Written by Hannah Sommer Garza, Ph.D.

As a trichotillomania (trick-o-till-o-may-nee-uh; TTM or “trich”) treatment provider, I have come across many myths and misconceptions about trichotillomania (hair-pulling disorder) from new clients, family members of new clients, other people in my social network, and even other medical and psychological treatment providers. “That’s where people believe there are bugs in their hair, so they pull to get them out, right?” I’m telling you, I feel like I’ve heard it all!

While I happily dispel myths and provide more accurate information in those situations, I have come to realize how little most people know about trichotillomania in general. I also think that the existence of these misconceptions can lead to individuals with trich feeling stigmatized at home, with friends, at school/work, and with their doctors/hairstylists/coaches (fill in the blank). I’m hopeful that by sharing up-to-date information, we can decrease stigma associated with trichotillomania and the pursuit of trichotillomania treatment. I believe that knowledge is power, and I hope that this post gives more power to individuals with trichotillomania.

What is Trichotillomania?

Trichotillomania, also known as hair-pulling disorder, is the repetitive pulling out of one’s hair. Pulling sites vary from one individual to the next with trich, and they can be from anywhere on the body where hair exists (e.g. scalp, eyebrows, eyelashes, arms, legs, pubic area, chest, stomach). Trichotillomania is considered a diagnostic mental health disorder, and it is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an Obsessive-Compulsive and Related Disorder. Trich is also considered a body-focused repetitive behavior (BFRB)  http://www.bfrb.org/learn-about-bfrbs alongside excoriation (skin-picking), and onychophagia (nail-biting).

According to the DSM-5, diagnostic criteria for Trichotillomania are:

1. Recurrent pulling out of one’s hair, resulting in hair loss

2. Repeated attempts to decrease or stop pulling

3. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

4. The hair pulling or hair loss is not attributable to another medical condition (e.g. a dermatological condition)

5. The hair pulling is not better explained by the symptoms of another mental disorder

Now that we’ve covered the basics, let’s get to the myths and misconceptions.

Myth:  Trichotillomania is Rare

Nope. Research shows that about 1 or 2 in 50 people have trichotillomania at some point during their lifetime. That means that of the approximate 325 million people in the United States (according to the U.S. Census Bureau), around 6.5 million to 13 million (MILLION!) people will meet diagnostic criteria for trichotillomania at some point during their lifetime. As an anecdote, since talking openly with family and friends about treating trichotillomania and other BFRBs, I have had people come out of the woodwork to tell me that they have trich, have a relative with trich, or know someone with trich. It’s a lot more common than you might think.

One reason trichotillomania may seem to be a rare problem is that many individuals with trich feel shame, embarrassment, or other undesirable emotions related to disclosing their trich to others. Social and cultural messages about hair, beauty, and mental strength can contribute to this too. Many individuals with trichotillomania go through great lengths to hide it, and may do so by wearing makeup, hairpins, hats, headwraps, or other concealing clothing. It is also common for individuals with trichotillomania to avoid doing certain activities that may lead to them being “discovered” such as attending sleepovers, going outside on a windy day, going swimming, going to the hair salon, etc. Taken together, the pressure to stay silent about trich due to stigma and people’s savvy with concealment make trichotillomania seem more rare than it really is.

Myth:  Only Girls Have Trichotillomania

Boys can definitely have trichotillomania. In fact, rates of trichotillomania are similar for boys and girls during childhood. They become much more skewed toward girls (80-90% of cases) in adulthood. It is suspected that women/girls are much more likely to seek professional help for trichotillomania compared to men/boys. A study found similar rates between men and women in the community (i.e. not treatment-seeking) and higher rates of women with trichotillomania in clinical settings (i.e. treatment-seeking). One theory is that men are better able to conceal their trichotillomania by shaving their face or head. In the U.S., people may not think twice about seeing a man with a shaved head, but a woman with a shaved head may get all kinds of odd looks or questions. “Do you have cancer?” Thus, societal norms about hair and hair loss may influence women to seek treatment more compared to men. The jury is still out, though, and more research is needed to give us a definitive answer about reasons for gender differences seen in epidemiological studies. Regardless of differences in rates, studies generally show that trichotillomania presentation is similar for men and women and response to treatment is similar for men and women.

