair Pulling - Trichotillomania

Hair Pulling - Trichotillomania

Making a Differential Diagnosis

What is a differential diagnosis? A healthcare professional uses a process called differential diagnosis to find out what may be ailing the patient. They review the patient's history, the patient's symptoms, and any results that occurred from a physical exam that was administered to the patient. The differential diagnosis ends up being a list of conditions or disease states that the patient could be suffering from. To obtain a differential diagnosis, it's important to ask the patient what their symptoms are, and how long the symptoms have been going on. We need to find out if the symptoms have a trigger, and if there's anything that the patient has done that has either improved or worsened the condition.

Recommending a diagnosis based on the patient’s symptoms, presenting problems, and history:

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.

Assessing the validity of the diagnosis using a sociocultural perspective:

Most people are familiar with obsessive-compulsive disorders, but they are not familiar with trichotillomania. There was a study done to find out how Obsessive Compulsive Disorder and Trichotillomania are related. These findings support previous work demonstrating significant differences between OCD and TTM. The classification of TTM as an impulse control disorder is also problematic, and TTM may have more in common with conditions characterized by stereotypical self-injurious symptoms, such as skin-picking. Differences between OCD and TTM may reflect differences in underlying psychobiology and may necessitate contrasting treatment approaches. (Lochner, 2008) It appeared that patients with obsessive-compulsive disorder seemed to have more disability that lasted for their lifetime, but they patients with trichotillomania felt that they did not respond to treatment as much. Patients with obsessive-compulsive disorder seemed to have higher comorbidity, they were also more susceptible to harm avoidance but did not seek novelty as much. (Leombrune, 2016) What is harm avoidance? Harm avoidance is when a person worries excessively. They are mostly very shy and experience a lot of fear and doubt. They may also become fatigued much more easily than normal. It has been discovered that patients with harm avoidance have less grey matter in their brain, especially in the occipital regions. Temperament is considered the more heritable personality component that is stable throughout life and is responsible for adaptive emotional responses and behavioral reactions to life experiences. It is assessed through four dimensions: Harm avoidance (HA), Novelty seeking (NS), Reward dependence (RD), and Persistence (P). (Leombroni, 2016)

Comparing at least one evidence-based and one non-evidence-based treatment option for the diagnosis:

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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)

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.

Historical perspectives and theoretical orientations that are inappropriate alternates for the conceptualizations in this case:

Individuals have been pulling their hair t for several centuries. At some point, hair pulling was considered an act that was encouraged among the ancient Egyptians. The term for trichotillomania is when a person pulls their hair as part of an aberrant act. It's when a person feels a strong urge to pull their hair out due to some anxiety or stress trigger. It is considered a new disease that is not fully understood. At this time, about one to two percent of the general population have the condition trichotillomania. People who are affected try to avoid group activities due to their appearance, as sometimes they have bald spots or areas without hair. It can lead a person to have a lower quality of life, and it is correlated with anxiety. One of the behavioral treatments for trichotillomania is to offer group treatment, but this may be considered an inappropriate alternative. While group therapy may be beneficial to some, the thought of joining a social group to talk about what is considered an embarrassing habit may cause an individual to feel more ashamed.


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.

Leombruni, P., Zizzi, F., Miniotti, M., Colonna, F., Castelli, L., Fusaro, E., & Torta, R. (2016). Harm Avoidance and Self-Directedness Characterize Fibromyalgic Patients and the Symptom Severity. Frontiers in Psychology, 7, 579.

Lochner, C. (2008) Obsessive-compulsive disorder and trichotillomania: a phenomenological comparison. BM Psychiatry20055:2

© 2018 Charlotte Doyle

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