Latest Treatment of Hair Pulling

Quit Trichotillomania

This video system is the only one in its kind because it starts by treating the cause instead of the effect. Its about understanding what triggers us to pull. Once we do that, we can treat the cause. Instead of the symptoms. But my main concern is not to tell you why you pull your hair, it is to get you to stop pulling as fast as possible. Im not going to give you a bunch of theory on why you might have. Youre going to learn 4 foundations you need to know to quit trichotillomania permanently, and create lasting change, starting by associating more pain to pulling than pleasure. And youre going to learn 3 up to date techniques to necessary to apply and utilize in order to permanently quit your hair pulling compulsions. The techniques video uses all of the foundations to literally reprogram your brain to associate more pain to pulling than pleasure, thus removing all hair pulling symptoms almost instantly. It does this all subconsciously, so that it now becomes automatic not to pull.Ultimately, you complete the program pull free :) This system literally reconditions your nervous system, so that all of the bad thoughts and feelings you have will disappear along with your hair pulling. This means that you will never have to struggle with will power or any thoughts you might have about your trichotillomania ever again.

Quit Trichotillomania Overview

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Differential diagnosis

Major depressive disorder can sometimes be associated with obsessive ideas, but patients with OCD usually fail to meet all the criteria of the former. Other psychiatric diagnoses closely related to OCD are hypochondriasis, body dysmorphic disorder, and trichotillomania. These patients have repetitive worries or behaviours, but they are focal and dissimilar from the multiple obsessions compulsions that patients with OCD usually manifest.

Aetiology Dynamic explanations

The current literature tends to ignore dynamic theory in favour of behavioural and biological models. However, dynamic formulations for trichotillomania have included disturbances in the mother-infant bond, early mother deprivation, hair acting as a transitional object, renouncement of adulthood, denial of femininity, attempts at masculinization, attempts to resolve the Oedipal conflict, symbolic castration, autoaggression, masochism, autoerotism, and hair pulling equating to a masturbatory equivalent 1' Loss or perceived loss is frequently reported as being associated with the onset of trichotillomania. (3) Such losses have been due to injury, isolation, decreased attention, or loss of contact with friends, parents, or other family members. Mothers of patients with trichotillomania have been characterized as ambivalent, competitive, and mutually dependent on their daughters, and fathers characterized as passive and emotionally distant. (12)

Serotonin dysregulation

A connection between trichotillomania and serotonin dysregulation is hypothesized due to the similarities between trichotillomania and obsessive-compulsive disorder 13 Reports of the efficacy of the serotonin-reuptake inhibitors in the treatment of trichotillomania supports this hypothesis, as does a correlation between the trichotillomania response to serotonergic drugs and baseline serotonin metabolite levels. (14) Challenge of trichotillomania subjects to the serotonergic partial agonist m-chlorophenylpiperazine results in a mild euphoria, a response typical of conditions characterized by impulse control, but not the typical endocrine, behavioural, and emotional responses observed in obsessive-compulsive disorder.(14) The dopaminergic and opioid systems, have also been hypothesized to be important in trichotillomania l4)

Ethological parallels

Abnormal grooming behaviours in other species include canine acral lick in dogs, feline psychogenic alopecia in cats, and feather picking in birds. Grooming in animals is often considered to be a fixed-action pattern, a complex innate behavioural sequence mediated by deep brain structures such as the basal ganglia. Inappropriate fixed-action patterns, referred to as displacement behaviours, are observed in situations characterized by heightened physiological stress or arousal. The conceptualization of trichotillomania as a displacement behaviour is supported by phenomenological similarities to animal displacement behaviours as well as similar treatment responses of both trichotillomania and animal grooming disorders to serotonin-reuptake inhibitors and opiate antagonists. (19

Course and prognosis

Trichotillomania usually develops in childhood or adolescence with a mean age of onset around 13 years. (34) Claims that trichotillomania is usually self-limited in childhood are only partially substantiated.(3) Prognosis may be better if the duration of trichotillomania at intervention is 6 months or less. Otherwise, the disorder typically takes on a chronic waxing and waning course. Prognosis following treatment has been poorly studied. However, patients with comorbid borderline personality disorder or anxiety disorders appear to be more resistant to treatment.(9)

