ABSTRACT: Trichotillomania (TTM) is an enigmatic psychiatric disorder that primarily affects women. TTM manifests itself in an overwhelming compulsion to pull out hair, from the scalp and other body sites. TTM is not well known by either the public or health care providers. Nurses need to be informed about this disorder as they can play a key role in the care of people with TTM.
BACKGROUND: Nurses are positioned for a key role in diagnosis and management of Trichotillomania (TTM). Currently classified as an Impulse Control Disorder (APA, 2000), TTM is characterized by an overwhelming compulsion to pull out one's hair, most notably from the scalp, but also the eyebrows, eyelashes, beard, extremities, and axillary and pubic areas. Hair pulling occurs in response to an irresistible urge, which when gratified, results in relief. Both males and females may sufferer from TTM, but the disorder occurs primarily among females. Although once thought rare, current estimates are that 3.4% of all females engage in clinically significant hair pulling in their lifetime (Stemberger et al., 2000). TTM has a profound impact on the personal and professional lives of sufferers who may expend an immense amount of effort to hide their condition. Thoughts of suicide are not uncommon among TTM sufferers.
Most research on TTM has been clinical or pharmaceutical in nature. Existing literature reflects efforts to understand the disease from neurobiological, phenomenological, psychosocial and pharmaceutical perspectives. The current consensus is that the etiology involves a complex interaction among biological, psychosocial, and social factors (Enos & Plante, 2001).
Identifying TTM can be challenging since sufferers go to great lengths to hide their symptoms, (Boughn & Jaarsma Holdom, 2004). Shame and embarrassment lead to symptom concealment and failure to seek medical treatment. However, in the last two decades people with TTM have begun to speak about their disorder, and consequently, awareness among health care professionals and the public has increased.
METHODS: In this study women from 21 states and Canada participated in 1-2 hour semi-structured interviews in which they described living with TTM. Grounded theory (Glaser & Strauss, 1967), which emphasizes the "emergence" over "forcing" in acquiring data, informed the data collection and analysis.
RESULTS: Detecting TTM: Participants described ritualistic behaviors such as pulling hair across or between the lips, saving and hiding hair; burning hair strands, and inspecting the hair follicle bulb. Some described biting or eating the hair or follicle bulb. Ingesting large amounts of hair sometimes results in a trichobezoar, a condition that necessitates surgical removal. Most participants described a trance-like state from which they emerged horrified at the amount of hair they had pulled out.
Three dimensions were described that should assist nurses in detecting TTM. The first dimension of detecting TTM involves visual inspection for signs of concealment of hair-pulling. TTM sufferers may wear wigs, hair pieces, hats or scarves-even in warm weather. Some create elaborate hairdos in which swaths of hair are pulled over bald areas, while others keep their hair very short to discourage pulling. Many diligently avoid activities resulting in close examination or disturbance of their hair such as going out in the wind, participating in athletics, and/or involvement in intimacy. Some women shave their heads to avoid pulling, and allow others to assume that they are undergoing chemotherapy.
The second dimension for detecting TTM necessitates close inspection of scalp and other hairy body sites. Hair may be evenly distributed but very sparse, or thick with bald patches or areas of broken hairs, especially around the crown or parietal areas. Absence of eyebrows, eyelashes, hair on the forearms, legs, axillary or pubic areas may also indicate TTM. Wounds caused by devices used in pulling out hair may be present.
The third dimension of detecting includes being vigilant to a patient's psychosocial history. As demonstrated in this study, a disproportionate number of TTM sufferers report traumatic childhood experiences. Forty of 44 women (91%) reported a history of trauma or violence and 38 (86%) associated such episodes with the onset on TTM. Examples of traumatic events include repetitive physical or sexual abuse, including rape or gang rape, by family members, acquaintances, or strangers (Boughn & Jaarsma-Holdom, 2003).
Treatment-Seeking: Participants reported using a wide variety of treatments including medications, individual, group and behavior modification therapies, and complementary/alternative therapies such as hypnosis, yoga, breathing techniques, neurobiofeedback, acupuncture/acupressure, and journaling.
Participants reported finding support on the Internet through anonymous cyberspace groups. These groups enable suffers who might not otherwise seek therapy to locate a supportive TTM community. Participants also reported utilizing non-traditional group therapy provided by the Trichotillomania Learning Center (TLC).
OTHER FINDINGS: Participants reported that the web was an anonymous, safe, opportunity for them to "come out" about hair pulling behaviors. They discovered that they were not alone and felt free to share their experiences with other sufferers on-line. They also located treatment information and resources through the internet. Participants who used on-line support reported that it was effective in decreasing their sense of isolation and curbing the urge to pull hair (Boughn & Jaarsma-Holdom, 2002). TTM sufferers involved with TLC report that the organization's efforts were effective in helping them to feel less isolated and better able to control their urges (Boughn & Jaarsma-Holdom, 2002).
Participants reported that one of the most frustrating aspects of having TTM was that health care providers were uninformed about their condition, and even sometimes disregarded their pleas for help.
NURSING IMPLICATIONS: Detection of TTM is problematic due to the secretive behavior that characterizes this disorder. Nurses should focus on identifying characteristic concealment behaviors, such as attempts to cover up bald patches. Finding wads of hair hidden, or discarded is another clue to the diagnosis of TTM. Nurses should also be aware of the association between childhood trauma and symptoms suggestive of trichotillomania.
Nurses who detect behaviors suspicious of TTM can initiate a discussion with the patient. If a patient reveals the disorder, the nurse should acknowledge that TTM is "real" by showing respect and concern. Psychiatric nurses may provide individual or group therapies. Advanced practice nurses can prescribe medications for conditions that accompany and aggravate TTM. Selective serotonin reuptake inhibitors (SSRIs), selective serotonin and norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and tricyclics have all been prescribed to treat trichotillomania and its associated symptoms (Boughn & Jaarsma-Holdom, 2002). Lastly, nurses can refer patients to other providers for therapy and medical treatment, and to complementary and alternative therapies such as to those described above. Nurses can also refer people with TTM to the TLC (831-457-1004 or www.trich.org), which offers individual contacts, referrals to groups, a national newsletter, organized retreats, and conferences for TTM sufferers, health care providers, and researchers.
Historically, nurses have been at the forefront in being cognizant of hidden, shameful or embarrassing disorders. Being informed about trichotillomania, even being able to diagnosis, treat and refer people with this enigmatic disorder, will serve to continue this noble tradition.
American Psychiatrie Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Boughn, S., & Jaarsma-Holdom, J. (2002). Trichotillomania: Women's reports of treatment efficacy. Research in Nursing & Health, 25, 135-144.
Boughn S, Jaarsma-Holdom J (2003), The relationship of violence and trichotillomania. J Nurs Scholarsh 35(2): 165-170.
Boughn, S., & Jaarsma-Holdom, J. (2004). Violence and Trichotillomania, Psychiatric Times, 21(10), 30-32.
Enos, S., & Plante, T. (2001). Trichotillomania: Assessing, understanding and treating hair-pullers. Journal of Psychosocial Nursing, 39, 10-18.
Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. New York: Aldine.
by Susan Boughn, EdD, MSN, RN, Professor of Nursing, The College of New Jersey
Funded by: Faculty Research Grant, The College of New Jersey
Editor: Claire E. Lindberg, PhD, RN, APRN, BC
Copyright New Jersey State Nurse's Association May/Jun 2005
Provided by ProQuest Information and Learning Company. All rights Reserved