Trichotillomania Part Four – Ok so I have Trichotillomania. Now what?

Trichotillomania is a hair pulling disorder that was first described in the 1889. There can be some ritual behaviors connected with this condition. Rolling the hair, running the hair over one’s lips, and pulling out specific hairs based on color, length and texture are all possible behaviors. (1) This condition is quite tricky to treat. There are several treatment options to consider. Some examples of treatments include comprehensive behavior treatment, and medication. (2–5)

Habit reversal training (HRT) is a type of comprehensive behavior therapy. This therapy focuses on one’s feelings, thoughts and behavior. Examples of items included in HRT are awareness training, reaction training and social support. When this type of therapy was evaluated in a large scale behavioral outcome study there was over a 90% reduction in hair pulling. (5)

There are also several different types of medications that are currently being tested for safety and efficacy. An example of a drug that has been looked at in the treatment of Trichotillomania is N-acetylcysteine. When trichotillomania patients were given this drug, they showed decreases in hair pulling symptoms with 56% of patients that were “much or very much improved”. (4) A possible issue in treating Trichotillomania with medication is side effects. Examples of side effects include constipation, dry mouth, and tremors. (6) Caution should be taken as anxiety and depression are already linked to this condition. (7)

The amount of options to try might seem overwhelming but with a discussion with your doctor and checking out some resource centers (such as Trichotillomania Learning Center www.trich.org) a right treatment plan can be made. Families and friends can play a major role as well in your treatment success. Using effective communication to correctly inform family members of your condition can be a great start on your way to recovery. Please stay tuned for a follow up blog on trichotillomania in children.

Article by: Sarah Versteeg MSc, Mediprobe Research Inc. 

1. du Toit PL, van Kradenburg J, Niehaus DJ, Stein DJ. Characteristics and phenomenology of hair-pulling: an exploration of subtypes. Compr Psychiatry. 2001 Jun;42(3):247–56.


2. Falkenstein MJ, Mouton-Odum S, Mansueto CS, Golomb RG, Haaga DAF. Comprehensive Behavioral Treatment of Trichotillomania: A Treatment Development Study. Behav Modif. 2015 Dec 7;


3. Ducasse D, Fond G. [Acceptance and commitment therapy]. L’Encéphale. 2015 Feb;41(1):1–9.


4. Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry. 2009 Jul;66(7):756–63.


5. Azrin, N.H, Nunn R.G., Frantz, S. E. Treatment of hairpulling (Trichotillomania): A comparative study of habit reversal and negative practice training. J Behav Ther Exp Psychiatry. 1980 Mar;11(1):13–20.


6. Rothbart R, Amos T, Siegfried N, Ipser JC, Fineberg N, Chamberlain SR, et al. Pharmacotherapy for trichotillomania. Cochrane Database Syst Rev. 2013;11:CD007662.


7. Teng, Ellen J, Woods, Douglas W, Marcks, Brrok A, Twohig, Michael P. Body-Focused Repetitive Behaviors: The Proximal and Distal Effects of Affective Variables on Behavioral Expression. J Psychopathol Behav Assess. 2004 Mar;26(1):55–64.

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My top 5 hair vices and how I overcame them, (plus one I’m still working on)

When it comes to our hair-growing abilities (or inabilities,) one of the main factors is genetics. A predisposition for conditions such as pattern-baldness or alopecia areata can obviously have a significant impact on your life¹ however there are some good and bad habits which can contribute to the hair that you do have to work with. And even though I should know better with the career path I chose, here are some of my past and present challenges with my own hair:

Traction alopecia

Everyone is super busy these days so I’m sure that you can appreciate that sometimes, (translation: always,) I feel pressed for time. My coping mechanism was to cut the time I spent in front of the mirror every morning by pulling my hair into the same bun on top of my head, often when it was still wet, putting me at risk for traction alopecia.

Traction alopecia occurs when there is enough pressure put on the hair follicle to pull out the hair strand prematurely². Repeated instances can affect the ability of the hair to grow back and extreme cases can lead to permanent hair loss. Very tight hairstyles such as braids and ponytails can result in traction alopecia. In my case, having wet hair made it heavier and more prone to breakage and pulling.

