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Trichotilomania

Criptal Graham

University of North Carolina at Pembroke

Trichotillomania

The purpose of this paper is to discuss and analyze the psychological and emotional effects of Trichotillomania or Trich. First, he reader will be informed of the definition and characteristics of this disorder. Second, the reader will be given the physiological symptoms that accompany this behavior. Third, the reader will be given descriptions of both Obsession Compulsive Disorders and Addiction Behaviors to correlate the behaviors of Trichotillomania. Lastly, the reader will be informed of the current treatments and medications that have been applied to samples in randomized controlled trials.

Definition and Characteristics of Trichotillomania

Trichotillomania (Trich) is the recurrent pulling of an individuals own hair resulting in immediate hair loss and baldness. This disorder is inclusive of immediate elevated levels of stress and anxieties. The urge to pull hair comes with an enormous amount of tension preceding the behavior of pulling hair (Beers, Fletcher, Andrew et.al).

Also trying to resist pulling the hair creates high levels of tension. Instant gratification of pleasure is experienced after one has tried to deny itself of hair pulling. Most victims of Trichotillomania report the pleasurable euphoric adrenaline that is experienced as the behavior is enacted (Ravindran, Da Silva, Ravindran, Richter & Rector, 2009).

Trich has some characteristics of depression because it causes the victim to have significant levels of depression due to the distress of limited social or occupational functioning due to the devastating physiological symptoms of hair loss. The visible appearance of hair loss takes a considerable amount of time to camouflage creating grief and low self esteem for the victim (Grant, Odlaug & Potenza, 2007).

Trich also has some characteristics of obsession compulsive disorder (OCD) due to it is a time consuming disorder. The victim spends countless hours repeating the same behaviors of hair pulling and in some extreme cases hair eating. The person committing the behavior of hair pulling spends a considerable amount of time trying to resist the urge to pull hair. Trich causes marked distress and instant pleasure once the hair pulling is initiated. Hair pulling precedes negative internal attitudes. Like the behaviors in OCD hair pulling reduces tension, boredom and anxiety. (Grant. Odlaug & Potenza, 2007).

It is a commonality for people who suffer with Trichotillomania to be diagnosed with OCD. It has been researched that Trich victims have elevated rates of OCD vs. the general public who suffers with OCD. Furthermore, family studies suggest there is a genetic link between Trich and OCD among relatives with Trichotillomania (Grant. Odlaug & Potenza, 2007).

Trichotillomania also has characteristics of addiction behaviors. Trich is characterized by repetitive behavior and decreased ability to control the strong urges to pull hair. Furthermore hair pulling increased over time to get the same pleasurable feelings. In correlation to addiction behaviors the addict increases its intake to maintain the desired effect of pleasure from the drug (Grant. Odlaug & Potenza, 2007).

Also, there is a strong urge and craving for the instant gratification of the pleasure in pulling hair. When that urge is not able to be quenched a severe level of anxiety is experienced when the person is unable to pull hair. The behaviors of Trichotillomania depict that of addiction by showing signs of tolerance, withdrawal, and craving symptoms. Similar to addictive behaviors Trich enacts repetitive compulsive behaviors despite adverse consequences (Hopkins Symptoms& Remedies, 1995, pg. 284).

The affected individuals show decreased control over problematic behaviors despite how hard they try not to engage in the behavior. Right before the affected person gives in to the strong urge and craving sensation to pull hair the stress levels are at a eutrophic high. Then once the cravings are met there is instant pleasure and gratification for only a short period of time. (Grant. Odlaug & Potenza, 2007).

Physiological Symptoms of Trichotilomania

The physiological symptoms of Trichitillomania are baldness and loss of hair. Trichotillomania can all areas of the body where there are hair particles. The most common form of picking is on the scalp. However many people pick hair from their eyebrows, pubic area, underarms, arms and legs (Jain, Solanki, Bhahangar & Jain, 2011).

Another physiological symptom of Trichotillomanial is anxiety. Before hair pulling takes place it has been determined that the affected person suffers a great deal of anxiety. The anxiety could be self inflicted because the person is trying to fight the strong urges to pull hair. Also the anxiety could be from external stressors that trigger the impulses and urges to pull hair (Ravindran, Silva, Ravindran et.al, 2009).