Myth:  Trichotillomania is the Result of Trauma

There is no clear evidence to support this myth. About 50% of people with trichotillomania report some sort of negative event or trauma occurring in their lives around the time they started pulling…BUT those events include common occurrences such as changing schools, moving to a new city, or parents divorcing. The other 50% deny experiencing ANY negative events when they started pulling. If trichotillomania was truly the result of trauma, trauma would be reported in much higher numbers. Additionally, many people experience negative events throughout their lives and do not go on to develop trichotillomania. Similarly, many people have trichotillomania without previously experiencing significant negative events. Ultimately, the research shows that there’s just not a clear link of trauma predicting trichotillomania. The causes of trichotillomania are still being researched, but the explanation appears to be much more complicated than one root cause. Furthermore, research suggests that there may be a related genetic component. Many BFRBs and Obsessive-Compulsive Related Disorders and sub-clinical features of these issues tend to cluster together within families.

Myth:  Trichotillomania is OCD

I hear this one a lot, so let’s set the record straight. Trichotillomania is in the Obsessive-Compulsive and Related Disorder section of DSM-5 because there are some noteworthy similarities among disorders in that section. The main similarities are that both people with trich and those with OCD report having compulsive urges and repetitive behaviors. Otherwise, contextual and functional subtleties differentiate the two.

OCD obsessions are intrusive thoughts or images that are distressing. “Obsessions” about pulling in trichotillomania are more likely to be associated with focused pulling, or purposeful pulling within the individual’s awareness. For instance, thoughts associated with urges like “this kinky hair needs to go” or “I will only pull one more” may precede pulling behaviors. These “obsessions” in trichotillomania would only relate to hair-pulling. If someone has “obsessions” about hair pulling AND another topic (e.g. germs), then it is possible that they meet diagnostic criteria for both trichotillomania and OCD. Studies have found approximately 6.5%-10.7% of individuals with trichotillomania to have a comorbid diagnosis of OCD.

An OCD compulsion is a repetitive mental act or behavior used in response to an obsession. For example, washing one’s hands extensively or repetitively (compulsion) in response to the fear of becoming ill (obsession). For these reasons, it is understandable why many people might get confused that repeated attempts to pull out one’s own hair is a “compulsion.” However, there are some noteworthy differences. With trichotillomania, there is an element of sensory self-soothing. Many people with trichotillomania report having an enjoyable feeling or feeling of relief during pulling (and often feelings of regret after pulling). In contrast, people with OCD are distressed by their obsessions and compulsions. Ultimately, it is important to understand the content of “obsessions” and the functions of pulling behaviors and other possible “compulsions” to differentiate between trichotillomania and OCD.

Conclusion

Researchers continue to explore features of trichotillomania in order to clarify some of the existing myths and misconceptions, and to find the best ways to treat trichotillomania and other BFRBs. There is a major multi-state study trying to do just that. If you’re interested in learning more or getting involved with the research initiative, check out the BPM Research Initiative  http://bfrb.org/research-programs-news/bpm.

Now that you know a little more of the truth about trichotillomania, you can help to spread the word and spread the knowledge. Let’s work together to reduce trichotillomania stigma. Look for our next post on more myths and misconceptions about trichotillomania, especially related to the reasons for pulling and treatment/recovery options. For more information about trichotillomania, check out the Trichotillomania Learning Center (TLC) Foundation for BFRBs http://bfrb.org/ .

Resources

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th Ed.; DSM-5). Washington, DC.

Grant, J. E., Stein, D. J., Woods, D. W., Keuthen, N. J. (2012). Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors. Washington, DC, London, England: American Psychiatric Publishing Inc.

Mouton-Odum, S., Goldfinger Golomb, R. (2013). A Parent Guide to Hair Pulling Disorder:  Effective Parenting Strategies for Children with Trichotillomania. Goldum Publishing.

I recently attended the 10^th Biennial Bereavement Conference presented by Baylor Scott & White Health Care System.  The conference was titled “Coping with Bereavement Complications,” and among the invited speakers was Dr. Edward K. Rynearson, M.D. who presented on the treatment of traumatic grief after violent death.

On a yearly basis in the U.S., violent deaths (suicide, homicide, and most accidental deaths) total between 180,000 to 200,000 and comprise about 5 to 7% of total deaths.

In 2014 for example, about 2.6 million people died in the U.S.  Of these, about 130,000 deaths were caused by unintentional injures from accidents (4^th leading cause of death), 42,000 suicides (10^th leading cause of death), and about 16,000 homicides.  In 2014 then, about 198,000 deaths, or about 7% of all deaths, were unnatural, sudden, violent, and in many cases, preventable.

