Getting to root of anxiety


Trichotillomania - pulling out your hair - is consdiered to be a compulsive disorder, writes CLAIRE O'CONNELL

HOW OFTEN have you used the expression “I was tearing my hair out” without giving it too much thought?

For some people it’s more than a figure of speech. For some, pulling out your own hair becomes a chronic, disfiguring and distressing behaviour.

As many as 1-3 per cent of the population compulsively pull out hairs – mostly from the scalp, eyelashes or eyebrows – due to a condition known as trichotillomania or “trich”, which is a considered to be on the obsessive compulsive disorder (OCD) spectrum, explains consultant psychiatrist Dr Michael McDonough.

“It is classified as a habit or an impulse disorder and I think that’s a good way of thinking about it,” he says.

The condition, which tends to affect women more frequently than men, can start in childhood but often manifests for the first time around adolescence, and stress can make it worse. But not everyone who has it finds it hard to manage, says McDonough, who heads the anxiety programme at St Patrick’s Hospital.

“Like a lot of problems, you have fortunate people who engage in it in a milder way and it doesn’t really affect their lives, and with others it certainly does affect their lives,” he says.

“For those people it tends to be a secretive behaviour that they are upset or ashamed about – people wake up the next day and think ‘why did I do that?’. That feeling of guilt generates its own stress and anxiety, which makes them vulnerable to more hair-pulling. And a lot of people who suffer from it spend time and sometimes a lot of money trying to hide hair loss with hairpieces, wigs or extensions.”

Compulsive hair-pullers often don’t even realise they are doing it, while at other times they may be more directed, explains McDonough.

“There are times when their hair-pulling is automatic, it’s inadvertent. [Patients] say well sometimes I just pull and it’s almost a repetitive habitual cycle, I can’t stop it, it helps to ease stress and it’s associated with a sense of release. That’s the more implusive end,” he says.

“Then there are other times when they seek out certain hairs or they try to achieve symmetry with their hair, or they direct it towards grey hairs.”

Some compulsive hair-pullers also engage in “oral behaviours”, says McDonough, where they play with the hair using their mouths, and as many as a fifth of them actually eat the pulled hair. “This can lead to a hairball which can cause obstruction,” he explains.

The causes of trich aren’t clear, notes McDonough. “I think it’s a tendency that is there for a good subset of people, and that tendency can be mild or it can get out of hand,” he says.

“For that subgroup where it gets out of hand, I would argue that the tendency then grows and that becomes a learning or behavioural cycle.”

Breaking that cycle needs an “all hands-on deck” approach to find out what works best for the individual, notes McDonough.

Physical barriers to pulling – like wearing gloves or putting sticking plasters on fingers can also help, while antidepressants can be useful in some cases, and McDonough is an advocate of using cognitive behavioural therapy (CBT) to help people understand and manage their own condition.

One approach encourages patients to steer their hands elsewhere when they are about to pull at a hair. “You can do an analysis of the behaviour and then you teach a competing behaviour – sit on your hand, put your hand in your pocket,” explains McDonough.

“So you associate the urge to pull hair with a new behaviour – you bring your hand up to the hair and then you learn a new response to move the hand somewhere else. It works reasonably well but it boils down to motivation.”

And he welcomes the results of a trial published recently in the Archives of General Psychiatry showing that a dietary supplement of amino acid N-acetylcysteine helped improve symptoms in over half of patients.

“I would say that is a very important development,” says McDonough, whose enthusiasm is echoed by counselling psychologist Leslie Shoemaker, an adviser to OCD Ireland. “The new amino acid study is a huge development,” says Shoemaker. “There is so little research [on trich], if they have found something that can help my patients I’m all for it.”

She notes that getting the right support can help people manage compulsive hair-pulling, and OCD Ireland has started monthly meetings for people with the condition.

‘It happens to me any time I am happy or sad’

It started when I was about three. I used to pull out my own hair and my sister’s hair, and when I was that young I’d eat the hair too.

It was causing problems and my mother had to bring me to the hospital a lot. They couldn’t understand what was wrong with me, I had X-rays and scans.

Then I was in the hospital one day and I started passing hair through my back passage.

They had to rush me down to theatre and they told my mother to kiss me goodbye. They took a hairball like a fox’s tail out of me. Another girl was having the same operation that day in England and unfortunately she died.

After that the hair-pulling stopped for a while but when I was pregnant with my second child it started up again.

Then, when she was small, she was waking in the night vomiting. I was back and forth to the hospital with her. When she started passing it through her back passage I knew what was wrong.

My daughter is still young now, so she doesn’t understand what she’s doing. I keep her hair tied up and I keep her active.

And for me, I can’t have my hair long any more, I keep it very short to try to stop me pulling at it. I have a strong level of it because it’s not only pulling out hair, it’s picking on skin that’s irritating me as well. I don’t realise I am doing it, and it happens any time I’m happy or sad.

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