When Pulling Your Hair Out Isn’t Enough…. A New Twist On Trichotillomania

We have had multiple comments from people who are responding to Dr. Schwartz’s blog about Trichotillomania (an impulse control disorder involving hair pulling). Several readers have expressed surprise that they are not the only people with this type of problem. A recent article in the New England Journal of Medicine was picked up by the media regarding another behavior that is sometimes associated with trichotillomania, called tricophagia, or eating hair.

The case discussed in the NEJM involved an 18-year-old woman who sought treatment for abdominal pain and swelling, vomiting after eating, and a 40-pound weight loss. Doctors discovered that she had been eating her hair for several years, and that her stomach was almost completely blocked by a ball of hair called a trichobezoar (or bezoar). Surgery was required to remove this 10-pound mass of black, curly hair (photo at http://www.cnn.com/2007/HEALTH/11/21/hairball.case/index.html

I bring this topic up not for the sensationalist tone that seems to permeate other articles. Instead, I’d like to raise awareness of the issue and suggest to people with the combination of trichotillomania and tricophagia that they are also not alone. Approximately 30% of people with trichotillomania also eat their hair after pulling it out. Not surprisingly, this behavior can cause other problems, such as gingivitis (gum disease). Even worse, as in the case described above, peristalsis (the rhythmic muscle contractions that propel contents through the digestive tract) doesn’t work on hair. So, swallowed hair gets trapped in the stomach lining and creates a mass, eventually causing the stomach to stop peristalsis completely. This hair mass can cause gastrointestinal blockage, tearing, diarrhea and vitamin/mineral deficiencies.

Smaller trichobezoars can be broken up by a water pick, laser, or shock waves and then removed by endoscopy (inserting a tube into the body) or laparoscopy (surgery performed through very small cuts in the abdomen, using specialized instruments). However, very large trichobezoars (as in the case above) usually require open surgery to remove (1% of people with tricophagia require this type of treatment).

Related to the issues of trichotillomania and trichophagia, I’d also like to bring up a paper published in the April 2007 issue of the American Journal of Psychiatry (Volume 164, pages 568-574). These authors studied the available literature and found that, for many people, starting with intensive Cognitive Behavioral Therapy may be the most effective treatment strategy.

The CBT should be specifically tailored to treat trichotillomania. The cognitive component should focus on the individual’s thoughts that lead to the hair pulling (and, if relevant, the hair eating) behavior and replace these with different, more positive, or more helpful thoughts. The behavioral component should include habit reversal treatment (mentioned in Dr. Schwartz’s article) which focuses on eliminating an unwanted chronic behavior.

If the CBT doesn’t work (or if the person cannot commit to intensive CBT) people can use medication. This review suggested that the tricyclic antidepressant clomiprimaine (Anafranil) or the SSRI citalopram (Celexa) are often the most effective medications. However, most of the time, the person should continue with CBT to achieve the most lasting change in behavior. Medication can address some of the underlying reasons why someone might engage in this behavior (e.g., brain chemical deficiencies, anxiety, mood regulation difficulties, etc.), but does not actually change the behavior itself. It was also noted that for some people, antidepressant medications may actually may the behavior worse.

Another point raised in the article was that people who have co-morbid (co-occurring) disorders such as depression, anxiety, or OCD may need medication to bring these type of symptoms to a manageable level before beginning intensive CBT with habit reversal therapy.