Making sense of the role of sense organs in trichotillomania.

Hallopeau, a French dermatologist, coined the term trichotillomania to describe alopecia (baldness) caused by self-traction of the hair, but the term now encompasses the entire syndrome of pathological hair pulling.[1]

In Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5),[2] the major change for trichotillomania (hair pulling disorder) is the fact that it and related disorders now have their own chapter in the obsessive–compulsive disorder section. Trichotillomania (hair pulling disorder) includes recurrent pulling out of one's hair, resulting in hair loss, repeated attempts to decrease or stop hair pulling, and the hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Furthermore, the hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition), and the hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).

There has been lot of debates and discussion if trichotillomania is an impulse control disorder, obsessive–compulsive spectrum disorder, or should be classified as a category of body-focused repetitive behavioral disorder.[3] Trichotillomania (hair pulling disorder) has been moved to obsessive–compulsive and related disorders in DSM 5; however, in International Classification of Diseases-10, it is classified under habit and impulse control disorders.[4]

Lifetime prevalence rates of trichotillomania have been estimated to vary from 0.6% to 3.6%. Trichotillomania often begins or is recognized in late childhood or early adolescence with an average age of onset around 13 years and displays a chronic but fluctuating course.[5] It involves an individual recurrently pulling hair, generally one hair at a time from any part of his/her body, the head, eyelashes, eyebrows, beard, genital area, underarms, chest, legs, or other area. The scalp is the most common area. Pulling typically is done with the fingers, but tools such as tweezers, brushes, or combs may also be used.[6]

Trichotillomania is associated with a significant functional impairment and psychiatric comorbidity across the developmental spectrum. As trichotillomania usually strikes during the sensitive developmental years, it can be especially disabling. Young adults with trichotillomania report impaired school, work, and social functioning, lowered career aspirations, and missed work days. Pulling can also negatively impact family functioning, contributing to family arguments, and secrecy, which in turn can increase stress and exacerbate trichotillomania symptoms. Adults also report that spending considerable financial resources on concealment methods and on treatments.[7]

POINT OF VIEW

The majority of literature and definitions focus on the act of pulling the hair, the preceding tension, and the relief of anxiety following the act. A variety of factors such as a sensation of itch, boredom, mood changes, stress, and negative emotions serve as triggers to pull the hairs.[8]

Pre- and post-pulling activities are documented in literature but are mentioned just as activities surrounding the hair pulling. They receive little or no attention in the whole diagnosis, understanding and management of the disorder. There are lack of satisfactory explanations provided for majority of the postpulling activities and behaviors.

An article by Woods and Houghton[5] mentions “Rituals and behavioral patterns often precede pulling, such as combing through the hair, feeling individual hairs, tugging at hairs, and visually searching the scalp and the hairline.

Pre- and post-pulling behavior are also clinically relevant. Although some individuals simply discard pulled hairs, others may play with the hair between their fingers, inspect the hair, bite the hair between the teeth, or ingest all or parts of the hair”.

Activities surrounding the hair pulling provide pleasure to the persons with trichotillomania which probably acts a positive reinforcement to pull the hair. The pleasure may come through various sensory modalities which may vary from person to person.

If hair pulling is only the primary goal, the patients should just pull the hair one by one and throw which hardly happens. They are involved in varied activities seeking pleasure involving all the sense organs which may vary from person to person.

Antecedent activities such as feeling the texture of the hair, twirling, curling, grooming, combing, desire to have an even hairline, identifying the right hair, and then, the particular hair is pulled, all involve the touch sensation.

The pulled hair is actually visualized for its characteristics such as length and color which involves the visual modality.

The hairs are rubbed against each other, the snap pulling sound involves the hearing modality; at times, patients do even smell the hairs mixed with sweat to experience pleasure (Olfaction).

Swallowing, tasting, the whole hair or a part of the hair is widely reported in literature which may be a way of experiencing the hair or else why should a person interested in only pulling the hairs swallow it.

Oral behavior using pulled hair is present in half the patients and 5%–18% ingest their hair.[9] Trichophagia is a condition where persons swallow hair. Few patients swallow only the root of the hair called trichorhizophagia. Trichobezoar is a condition wherein swallowed hair starts accumulating in the stomach over a period to form a concretion which presents later with features of malnutrition and intestinal obstruction.[10]

In a study by Grant et al.,[11] the rate of trichophagia in 68 individuals with DSM-IV-TR trichotillomania was approximately 1 in 5 (20.6%).

CONCLUSION

All the sense organs are involved in the varied pre-/post-pulling activities which vary from person to person and serve to maintain the behavior by reinforcements. It is also possible that in a subset of people, the pleasure-providing behaviors are these surrounding acts and hair pulling is just the modality of fulfilling it. Our diagnostic guidelines focus only on the hair pulling act. The behaviors surrounding the hair pulling problem will further help in the psychological management and also bring new insights into this poorly understood illness.