When my hair dresser gave me a very stern lecture, I did learn to change my habits. I now have a few quick and easy hairstyles that I alternate between so that I avoid putting pressure in the same spots every day. I have also replaced my use of hair elastics which were causing a lot of damage with some gentler accessories such as soft headbands and various smooth plastic clips.

Cosmetic over-processing

In the past, I have tried some lightening treatments which led to some very noticeable damage. Going forwards, I just decided to avoid the use of permanent dye altogether. For those who really enjoy experimenting with colour, there are some options to keep damage to a minimum. Researchers recommend waiting a minimum of six weeks between harsh chemical treatments such as dyes or straighteners/relaxers³. A second option is to choose a non-permanent dye. Permanent dyes are designed to penetrate the outer layer of the hair strand, the hair cuticle, which can be damaged in the process⁴. A non-permanent dye will need to be applied more frequently and generally provides less colour options, however it will be designed to coat the hair strand, thus avoiding possible penetration damage.

Spring shed

Spring is pretty much the worst time of the year for my vacuum. Although not directly within my control, I definitely experience seasonally-related shedding^5–8 and springtime is the most noticeable for me.

Hair growth normally follows a cycle where at any given moment in time there will be follicles actively growing, resting or shedding. During seasonally-related shedding, many of the follicles become synchronized, meaning more hair than usual is shed at the same time, however those follicles also return to the growth cycle so there is no concern for hair loss⁹.

With three females in my household who prefer Rapunzel-inspired hair styles, (and I am by far the worst offender,) we make sure all of the drains have hair traps and wait it out. The shedding usually stops by the time my grass allergies kick in and all the hair seems to have grown back in time for the fall shed making this one more annoying than a problem.

Fall shed

Very similar to the spring shed, just maybe a slightly milder version.

Itchy scalp

This one seems to be a result of my sedentary lifestyle. While I’m sitting at my desk thinking my hardest I will often literally put my hands on my head, (maybe I’m subconsciously trying to encourage my thoughts or something?). This can lead to some mild scratching/pulling and damage.

Dandruff as well as the presence of microorganisms including yeast can also potentially lead to an itchy scalp. There are a plethora of products and shampoos targeted at reducing dandruff and likewise shampoos containing anti-microbial ingredients such as ketoconazole or salicylic acid can help to reduce microbe populations. Reducing the amount of styling products you use could also be beneficial.

Now that I am aware of the habit though I’m thinking that I can just cut it out. I will let you know when that happens.

References

1. Santos Z, Avci P, Hamblin MR. Drug discovery for alopecia: gone today, hair tomorrow. Expert Opin Drug Discov. 2015 Mar;10(3):269–92.


2. Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Determinants of marginal traction alopecia in African girls and women. J Am Acad Dermatol. 2008 Sep;59(3):432–8.


3. Ahn HJ, Lee W-S. An ultrastuctural study of hair fiber damage and restoration following treatment with permanent hair dye. Int J Dermatol. 2002 Feb;41(2):88–92.


4. Marsh J, Gray J, Tosti A. Root-to-Tip Hair Health. In: Healthy Hair [Internet]. Cham: Springer International Publishing; 2015 [cited 2016 Feb 29]. p. 29–44. Available from: http://link.springer.com/10.1007/978-3-319-18386-2_2


5. Ebling FJG. The Hormonal Control of Hair Growth. In: Orfanos CE, Happle R, editors. Hair and Hair Diseases [Internet]. Berlin, Heidelberg: Springer Berlin Heidelberg; 1990 [cited 2016 Mar 14]. p. 267–99. Available from: http://www.springerlink.com/index/10.1007/978-3-642-74612-3_12


6. Messenger AG. The control of hair growth: an overview. J Invest Dermatol. 1993 Jul;101(1 Suppl):4S – 9S.


7. Courtois M, Loussouarn G, Hourseau S, Grollier JF. Periodicity in the growth and shedding of hair. Br J Dermatol. 1996 Jan;134(1):47–54.


