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Trichotillomania (TTM) is repetitive or compulsive hair pulling. Most commonly, TTM is the excessive pulling out of eye lashes, eye brows and/or hair on the head (scalp). However, the hair pulling may affect other or even all areas of the body. TTM is not diagnosed unless the hair pulling is severe enough to cause emotional or social problems. TTM, like most disorders, may be mild to severe and anywhere in between. A person may have TTM at one point in their life or at many points or even constantly to varying degrees for life. TTM usually affects appearance to only a limited degree for weeks to months and typically the hairs grow back without any lasting damage. In more severe and chronic cases where many hair roots are pulled out, the bald spot may become permanent. Plastic surgery may even be advised.

TTM is most often seen in adolescent girls and young women but may appear at any age and in males as well. TTM may appear alone but is often associated with an anxiety disorder and/or some depression. The anxiety, such as obsessive compulsive (OCD) features, usually seems directly related to the cause of TTM while the depression seems more often related to the distress of having TTM. More recently, the overlap between obsessive thoughts, compulsive actions, and tics (such as in Tourette's syndrome) has caused clinicians to rethink the overlap between these symptoms and the hair pulling of TTM. TTM both tends to run in families and seems caused by abnormalities in the basal ganglia areas deep in the brain that also play a key role in Tourette's, OCD, and skin picking.

Many cases of minor to moderate TTM in youth will pass with development and time, with or without treatment. Societal forces focusing excessively on the lashes, brows, and hair of teenage girls don't help. Dermatologists see people with TTM, just as they often see patients with so called "neurotic excoriations" or psychogenic dermatitis or neurodermatitis. These patients scratch or pick their skin excessively. Although treatment often helps, the best treatments for TTM are not proven yet. Typically the person with TTM is greatly troubled by the urge to pull or pick but may try to suppress it. The urge is often increased by stress. Unfortunately, only a few minutes of giving in to the urge to pull or pick leads to weeks of an obvious bald spot. The youth's guilt and frustration with her lack of control and the parent's upset or the negative social effects can lead to substantial family turmoil as each feels powerless and frustrated at this too often misunderstood disorder.

Dermatillomania (DTM) is commonly known as “skin picking” or compulsive or pathologic skin picking but is also known or can be web searched as neurotic excoriations or the medical terms psychogenic dermatitis or neurodermatitis. These terms include scratching, rubbing, and other behaviors as well. It may be confined to just the face, parts of the body, hairy areas, irregular skin such as “bumps”, real or imagined blemishes, acne, sores, etc or even all over. It may be mild to severe, include unintentional or intentional harm, and even cause permanent scarring. Much of what I said above about TTM is also true of DTM. In fact, DTM may be more common and may often accompany TTM. Both may be hidden by clothes, make-up, wigs for TTM, and various cover stories. Both may persist for many years or even for a lifetime. Both may cause intense shame and indicate or cause self loathing.

Treatment for TTM and DTM includes cognitive and behavior management, known as CBT techniques aimed at distracting or redirecting the urge and behavior. Help to identify both thinking errors, thinking distortions, and to examine and change behavior patterns that may knowingly or unknowingly reinforce or feed into the habit can make a big difference. Habit Reversal techniques help by identifying triggers and routines and then replacing them with healthier substitute behavior or actions and thoughts incompatible with hair pulling, picking, or skin picking and related habits. Learning alternate stress management, relaxation techniques, and healthy life choices as well as education about the condition helps those affected and their loved ones to cope better. Success is greater when these conditions are treated sooner and when milder. However, even severe cases can be helped.

There are also books, support groups, websites and national organizations dedicated to helping and educating both those suffering from these conditions and others. These include Dermatillomania Center regarding Skin Picking http://www.skinpick.com and the Trichotillomania Learning Center (TLC) http://trich.org.

Medication treatment follows from the newer understanding of the brain circuitry involved. Frequently, an SRI such as fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine, citalopram or escitalopram (Lexapro) is a first choice and other medications with dual action (venlafaxine, Cymbalta = duloxetine), or a booster or tic medicine such as Pimozide (Orap), risperidone, or ziprasidone (Geodon) may be useful. Non medicine alternative options may help as much or more. The over the counter amino acid N.A.C. (N-Acetyl-Cysteine) which helps regulate glutamate has been shown in one good study to be worth considering for TTM for at least some people.

As in other psychiatric disorders, a combination of psychotherapy and medication is often best, especially for the moderate to severe or chronic and recurrent cases. Although medications may help they are too often not as helpful as in other conditions. Thus, the role of therapy including psycho-education and support groups are often more important.

(07/14)