Chapter References

Christenson, G.A. and Mansueto, C.S. (1999). Trichotillomania descriptive characteristics and phenomenology. In Trichotillomania (ed. D. Stein, G. Christenson, and E. Hollander), pp. 1-41. American Psychiatric Press, Washington, DC. 5. Christenson, G.A., Pyle, R.L., and Mitchell, J.E. (1991). Estimated lifetime prevalence of trichotillomania in college students. Journal of Clinical Psychiatry, 52, 415-17. 6. O'sullivan, R.L., Keuthan, N.J., Christenson, G.A., Mansueto, C.S., Stein, D.J., and Swedo, S.E. (1997). Trichotillomania behavioral symptom or clinical syndrome. American Journal of Psychiatry, 154, 1442-9. 7. Muller, S.A. (1990). Trichotillomania a histopathologic study in sixty-six patients. Journal of the American Academy of Dermatology, 23, 56-62. 9. Swedo, S.E. and Leonard, H.L. (1992). Trichotillomania. An obsessive compulsive spectrum disorder Psychiatric Clinics of North America, 15, 777-90. 10. Reeve, R. (1999). Hair pulling in children and adolescents. In...

Definitions of impulse control disorders

In DSM-IV, impulse control disorders are listed in a residual category, 'Impulse control disorders not elsewhere classified', which includes intermittent explosive disorder, kleptomania, pathological gambling, pyromania, trichotillomania, and impulse control disorders not otherwise specified. Examples of impulse control disorders not otherwise specified are compulsive buying or shopping (also called buying mania or oniomania), repetitive self-mutilation, psychogenic excoriation (also called compulsive skin picking), and onychophagia (severe nail-biting). (1> In ICD-10, habit and impulse disorders are also listed as a residual category. Similar to DSM-IV, it includes pathological gambling, pathological fire-setting (pyromania), pathological stealing (kleptomania), trichotillomania, other habit and impulse disorders (which includes intermittent explosive (behaviour) disorder), and habit and impulse disorder, unspecified.

Clinical Features

The typical onset of ChAc is in young adulthood, but may occur at younger ages. Initial presentation with a variety of neuropsychological syndromes is being increasingly recognized, including depression, psychosis, obsessive-compulsive symptoms, trichotillomania 78 , tourettism 90, 108 , anxiety and agitation (see chapter by Sano). Self-mutilation due to lip- and tongue-biting may be due to apparent obsessive behaviors or to involuntary movements 145 . Behavioral changes suggesting a frontal lobe-type syndrome, including disinhibition and self-neglect, may present prior to development of the movement disorder. Dementia is frequently seen, with deficits primarily in memory and executive skills. The use of psychiatric medications may obscure the diagnosis for several years, as the involuntary movements are attributed to tardive dyskinesia.

Associated features

Hair pulling is typically accomplished by grasping individual hairs between the thumb and index finger, (3) although some patients utilize tweezers or other devices to pull out hair. Hair which is coarse, kinky, or in other ways texturally distinct may be preferentially targeted. For some patients the examination of the hair in general, or root in particular, is an important aspect of their behaviour. Half of hair pullers rub the pulled hair over their lips or bite off the hair end or root approximately 10 per Fig. 1 Tonsure pattern of hair loss in trichotillomania. Trichotillomania is typically painless.(4) Increased pain tolerance (and or thresholds) has been proposed as a permissive factor to the development of trichotillomania, but this has not been verified. A minority of patients describe pain as pleasurable. (3) A distinction between 'automatic' versus 'focused' hair pulling has been proposed. (4) Automatic hair pulling occurs with little or no awareness, and as a parallel...

