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.