. Infants and children, particularly if mentally disturbed or abnormal, may acquire the habit of swallowing foreign material which if it persists may lead to the formation of a bezoar in the gastrointestinal (GI) tract. This foreign material may be vegetable or any other substance. If it contains hair, it is known as a trichobezoar. Trichobezoar usually occurs in patients with history of trichotillomania (Jain, Solanki, Bhahangar & Jain, 2011).

Another physiological symptom of Trichotillomania is hair eating as mentioned above called “Trichobezoar”. When the victim is at a state of pulling hair it is common for the person to draw more attention to the hair shaft. The affected person pulls their own hair then looks at the roots and in some cases eats the roots or the entire string of hair. The physiological symptom of this is sometimes the hair gets stuck into the gastrointestinal system and causes a “j” shape clump of hair that has to be surgically removed from the person(Jain, Solonki, Bhantnager & Jain, 2011).

. This is only noticeable when the affected person complains of pain in esophagus or stomach then an upper GI endoscope is done and will confirm the swallowing of multiple strands of hair. Then the affected person has to undergo gastronomy with the aide of the endoscope to find the trichobeozar and remove it from the esophagus and stomach area (Jain, Solanki, Bhahangar & Jain, 2011). This is a more extreme Trichotillomania victim. Most only eat the roots or for pleasure stroke the roots of the hair across their cheeks after pulling it out of the hair shafts (Jain, Solonki, Bhantnager & Jain, 2011).

Prevalence of Trichotillomania

There are 2.5 million people in the United States who are affected by Trichotillomania. The percentage of the general population, who are affected with Trich, range from 0.6% to 3.4%. Furthermore the percentage of College students Despite the prevalence of the disorder the awareness and acknowledgement of this disorder is very low. Most people who are affected Trichotillomania are ashamed to acknowledge that they suffer from the disorder. Fears of how they are perceived by family members, peers, co-workers make the affected person hide the physiological symptoms.

Victims of Trich often do not share their experiences with their doctor to the fullest so the disease is often misdiagnosed. Furthermore there are a significant number of doctors who do not have a competent level of education on this rapidly spreading illness. Therefore, many clinicians have not evaluated or treated a Trichotillomania victim (Tolin, Franklin & Gretchen, 2009).

Gender

Trich is commonly reported among females. However there are few cases of males who have reported being affected by Trich. Commonly the disorder is in victims who possess long strains of hair (Tolin, Franklin & Gretchen, 2009).

Age

Trichotillomania generally begins in late childhood or early adolescence. If untreated it chronically continues into adulthood and entire life. Children have been seen in toddler ages demonstrating hair pulling symptoms. These children are then evaluated by a pediatrician who has seen Trich and recognize the physiological effects (Ravindran, Silva, Ravindran et.al, 2009).

Causes of Trichotillomania

Causes of Trichotillomania are multidimensional and very complex. For no one victim are the causes the same. Different therapists and clinicians view the causes from the perspective of their professional practice. First, Psychoanalytic theorists view hair pulling as a means of working through real or perceived threats of object loss(Grant, Odlaug &Potenza, 2007).

Second, some clinicians believe Trich is cause by neurobiological factors because there is a link between serotonergic activity and grooming behaviors. Third, Behavioral Therapists believe Trich is a coping mechanism in response to stress that is reinforced through operant and classical conditioning by means of tension reduction (Franklin, Edson, Freeman, 2010).

Lastly, other clinicians regard Trich as individuals who inflict self-injury. Clients report behaviors are triggered by overwhelming psychological pain or negative affective situations. The pulling of hair is diagnosed to be a remedy to relieve the body of unwanted tension (Kress, Kelly,& Mc Cormick, 2004).

Treatments of Trichotillomania

There are multiple alternative treatments and drugs used to prevent this disorder. Cognitive Behavioral Therapy and Habit Reversal Therapy is used on the affected people. Along with psychotropic drugs which have reports of adverse negative reactions( Marcini, Ameringen & Patterson et.al, 2009).

Methodology

The client a 16 year old female was referred to the agency for Trichotillomania. She was referred by her immediate family. The client, the mother and the three other siblings came into my office for the intake and assessment process. The mother of the child was in immediate denial she thought her daughter just had a habit she should just stop doing.

The young lady seemed rather timid and shy she did not give any additional information only what the clinician asked of her. The young girl stated that she has always had some issues with anxiety due to having an alcoholic dad. The mother and child consented to behavioral therapy with our office along with taking the prescribed drug clomipramine.

