Trichotillomania: Diagnosis, Neurobiology and Treatment

By: Suzanne Feinstein, PhD

How is trichotillomania diagnosed?

The Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association Definition lists five criteria that characterize a clinical diagnosis of Trichotillomania.

A) recurrent pulling out of one’s hair resulting in noticeable hair loss

B) an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior

C) pleasure, gratification or relief when pulling out the hair

D) a disturbance that is not better accounted for by another medical disorder (ie, a dermatological condition)

E) a disturbance that causes clinically significant distress or impairment in social, occupational, or other areas of functioning

What is the biology behind trichotillomania?

There is a void of information about the neurobiology of trichotillomania, and therefore it is a poorly understood disorder. However, there are theories pertaining to why people pick and pull based on genetic and neuroimaging studies.

Because people demonstrate both a lack of awareness with regard to their pulling as well as a focused compulsion to pull, it is implicated that there is a mixed circuitry of neurotransmitters at work.

Brain imaging technology shows hyperactivity in both the right-frontal cortex which mediates fear-based and tension-induced behaviors. This area is found to be over active in people with Obsessive Compulsive Disorder and other anxiety disorders.

Also at work is the nucleus accumbens in the striatum which is known to have an important role in reward, pleasure, addiction and fear, dictating our primitive urges by preserving the earlier stages of development. It attempts to satisfy the most basic levels of comfort, convenience, or efficiency. This part of the brain is found to be over active in people who struggle with compulsive gambling, binge eating and drug addiction.

Understanding that there is a difference in brain functioning and genetics is often useful in the process of self-acceptance and in gaining cooperation in therapy since it highlights that this is more than just a mere bad habit. It helps people understand that they need to break through a biology that is not their fault and that it is okay to reach out to a therapist for assistance.

How is trichotillomania treated?

Habit Reversal Therapy (HRT) is the gold standard for treating trichotillomania and other body focused repetitive behaviors. HRT works to rewire the neurocircuitry of the brain so that the blood flow is directed away from the reward seeking parts of the brain and toward the orbito-frontal region which is responsible for higher executive functioning such as awareness, decision making and strategizing.

As part of HRT, record keeping is an important step in heightening your awareness because it helps you discover specific ritualistic patterns. When you stop to chart the behavior, you will be more alert to the specifics behind the behavior. This type of awareness building creates new routines, new postures, and new ways of utilizing the hands in order to reverse this problem.

Competing Response: Clients are taught to how to retrain their muscle memory and weaken their urge to pull by using a physical action that opposes the movements and gestures needed to pull. For instance, pullers are taught to tighten their fists as soon as they catch themselves in the pull cycle so that their fingers cannot form the pinch and grasp reflex.

Stimulus Control techniques are an integral component to HRT. Patients utilize tools and obstacles that will assist them in breaking the habit. By controlling the tactile and visual stimuli that perpetuate the habit, you can effectively shut down the reward systems while simultaneously alerting the senses. Stimulus control techniques such as wearing hats, scarves, and buns, covering mirrors, removing lightbulbs, and wearing band aids on your fingertips make it more difficult to access the hair and skin. Play dough, jewelry, stress balls, and other fidget toys can also assist in satisfying these sensory urges.

Relaxation Training such as deep muscle relaxation and guided imagery help people become more aware of their internal tension. By relaxing isolated muscles, a person can learn to unravel the physical tension that generally precedes pulling and picking behaviors.

Diaphragmatic Breathing: Learning how to slow down your breath, take rhythmic breaths through the abdomen, and exhale fully is an important skill in the relaxation practice. This type of breathing helps to relax the body, refocus the mind and ultimately rechannel the physical urge to pull.

Exposure Therapy and Response Prevention (ERP): ERP helps people desensitize to the physical tension that precedes the urge to pull. The individual is asked to isolate a high urge hair, feel it, inspect it, and then allow the urge to decrease on its own without the reinforced reward of pulling.

Treatment is highly effective using the above techniques. If you struggle with trichotillomania, you do not have to handle this problem alone. If you are ready to take the next steps for your mental wellness, take a look at our website www.behaviortherapynyc.com or contact us today to schedule your first appointment.

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