These types of violent losses give rise to a grief process that is more likely to be complicated.  To be bereaved by such a loss is to feel helpless, powerless, and to question “why” this happened. It is also to feel deep pain over the thought that our loved one died in such a horrific manner, alone, without our presence nearby. This is to say that there are some unique dimensions to grief after the loss of a loved one to a violent death.  Violent dying defies reason.  One can’t make meaningful sense out of it by thinking about it over and over again.  This is a death that never should have happened, and mourners are likely to be plagued by intense, highly disturbing visual imagery of what they imagine happened to their loved one.

To get a sense of the scope and intensity of the pain of these types of losses, 30 to 50% of mourners will experience depression or significant anxiety in the first year after such a loss.  Those at highest risk are mothers who have lost a child (a full 30% of whom will display PTSD symptoms a full five years after the loss).  Excruciating suffering is normal (for a time) after such a loss.

A particular form of grief therapy is helpful to many bereaved people in such a situation.  Initially, interventions are designed to assist in the reduction of acute distress.  In this phase, attention is paid to creating coping strategies to manage one’s own emotional and body-focused expressions of distress (i.e., self-regulation).  After self-regulatory skills are more readily available to a person, the narrative of the person who died, their relationship to the bereaved, and the manner of dying is processed, including commemorating the person for whom they were while they were alive.  Over time, the focus shifts to reengaging in life in ways that are personally meaningful.

Medications may be helpful for the depressive features and anxiety, but they will not help much with the grief component underlying the distress.

Despite the shock, horror, agony, despair, and utter shattering that occurs in individuals and families after the death of a loved one to a violent death, experience teaches that one can (and most likely will) prevail in the long run.

Dr. Rynearson’s website vdbs.org: Violent Death Bereavement Society has a tremendous amount of valuable information, including research findings and grief and bereavement resources.

With the recent events that have taken place in this country it is hard to imagine how and when these acts of violence will cease. It can be difficult to feel safe and calm when the world is painting a different picture. National events like those in Baton Rouge and Dallas can cause anxiety for both children and adults. Are we safe? When will the violence stop? When will the next tragedy happen? Where will it happen? These are all questions many of us have asked ourselves over the past couple of weeks. If your thoughts are racing with questions like these, know that you are not alone.  In times of stress in our country it is important to take a step back and remind ourselves that we are all responsible for our own actions and choices, and we must remain calm and steadfast when external situations make us feel out of control.

So, what can you do? Don’t worry, if you are concerned about the state of the world, or struggling with anxiety in general, there are steps you can take to overcome it. First things first, you are safe. You are likely reading this blog from your home, office, or on your smart phone while running errands. One of the best things you can do to create stability in your life is to maintain your routine. Maintaining your everyday routine will allow you to feel a sense of control in an ever changing world. Along the same lines, it is also important to separate out the things you can control from those you cannot. If you can focus on the specific difficulties in your life that you can control, you usually end up feeling much better about everything else. The interesting thing about anxiety is that once you let go of wanting to control everything and just focus on living, your anxiety will decrease. If your anxiety about the state of our country still feels intense—take action! Write a letter to your local congressman or state senator, engage in a random act of kindness the next time you are at Starbucks, or take some baked goods to your local police station or firefighters. Once you do something productive and proactive you will notice that you will begin to feel better. Your act of kindness will also help others to feel better. And last but not least, spend some time with your family and loved ones. They will remind you of not only what is important in your life, but also that people do love each other.

Dr. Rosie

When you think of “coping” with a problem, how do you define that term?  Here are three definitions of “cope.” (1) To deal with and attempt to overcome problems and difficulties, (2) To deal effectively with something difficult, (3) To deal successfully with a difficult situation.  Notice that in each of these definitions of coping, it is not simply enough to “deal with” a problem; the key is to do so in such a way as to “overcome” it “effectively” or “successfully.”

When you become aware of a problem in your life, what do you do?  The problem might be a troubling present situation, or may be one that is coming, perhaps just around the corner.  Viktor Frankl, a famous doctor, writer and concentration camp survivor, teaches us that there are some situations in which there is absolutely nothing we can do to alter a painful external situation (e.g., being in a concentration camp, being held hostage, etc.), and that in such a situation, one can still exert the “last of the human freedoms,” to alter one’s attitude toward one’s situation and one’s suffering.  However, in most situations, we can most certainly make decisions and act in ways to make our problems dissipate or resolve.