In the late 1980’s the young girl recapped waiting on her friend to ask her mother if she could go to a party with her. The girl said she had so much anxiety while her friend’s mother contemplated her decision until she found herself stroking her eyebrows. The client stated that there was no pain in the motion it seemed to soothe her anxiety.

Once the client realized that she had been a few minutes in that state she realized that there was a hole in her eyebrow. The client immediately pulled out make up and filled in the hole with a dark eyebrow pencil. The problem appeared to be solved. The client stated she was in for a rude awakening she continued the behavior of hair pulling.

Without any knowledge at that time of Trichotillomania she found that years had passed and the trauma had increased. The hair pulling behavior had worsened and her anxiety levels were more noticeable. She not only pulled hair from her eyebrows but from the scalp, pubic area, and underarms. The task of concealing the disorder became greater while her self-esteem became smaller.

The family’s observations were that the client’s whole appearance changed drastically for periods of time. Then for a short brief period the client would appear to look normal. They witnessed countless hours that the client looked immobilized and in a trance while stroking her hair or eyebrows.

About 10 years of the behavior passed and the client went to the medical doctor and was diagnosed with Trichotillomania. After meeting with a Behavioral Counselor the medical clinician prescribed the psychotropic drug clomipramine. The client was not given any therapy with the drug.

The client had only taken the psychotropic drug for a short period of time before realizing the drugs side effects. The client reports that she had increased night mares that were unbearable. Without having the consent from her doctor the client took herself off the medication. After a couple of weeks the client experienced withdrawal symptoms from the drug. The symptoms she described as ears ringing with a screechy pitch and shaking at night time.

Procedure

Based on the concerns of the families and the high level of stress involved, the social worker thought it would be beneficial if the client begins Cognitive Behavioral and Habit Reversal Therapy. The Cognitive Behavioral Therapy is where the client evaluates and accesses her thoughts and feelings before the problematic behavior.

These therapy sessions will allow the client to express her thoughts with another individual. In the past, she had thoughts and behaviors and just dealt with them within. The client and she will be able to evaluate her conditions prior to the behaviors by keeping a record of the times and dates of the behaviors. As well as noting the external situations around her at the time (Dig, 2007).

Many behavioral techniques have been used in the treatment of trichotillomania, including self-monitoring and competing reaction training (Diefenbach et al., 2000; Mansueto et al., 1997). Self-monitoring requires clients to record their urges to pull their hair, including the frequency, duration, and situations in which the urges occur, and to save their hair in an envelope and bring it to each counseling session (Krest, Kelly & McCormick, 2004).

Initially, the client will be the sole beneficiary of the Cognitive Behavioral Therapy. Further into treatment the client’s immediate family members who initially observed the behaviors can attend the sessions.

Baseline Assessment

Along with Cognitive Behavioral Therapy with the client the social worker administered a survey instrument that measured and evaluated the behaviors of the client. The baseline scores for the client consisted of a week of measuring the behavior for two weeks before the therapy began. The client did her intake and assessment by using a Self- Rating Anxiety Scale (SAS) and brought the findings to the therapy sessions. The social worker added up the scores for each week. The recordings of the baseline assessment indicated high activity of hair pulling scoring the number 80 before the intervention was administered.

The third week treatment was administered and the baseline intervention was scored at 40. Then the next week the client reported a stressful week and the numbers increased back to 80. During the fourth week of intervention the client had a drop in the numbers to 60. These numbers signify extreme conditions according to the SAS Scale (Fischer & Corcoran, 2007)

Instrument

The Self Rating Anxiety Scale (SAS) is a twenty question survey that measures the anxiety one may have while indulging in problematic behaviors. The social worker administered the survey based on the fact that the survey’s purpose is to assess anxiety as a clinical disorder and quantify anxiety symptoms (Fischer & Corcoran, 2007). This helps the social worker to relate the problematic behavior of Trichotillomania with the client’s current level of anxiety.

The twenty detailed questions on the SAS which the client has consented to completing records the number of times the client experiences anxiety daily (Fischer & Corcoran, 2007). The client will measure her anxiety every Monday and Friday mornings before coming to therapy. The scores on the scale range from 1 to 4 indicating the lower numbers to be some or no anxiety and the larger numbers to be most or all the time anxiety is present that day. Therefore using the SAS scale the maximum score the client can get is 80 (Fischer & Corcoran, 2007).