Brain localization

The repetitive nature of trichotillomania as well as its similarity to tics and grooming behaviours implies a potential involvement of orbitofrontal-basal ganglia brain circuitry 1,4) Volumetric magnetic resonance imaging studies demonstrate a reduced left putamen volume but no caudate abnormalities. (1J> Baseline glucose hypermetabolism of the right superior parietal lobe, bilateral cerebellum, and whole brain, as well as a negative correlation between anterior cingulate and orbitofrontal metabolism and serotonin-reuptake inhibitor (clomipramine) treatment response, has been observed using positron emission tomography. (1.5> Studies of neurospsychological testing have been inconsistent, but they suggest a possible visuospatial dysfunction mediated by corticostriatal pathways. (1J The onset of trichotillomania in very young children has been observed to be associated with streptococcal infection, and has been hypothesized to occur when antistreptococcal antibodies crossreact with...

Behavioural therapy

Many behavioural techniques are effective for treating trichotillomania. (1.I9,) However, most of the behavioural literature is limited to case reports and case series lacking randomized controlled methodologies. Behavioural approaches have included self-monitoring, therapist praise, token economy, differential reinforcement of other behaviours, relaxation training, rational emotive therapy, self-instruction, and covert desensitization. Punishment aversive techniques include self-administered rubber band snaps, faradic shock, aromatic ammonia inhalation, hand slaps, and response cost. The mildly aversive techniques of overcorrection and facial screening have been used with the developmentally disabled. Painting aversive-tasting substances on to the thumb has been successful in treating both thumb sucking and hair pulling when these behaviours covaried in young children. Aversive techniques have generally been used only when other approaches have failed, or where the patient has a...

Treatment management

The relative paucity of treatment studies of trichotillomania preclude any convenient treatment algorithm. ( 6,) However, several aspects of an individual case can be useful in considering an appropriate treatment. Consideration of comorbid conditions in treatment selection is important, since treatment of the comorbid condition itself is often indicated and trichotillomania may be a manifestation of the comorbid condition rather than a separate issue in some cases. Treatment with a serotonin-reuptake inhibitor is recommended in cases of comorbid depression, obsessive-compulsive disorder, panic disorder, social phobia, and or bulimia nervosa. The use of anxiolytics is reasonable in cases of generalized anxiety. Lithium should be considered in cases of mood instability. The presence of tics is a reasonable indication to consider a dopamine antagonist, probably as an augmentor to a selective serotonergic agent. The risks of extrapyramidal symptoms and tardive dyskinesia need to be...

Discussion

The finding of a marked volumetric reduction of the head of the caudate nucleus appears to be in good agreement with the clinical picture seen in ChAc, of disturbances to frontostriatal function. These manifest as cognitive (particularly executive) impairments, personality changes, compulsive motor behaviour and the development of chorea 28 . The particular vulnerability of the head of the caudate nucleus, where the peak area of volume loss was found, correlates with the finding of cognitive and behavioural disturbances which are thought to be related to dysfunction of cortico-subcortical loops that connect the anterior cingulate and orbito-frontal cortex with the caudate head 1 . Dysfunction in this loop is described in obsessive-compulsive disorder 5 , which is perhaps the most common major mental disorder seen in ChAc. The presentation in adolescence and early adulthood could be related to interruption of the developmental trajectory of these fronto-striatal connections which begin...

Rett syndrome

Other behavioural problems reported in Rett syndrome include self-injurious behaviours which may occur in 40 to 50 per cent of the affected girls. Often the self-injurious behaviours are associated with abnormal hand movements and involve biting and chewing of fingers and hands. More severe forms of self-injurious behaviour involve hand-to-hand banging, hand-to-object banging, hair pulling, scratching, and head banging. Sleep problems particularly involving laughing at night may affect up to 74 per cent of cases. There were descriptions of brief attacks of hyperventilation associated with impaired consciousness in about one-third of children with Rett syndrome. Although these attacks were deemed to be non-epileptic in origin, focal or generalized seizures have been reported in about three-quarters of cases.(23) EEG recordings revealed abnormalities starting from paroxysmal slow-wave abnormality to a relatively unresponsive theta patterns. (4)