8. Wehr TA, Duncan WC, Sher L, Aeschbach D, Schwartz PJ, Turner EH, et al. A circadian signal of change of season in patients with seasonal affective disorder. Arch Gen Psychiatry. 2001 Dec;58(12):1108–14.


9. Headington JT. Telogen Effluvium: New Concepts and Review. Arch Dermatol. 1993 Mar 1;129(3):356.

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Trichotillomania Part Two – Comparing Urges

There are quite a few characteristics associated with Trichotillomania. At the core, this condition consists of the repetitive pulling of one’s hair. The scalp is the most common hair pulling site, however other areas include eyelashes, eyebrows, pubic hair, body hair and facial hair. (1) Fingers, tweezers, pins or other mechanical devices have been used by individuals to pluck the hairs. Tension before pulling a hair or when trying to resist pulling is a known characteristic symptom of this condition. (2) People have reported sensations that draw them to hair pulling like itching, tingling, pain; however that may not be the case for everyone.

To make this relatable for those who do not have trichotillomania, please visualize a chocolate bar. A really good melt in your mouth chocolate bar. That feeling you get, that urge to go right now and eat that delicious chocolate bar has actually been compared to the urge of hair pulling in individuals with Trichotillomania. A study done on 208 people with trichotillomania were asked about their hair pulling urges and attempted to compare these urges towards urges for junk food (insert feelings toward that amazing chocolate bar here).  Twenty-seven to 59% of individuals said that the urge to pull hair was actually much more severe than the urge to eat junk food.  (3) When the hair is plucked feelings of pleasure or relief can even arise. An individual with trichotillomania can share similar characteristics of those of an addict. Some similarities include repetitiveness, lack of control over the behavior, an urge to do it, and experiencing pleasant feelings while doing it. (4)

This condition is often life-long, difficult to treat and usually starts in childhood, around age 4 to 17. (5) Please stay tuned to a follow up blog describing the health consequences of trichotillomania, treatment options and trichotillomania in children.

Article by: Sarah Versteeg MSc, Mediprobe Research Inc. 

1. Cohen LJ, Stein DJ, Simeon D, Spadaccini E, Rosen J, Aronowitz B, et al. Clinical profile, comorbidity, and treatment history in 123 hair pullers: a survey study. J Clin Psychiatry. 1995 Jul;56(7):319–26.


2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th Edition. Arlington, VA: American Psychiatric Publishing; 2013.


3. Madjar S, Sripada CS. The Phenomenology of Hair Pulling Urges in Trichotillomania: A Comparative Approach. Front Psychol. 2016;7:199.


4. Grant JE, Odlaug BL, Potenza MN. Addicted to hair pulling? How an alternate model of trichotillomania may improve treatment outcome. Harv Rev Psychiatry. 2007 Apr;15(2):80–5.


5. Keuthen NJ, O’Sullivan RL, Sprich-Buckminster S. Trichotillomania: current issues in conceptualization and treatment. Psychother Psychosom. 1998 Oct;67(4-5):202–13.

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Why am I losing my hair – the facts on cosmetic over-processing

There are many reasons for hair loss, some of which have been discussed throughout this blog: pattern baldness, alopecia areata, shedding (telogen effluvium) and even rare hair disorders. Likewise we have also mentioned possible treatment options, the evidence supporting them, as well as the possible side effects. There are some cases however where improving your hair loss can be as easy as recognizing the behavior that can exacerbate it.

You have probably already heard that regular everyday styling can lead to over-processing. Moreover over-processing is a leading cause of physical hair damage. Heat processing tools such as curling and straightening irons as well as harsh chemicals found in hair dyes can significantly affect the integrity of the hair fiber¹. Daily styling can compound the damage, further weakening the hair fiber and increasing the likelihood that it will break off.

The hair cuticle is an outer layer of the hair fiber which protects the inner layer, the cortex, from damage. To function properly, bleaches, dyes, and processing chemicals such as those used in straightening treatments must reach the inner cortex layer. If these chemicals are applied for too long, in high concentrations, or too often, the cuticle can be damaged or lost, exposing the cortex. An exposed cortex may then lead to the splitting and breaking related to cosmetic over-processing.