Intervention and Evaluation

The intervention of Cognitive Behavioral Therapy was implemented on the third week. The client would complete the SAS and the Social Worker and client would evaluate the process each week. The main issue with the client’s disorder is that it appears to be triggered by high levels of anxiety. It appeared that by the fourth week although the numbers came down the client still recorded high levels of anxiety.

At the fourth week of treatment the client was pleased with the scores of the SAS scale and hopeful that the numbers would continue to decrease.

Discussion and Application to Social Work Practice

According to Flessner & Garcia Trichotillomania (TTM) is a psychiatric disorder characterized by the repetitive pulling out of one’s hair, resulting in noticeable hair loss as well as clinically significant academic, social, and/or occupational impairment (Flessner, Garcia et.al, 2010).

The social workers role is to establish that the safety and well-being of the client is in all aspects of their life. The impairments that this disorder causes in most victims indicate the need for a social workers intervention. For example, if an underage child is not going to school because of shame of the physiological symptoms that the disorder has then the parents would be held liable for truancy. Furthermore if the client is not able to function and work due to the negative side effects of psychotropic drugs and they reside in their home in negligence then an adult Protective Social Worker would be needful to go into the home and place guardianship over that individual.

One limitation Cognitive Behavioral Therapy with a Trich client is that the individual is basically in control over their own thoughts and behavioral patterns. It takes constant work efforts to maintain the maintenance stage. This requires the client to be committed to the therapy and eliminate all external situations that causes anxiety and may trigger a re-occurrence of the behavior (Flessner, Garcia, 2010).

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References

Arun Ravindran, Tricia da Silvia, Lakshmi Ravidran, Margaret Ricter, Neil

Rector

Obsessive Compulsive Spectrum Disorders: A Review of the Evidence Based

Treatments, 2009

Joe Grant, Brian Odlaug, Marc Potenza, 2007

Addicted to Hair Pullin? How an Alternate Model of Trichotillomania may improve treatment outcome

Manish Jain, Sohan Solonki, Ankur Bhantnager,Pavan Kumar Jain, 2011

An unusual Case Report of Rapunzel Syndrome Trichobezoar in a 3- year old Boy

Victoria Kress, Brandy Kelly, Laura McCormick, 2004

Trichotillomania: Assessment, Diagnosis and Treatment

Christopher Flessner, Abbe Marrs Garcia, 2010

Trichotillomania Understanding and treating Trich: Not just a benign habit

David Dig, 2007

I can’t stop pulling my hair: Using numbing cream as adjunct treatment for Trichotillomania

Truong Christine, 2009

Trichotillomania in youth: A Retrospective Case Series

Catherine Marcini, Michael Ameringen, Beth Patterson, William Simpson,

Pediatric Trichotillimania” Descriptive Psychopathology and an open trial of Cognitive Behavioral Therapy

David Tolin, Martin Franklin, Gretchen Diefenbah, 2007

Behavior Therapy for Pediatric Trich: Exploring the effects of age on treatment outcome

Martin Franklin, Aubrey Edson, Jenifer Freeman, 2010

Simeon Margolis M.D. Phd, 1995

John Hopkins Symptoms & Remedies Medical 10 Edition

Beers Mark, Fletcher Andrew. Et.al, 2003

The Merck Manual of Med Information, Second edition

Appendix A:

Below are twenty statements, please rate each using the following scale

1= some or little of the time

2=some of the time

3=Good part of the time

4=Most or all of the time

Record on the left of scale

-1. I feel more nervous and anxious than usual

-2. I feel afraid for no reason at all

-3. I get upset easily or feel panicky

-4. I feel like I am falling apart and going to pieces

-5. I feel that everything is all right and nothing bad will happen

-6. My arms and legs shank and tremble

-7. I am bothered by headaches, neck and back pains

-8. I feel weak and get tired easily

-9. I feel calm and can sit still easily

-10. I can feel my heart beating fast

-11. I am bothered by dizzy spells

-12. I have fainting spells or feel like it

-13. I can breathe in and out easily

-14. I get feelings of numbness and tingling in my fingers, toes

-15. I am bothered by stomachaches or indigestion

-16. I have to empty my bladder often

-17. My hands are usually dry and warm

-18. My face gets hot and blushes

-19. I fall asleep easily and get a good night’s rest

-20. I have nightmares

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