Trichotillomania
The patient often appears to be indifferent or to have poor insight as to the cause of the illness. During interviews, the patient’s responses are ambiguous and could baffle an inexperienced physician. It is worthwhile to remember that hair manipulations frequently occur while patients are engaged in sedentary activities such as reading, writing or watching television. For some reason, many patients claim that their hairs do not grow longer than 1.5cm, and frequently comment of itching scalp skin.
The compulsive behavior perpetuating the alopecia has not yet been fully explained, but it may be included in a category of impulse control disorders. The continued repetitive behavior of hair manipulation may require a certain mental state characterized by tension with gratification or relief from the hair-pulling. However, it is not sufficient to call the hair-pulling a purely compulsive reaction. The initial impulse can be triggered by varied cues in the patient’s mind.
Internal cues include various emotions such as anger, frustration and loneliness. External cues might include an environment where the patient is prone to manipulate the hairs without being interrupted. Although no universal cause of these cues is known, an unsatisfying family relationship or loss of maternal love, especially in children, is most often evident.
Also, it may be possible that once the behavior is established, it becomes habitual, regardless of the initial causative emotional problem.
The kinds of manipulations to which hairs can be subjected include rubbing, twisting, breaking, plucking and pulling. Although the name Trichotillomania suggests the act of plucking (from the Greek word “tillein”, meaning “to pluck”), actual plucking seems to be a minor component of the total hair manipulations. If the force of pulling (versus plucking) induces premature entry of the follicles into the catagen phase, this would subsequently lead to increased hair shedding.
Likewise, breaking of hairs may not be accomplished by only a single manipulation of the hair shaft. Repeated trauma to the hair would make the already-manipulated hair more vulnerable to the subsequent injury, resulting in hair that is more easily broken. For these reasons, patients may believe the alopecia is due to a disease of the hair itself.
These behaviors can occur deliberately, semiconsciously or often unconsciously. Therefore, a patient’s ambiguous answers to the physician’s questions are not surprising, and they do not represent intentional malingering. To understand Trichotillomania, is it necessary to have an understanding of both the biology of hair and the patient’s psychological state.
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