When one thinks of being impulsive or doing something without feeling like one can control the urge, one would likely think of obsessive compulsive disorder. Although obsessive compulsive disorder does seem to portray impulses, it is not an impulse control disorder. Amongst the many impulse control mental disorders, trichotillomania appears to stand out. Trichotillomania is defined as the repeated pulling of hair resulting in noticeable hair loss (Himle, 2008, p. 1187).
A diagnostic criterion for trichotillomania consists of multiple qualifications. The DSM IV-TR describes trichotillomania as an impulse-control disorder (Ellis, 2009). The diagnosis of the disorder, as defined by the DSM-IV-TR, requires the repeated pulling of an individual's own hair resulting in noticeable hair loss, a sense of an increase in tension directly prior to the pulling of the hair, some sort of relief, pleasure, or gratification from pulling the hair, the hair pulling is not better characterized by some other disorder, and the hair pulling must cause a significant amount of distress or impairment to social, occupational, or other areas of functioning (Ellis, 2009).
Although not a newly discovered disorder, trichotillomania has only not been understood as well only until relatively recently. According to Duke (2010), the disorder was "first described by the French physician Francois Henri Hallopeau (1889)" (p. 182). Since the year 1889, trichotillomania has been considered a rather rare disorder, with a prevalence of about 0.05% (Duke, 2010, p. 182). Only until the 1990s did research studies come to reveal the disorder appear to be more common than previously understood. A survey of 2524 college students in 1991 found a lifetime prevalence rate of 0.6%, where as a sample of 794 seventeen-year-old Israeli adolescents reported a rate of 1.0% (Duke, 2010, p. 183). Regardless of the true prevalence rate, it is clear the disorder has a much more common occurrence amongst people than what was previously speculated when the disorder was originally defined.
The precise prevalence rate for the American general adult population appears to be anywhere between 2 - 4% (Trichotillomania Learning Center, 2009). However, issues regarding such statistics lie with the consistent denial of the disorder by many or the failure to seek professional help, thus making it difficult to conclude accurate findings of incidence (Ellis, 2009). Despite this, prevalence amongst gender proves adult women to be at least four times more likely to develop trichotillomania than men (MedlinePlus). This large difference in occurrence between men and women is largely explained by more women seeking help from professionals than men as men have the advantage of shaving their heads to avoid social stigma where as women do not (Duke, 2010, p. 183). However, this difference in gender is not shown in all ages. According to Duke (2010), research studies have shown the lifetime prevalence rate for children was "about equal for both genders" (p. 183). For children, the average age of onset is 13 years old with a duration of 21 years. Although, despite this, some children as young as 1 year old have been diagnosed with trichotillomania (Ellis, 2009).
Amongst all of the occurrences of trichotillomania, to this day the causes of the disorder are widely unknown (Ellis, 2009). There are many speculations, however, for the cause of trichotillomania including biological, psychological, and social factors (Duke, 2010, p. 186). Of these factors, some hypothesized causes are serotonin deficiency, structural brain abnormalities, abnormal brain metabolism, and large amounts of stress (Ellis, 2009). Serotonin was first linked to impulse control behaviors in a study in 2003 on compulsive gambling. Since then, serotonergic drugs have been involved in the attempt to treat trichotillomania. Although improvement appeared at first, the effectiveness wore off over time (Duke, 2010, p. 186). Structural brain abnormalities appeared to be a plausible cause when magnetic resonance imaging (MRI) studies "demonstrated that some individuals with trichotillomania have abnormalities of the lenticulate" as stated by Ellis (2009). Reduced left putamen volumes were also found, indicating individuals with trichotillomania have an abnormal fronto-striatal motor circuit in the brain (Duke, 2010, p. 186). Other studies, involving positron emission tomography (PET) scans, have also revealed abnormalities in the metabolism of the brain in individuals with trichotillomania. These abnormalities show a high metabolic glucose rate in the global, bilateral, cerebellar, and right superior parietal areas (Ellis, 2009). Other studies, ranging from 1973 to 2000 have also shown stress to have connection with trichotillomania as an etiological factor. According to Duke (2010), "Specifically, trichotillomania may develop as a coping behavior in response to stress, and be reinforced through tension reduction" (p. 187). In the end, these speculations remain solely speculations.
Whilst there is no knowledge of what causes trichotillomania, the symptoms that afflict the individuals with the disorder still persist. There have been many options of treatment developed over the years for trichotillomania, but of the options only behavioral and pharmacological approaches have become so vigorously tested (Duke, 2010, p. 189). Selective Serotonin Reuptake Inhibitors (SSRIs) were first tried in the attempt to treat the disorder due to the neurotransmitter serotonin's relation with trichotillomania. Disappointingly, the SSRIs only treated mostly the comorbid symptoms of depression and anxiety the patients seemed to experience. With the unsatisfactory results of the SSRIs, researchers had to resort to other options of pharmacological treatment. One trial of the use of lithium proved hopeful. In the trial, 8 out of 10 of the patients showed reduction in hair pulling (due to the drug's ability to reduce aggressiveness, impulsivity, and mood instability) and mild hair regrowth (Duke, 2010, p. 189). However, even though lithium seemed to prove as an effective treatment for trichotillomania, because of the adverse side effects of medication, behavioral treatment is preferred (Duke, 2010, p. 189). The most widely tested behavioral treatment for trichotillomania is behavioral habit reversal training (HRT) (Himle, 2008, p. 1187). Behavioral habit reversal training consists of, but is not limited to, competing response training, awareness training, identifying response precursors, and annoyance review. With these components, behavioral habit reversal training aims to reduce hair pulling by making the individual aware of the factors that influence the urge to pull the hair in the first place (Himle, 2008, p. 1188).
In conclusion, trichotillomania is an impulse control disorder with no known cause, not well known prevalence rate, and has hopeful options of treatment. Over the course of time, the amount of knowledge of trichotillomania has increased dramatically. As researchers perform more tests and discover the true cause and nature of the disorder, one can only hope a cure or successful treatment can be developed for those who are afflicted with the distressing mental disorder known as trichotillomania.
Duke, D. C., Keeley, M. L., Geffken, G. R., & Storch, E. A. (2010). Trichotillomania: A Current Review. Clinical Psychology Review, 30, 181-193.
Ellis, C. R., Roberts, H. J., & Schnoes, C. J. (2009). Anxiety Disorder, Trichotillomania. Retrieved March 18, 2010, from http://emedicine.medscape.com/article/915057-overview.
Himle, J. A., Lokers, L. M., & Perlman, D. M. (2008). Prototype Awareness Enhancing and Monitoring Device for Trichotillomania. Behavior Research and Therapy, 46, 1187-1191.
MedlinePlus (2010, February 23). Trichotillomania. Retrieved March 18, 2010, from http://www.nlm.nih.gov/medlineplus/ency/article/001517.htm.
Trichotillomania Learning Center (2009). Hair Pulling: Frequently Asked Questions. Retrieved March 18, 2010, from http://www.trich.org/about/hair-faqs.html.