Yet how many times do we find ourselves doing counterproductive things?  We want for the situation to get better and to feel better, but we hesitate to do what is required of us in that situation.  We make the mistakes of being in denial, avoiding, procrastinating, etc. While these avoidance techniques may help you to (temporarily) feel better, what they are also doing is allowing the problem to fester and perhaps get worse.

So, we need to get clear on what exactly the problem is, its’ scope and dimensions, and to do that we need to face it.  After all, how can we solve a problem if we won’t allow ourselves to understand it.  The goal is to figure out a solution, a way forward, to devise a plan, and then to execute the required steps to get there.  So, ask yourself when you come across a situation that is a challenge or problem, “Do I want to solve this, or, not?”  It seems to me that it is far preferable to do all that one can do to alter the actual situation so that the problem is successfully managed.   We can all learn to cope better by sharpening our problem-solving skills, but remember, the most important idea here is that one must first be willing to face and directly confront our problems.  If you will allow yourself do this, you are already on the road to coping better.

Cheers,

Steve Bailley, PhD

Ask anyone on the street what they imagine when they hear the words “therapy” or “psychologist” and you’ll likely hear something along the lines of lying on a long couch, talking about the past, and some form of analysis, whether it be your dreams, childhood, unconscious, or relationship with your mother.

When new patients come in for therapy, they often do not know what to expect. And they often come in with these preconceptions. However, when it comes to mental health treatment, there is a significant amount of variety, from level of training (masters, doctorate) to type of provider (counselor, social worker, physician, psychologist) to treatment approach (psychoanalysis, cognitive behavioral therapy).

We know from research that the single most important factor associated with treatment success is the strength of relationship between patient and therapist, something called therapeutic alliance. However, therapeutic alliance by itself is only one piece of the puzzle, as there are a number of other factors also associated with treatment success. One of these factors is treatment approach, also called theoretical orientation. This refers to how a therapist generally understands and explains a patient’s symptoms or difficulties, and importantly, guides how the therapist will provide treatment.

Cognitive behavioral therapy (CBT) is a treatment approach that assumes emotions, thoughts, and behaviors are connected and influence one other. Patients typically come in for therapy because of unpleasant or painful emotions, such as anger, depression, anxiety, or worry. But the problem is this: Telling someone, including ourselves, not to feel a certain way has little or no effect. Just think of the last time you were angry and someone asked you to calm down, or feeling depressed and told you to cheer up.

Put simply, we can’t change the way we feel just by choosing to feel differently. However, we can change the way we think and we can change the way we behave. And because these are related to our emotions, we can target how we feel.

For example, say your friend is feeling depressed. Simply telling them “don’t be sad” wouldn’t have much success. But suppose your friend is also having thoughts such as “I can’t seem to do anything right,” “things will never get better,” or “I’m a failure.” And suppose they’re isolating themselves, not exercising, or socializing with friends or family. It’s no surprise these patterns would make your friend’s depression worse.

A cognitive behavioral therapist would challenge these thoughts: Is it really true you can’t do anything right? What evidence do you have that nothing will get better? Have things ever been difficult in the past and actually did get better? And what does being a failure even mean? Living under I-10 addicted to heroin? The therapist would also target the behaviors maintaining depression. In-between sessions, they would assign homework to increase more adaptive behaviors, perhaps call one friend each day, walk/run around the block three times this week, or engage in activities they used to find pleasurable.

The take home message is this: Our thoughts and behaviors are not written in stone. They are malleable. Changeable. And behaviors can be learned. Unlearned. Relearned. And it is this very process of change that lies at the core of cognitive-behavioral therapy, and why it is so often successful.

Tyson Reuter, Ph.D.

Change is hard, but beautiful. After 17 years of being in the same office practicing psychology, we are moving. Not only will we have a new location, but we also have a new practice. Psychology Houston, PC was a concept to bring evidence-based treatment to Houston in a cohesive and direct way. All of us in the practice specialize in treating people with diverse backgrounds and issues utilizing state of the art treatment that has been proven to work in research studies. Treatment is effective, but conducted in a way that really focuses on the therapeutic relationship. In the end, it doesn’t matter what treatment you are doing, if your client does not feel safe, trust in the therapist, and comfortable in the relationship, the treatment will likely not work. So as I packed up my office yesterday I felt sad, but excited for this new beginning. Change is hard and creates many questions and fears about the unknown. As I teach my clients, I am focusing on embracing the unknown, going boldly into the future, curious about how things will unfold over the years to come. Thanks to everyone who has contributed to this move and to all of my clients who have supported my practice over the years, to you all I am truly grateful.

Suzanne Mouton-Odum, Ph.D.