The cuticle can also be damaged through rough styling techniques including aggressive brushing and back combing. Regularly using a blow dryer on high heat is another good example of how to damage the cuticle.

While over-processed and damaged hair is difficult to treat, perhaps very obviously, relaxing your hair care routine can allow the hair fiber to recover. For instance, experts have recommended leaving a minimum of eight weeks between treatments ². Overall, generally limiting harsh treatments will help to encourage the regrowth of healthy, undamaged hair³.

Article by: Dr. J.L. Carviel, PhD, Mediprobe Research Inc.

References

1. Marsh J, Gray J, Tosti A. Root-to-Tip Hair Health. In: Healthy Hair [Internet]. Cham: Springer International Publishing; 2015 [cited 2016 Feb 29]. p. 29–44. Available from: http://link.springer.com/10.1007/978-3-319-18386-2_2


2. Ahn HJ, Lee W-S. An ultrastuctural study of hair fiber damage and restoration following treatment with permanent hair dye. Int J Dermatol. 2002 Feb;41(2):88–92.


3. Khumalo NP, Jessop S, Gumedze F, Ehrlich R. Determinants of marginal traction alopecia in African girls and women. J Am Acad Dermatol. 2008 Sep;59(3):432–8.

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Top 5 habits that could lead to hair loss

Some of the most common reasons for hair loss are determined by your genetics. People can inherit a pre-disposition for hair loss conditions such as male pattern baldness and alopecia areata. Even so, your hairline is not absolutely completely out of your control. There are some habits which have been shown to be associated with hair loss that you can moderate or avoid all together.

Use of harsh chemicals

Unsurprisingly, regular use of harsh chemicals such as dyes, straighteners and relaxers can damage your hair, leading to splitting and breaking¹. Researchers investigating hair loss caused by over-processing recommend waiting a minimum of eight weeks between treatments¹. Also be cautious that the product is not applied for too long, or in an unnecessarily high concentration.

Your hairstyle

Fans of tight hairstyles such as ponytails and braids, beware of traction alopecia. When pressure on the hair follicle is forceful enough, the hair is pulled out prematurely. It is designed to grow back, however if the cycle is repeated on a regular basis, permanent damage to the hair follicle can result in hair loss². The concept is similar to waxing or epilating body hair. The more often you wax, the less hair you notice growing back. To avoid traction alopecia, try varying your daily hairstyle.

Tight hats

Similar to the tight hairstyle, a hat worn tight enough to pull on the hair, or helmet that rubs in the same spot over long periods of time can also lead to traction alopecia.

Diet, weight and the party-animal

Your diet and weight can influence many aspects of your life, including your hairline. Consumption of alcoholic beverages as well as obesity at a young age has been linked to male pattern baldness^3,4.

Sun exposure

Do you work outside or live in a sunny climate? Increased exposure to sunlight has also been associated with the development of male pattern baldness⁴.

Overall, although your genetics are most likely going to play a large role in your hair retention, there are some ways in which you can contribute. If you are worried about your hairline, your dermatologist or hair restoration expert can help assess your individual situation.

Article by: Dr. J.L. Carviel, PhD, Mediprobe Research Inc.

References

1 – Ahn HJ and Lee W-S. An ultrastuctural study of hair fiber damage and restoration following treatment with permanent hair dye. Int J Dermatol. 2002 Feb;41(2):88–92.

2 – Khumalo NP, Jessop S, Gumedze F and Ehrlich R. Determinants of marginal traction alopecia in African girls and women. J Am Acad Dermatol. 2008 Sep;59(3):432-8. doi: 10.1016/j.jaad.2008.05.036.

3 – Severi G, Sinclair R, Hopper JL, English DR, McCredie MRE, Boyle P, et al. Androgenetic alopecia in men aged 40-69 years: prevalence and risk factors. Br J Dermatol. 2003 Dec;149(6):1207–13.

4 – Su L-H and Chen H-H. Androgenetic alopecia in policemen: higher prevalence and different risk factors relative to the general population (KCIS no. 23). Arch Dermatol Res. 2011 Dec;303(10):753–61.

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