Though the root causes of typical trichotillomania are poorly understood and hypotheses range from genetics, glutamate regulation, trauma, and many combinations thereof, a few case studies over the years have been able to induce trichotillomania using drugs. To be clear, they didn’t induce trich on purpose, they found that various substances incidentally cause hair pulling and that stopping these substances stopped hair pulling. They then wrote it down, published the science, and called it a day. So far, no studies seem to exist on trich as a side effect of any medication, but BFRB research is relatively young and case studies, though anecdotal, point a huge flashing arrow saying hey, look over here. Hopefully it is only a matter of time (and funding) before the research catches up and we get some proper peer-reviewed studies on substances that might cause or exacerbate trich symptoms. Anyway, here’s the science.
A first-of-its-kind study conducted by researchers at the UCLA and the University of Wisconsin was released this January a study analyzing relationship between sleep functioning and trichotillomania (TTM) and excoriation disorder (ExD). The study, Sleep functioning in adults with trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, and a non-affected comparison sample, published in the Journal of Obsessive-Compulsive and Related Disorders, compared trends in over four hundred people with TTM or ExD and nearly 150 healthy control subjects, making it possibly the largest study of BFRBs and sleep to date.
The study recruited participants online, screened for eligibility, then administered a battery of sleep TTM/ExD-related questions. While online self-reporting can potentially result in selection and self-diagnosis biases as compared to surveys conducted clinically, such marvels of the internet age like SurveyMonkey have undoubtedly contributed to humanity’s ability to do science at a 21st century pace.
The findings conclude that comprehensive treatment for TTM and ExD should include assessments for contributing sleep-related factors. Current assessment tools for BFRBs do not include items regarding sleep and clinicians should explicitly inquire about sleep patterns and address triggering environmental factors.
The authors suggest wearing protective clothing like gloves or long sleeves to sleep if necessary and in severe cases of sleep-related BFRBD, undergoing polysomnography to assess underlying dysregulation in sleep maintenance processes. Patients can also receive
medication or behavioral interventions to address sleep disturbance or anxiety.
Like many other psychology fields, BFRB research is becoming more cross-disciplinary as evidence emerges linking conditions in different fields. While this study only produced correlations between TTM, ExD, and sleep, correlation is the first step toward discovering causation and then treatments. Encouragingly, this study has given clear evidence that assessment of sleep disturbances should be included in comprehensive BFRB assessments in order to give a more complete view of the condition’s effect on patents’ quality of life and general well-being.
Trichotillomania (TTM) is a misunderstood condition on several fronts. Causes are not known, current treatments are behind the times, and few specialists exist. But also the condition is sometimes mistaken for others, especially obsessive-compulsive disorder (OCD).
Obsessive compulsive disorder is defined by two characteristics: an obsession and a compulsion (imagine that). The obsession is a recurring and persistent thought that causes anxiety or distress. The compulsion is a ritual that can neutralize the distress caused by the obsession. The compulsion may or may not be directly related to the thoughts. People with OCD usually realize the irrationality of their compulsion. In some cases, the compulsion may be purely mental, such as counting steps, and therefore unnoticed by others.
Trichotillomania, on the other hand, is not a direct response to intrusive thoughts, nor does it usually involve a ritualistic behavior. Trichotillomania involves an impulse to pull out one’s hair, similar to the impulse to bite one’s nails or picking at one's scab. It’s often triggered by seeming imperfections (split ends, etc.) and the tactile response of the pulling often produces a short-term calming effect. This puts it in the category Body-Focused Repetitive Behaviors (BFRBs) and not OCD disorders.
TTM is far more common in females (70% - 90%) while OCD has roughly equal distribution across sex. TTM typically presents in early childhood. OCD presents between childhood and early adulthood.
How to tell them apart
Is the behavior unconscious?
People with OCD are usually aware that they are carrying out their rituals. People with trichotillomania often pull their hair out without noticing it. If a behavior often begins unconsciously then you’re more likely dealing with a body focused repetitive behavior (BFRB) than with OCD.
What stress does the compulsion reduce?
OCD behavior is a response to anxiety or distress about the obsession, but BFRBs may or may not be a response to stress. However, BFRBs become more frequent in response to stress. This can make it difficult to distinguish between the two.
One way you can distinguish between the two is by asking if the behavior is a response to stress in general or is always a response to the same specific stressor. A calming behavior performed in response to general stress is more likely a BFRB such as trichotillomania whereas a ritual always performed in response to a specific stressor is more likely OCD.
People with OCD are generally aware that they are carrying out their compulsions, but people with TTM and other BFRBs may or may not be conscious that they are pulling their hair. So if someone is performing a behavior unconsciously it’s more likely a BFRB. This is one of the easiest ways to distinguish the two.
Comorbidity is “Any distinct additional entity that has existed or may occur during the clinical course of a patient who has the index disease under study,” or in plain English, given one condition, a tendency to have a specific second condition. It may be that one condition causes the other, or that a third condition causes both, so the direction of causality is not alway easy to determine. Both TTM and OCD are comorbid with a number of mental health conditions, many of which overlap. OCD and TTM are both comorbid with each other.
TTM is comorbid with:
OCD is comorbid with:
OCD and TTM are treated in a similar fashion. Both are sometimes treated with SSRI antidepressants but these are more effective on OCD than TTM; success with TTM has been mixed. Cognitive behavioral therapy is effective for many patients with either OCD or TTM. A good amount of research supports the amino acid variant and dietary supplement n-acetylcysteine (NAC) as a treatment for TTM. Recent research has supported NAC for OCD as well. OCD compulsions are generally too complex to monitor with hand-tracking bracelets like Slightly Robot, though at least one study has shown benefits of automatic hand-monitoring systems for TTM.
Flessner CA, Knopik VS, McGeary J. Hair pulling disorder (trichotillomania): genes, neurobiology, and a model for understanding impulsivity and compulsivity. Psychiatry Res. 2012 Apr 24;
Lochner C, Seedat S, du Toit PL, et al. Obsessive-compulsive disorder and trichotillomania: a phenomenological comparison. BMC Psychiatry. 2005;5:2. doi:10.1186/1471-244X-5-2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC546013/
Feinstein, A. R. (1970). The pre-therapeutic classification of co-morbidity in chronic disease. Journal of chronic diseases, 23(7), 455-468.