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Trichotillomania and Excoriation Disorder - Symptoms, Neurobiology, Etiology, and Management

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Trichotillomania and excoriation disorders are two separate conditions that come under OCD (obsessive-compulsive disorder). Read the article to know more.

Written byDr. Dharmashree. R. D

Medically reviewed byDr. Vipul Chelabhai Prajapati

Published At July 21, 2023
Reviewed AtJuly 28, 2023

Introduction:

Trichotillomania (TTM) and excoriation are two psychiatric conditions with similar origins to OCD. TTM is specific to hair, and excoriation is specific to skin. Both diseases show symptoms in different locations though the cause of these two conditions is the same. Both conditions cause distress and result in various medical problems.

What Is Trichotillomania?

Trichotillomania is a hair-pulling disorder. The individual tries to pull hair from his body, generally from the scalp, eyebrows, and eyelids. They make many attempts to stop the behavior of pulling hair but result in embarrassment, loss of control, or shame. This behavior is accompanied by other behaviors involving searching for hair, a particular method of pulling hair, testing, or feeling of hair presence at the site where the hair is removed.

This condition is more common among females than males and in childhood. Both genders are equally affected. Individuals with this condition always show low self-esteem and try to avoid social interactions. Triggers for this condition include,

  • The feeling of hair on the scalp.

  • Being anxious, bored and angry.

  • Thinking of hair strongly.

There are two types of the hair-pulling present.

1. Automatic Pulling: Not being fully aware of the action of pulling hair.

2. Focused Pulling: The individual sees and feels that hair should be pulled from that site.

Individuals use both types of hair-pulling techniques, and it keeps changing over time.

What Is Excoriation Disorder?

Excoriation disorder is characterized by the pulling of skin from their own body from different sites like the face, arms, and hands. Individuals may pick the skin from healthy skin or old lesions like pimples, calluses, at scabs from old picking. These individuals use fingernails, tweezers, pins, or any other objects.

Apart from pulling the skin, also perform actions like rubbing, squeezing, lancing, or biting. They spend most of their time on the behavior. Sometimes several hours of a day are spent on such actions. This condition results in dysfunction of work and social activities. Triggers for this condition include stress, anxiety, anger, boredom, tiredness, and time away from scheduled activities.

What Are the Symptoms of Trichotillomania and Excoriation?

Trichotillomania and excoriation both lead to many medical consequences. Symptoms of trichotillomania are,

  • Hair loss due to repetitive actions of removing hair.

  • Keep trying to stop the action of hair pulling and trying to do it less often.

  • Negative feelings, thinking, and getting affected in work and social life.

  • Hair loss is not due to any other reasons.

  • They do not feel that hair loss is due to any mental health condition but believe their appearance is like that.

  • Trichophagia (eating of pulled hair) can be observed among 20 percent of individuals affected by this condition. This may further lead to gastrointestinal tract obstruction because of hairball formation.

Symptoms of excoriation include

  • Tissue damage occurs, and this may further lead to infections.

  • Septicemia may also be possible due to skin picking.

  • Repetitive behavior of excoriation may lead to skin grafting or blood transfusion.

  • Creates cuts, bruising, and bleeding by doing the action.

  • Picking moles and scars to smooth or perfect them.

  • Not realizing that action is being done or doing the action in sleep also.

  • Start the act of picking skin during stress or anxiety.

Individuals with these conditions consider that these acts are just bad habits than psychological disorders.

What Is the Neurobiology of Trichotillomania and Excoriation?

Many things related to neurobiology are not known much. Early research suggests that it is familial. Another study showed that 40 percent are affected due to genetic factors, and the remaining are due to other environmental factors.

It is observed that many brain structures and functions are involved in these two conditions. Excess gray matter density was observed in trichotillomania in structures like the striatum, amygdalohippocampal formation, and frontal and cingulate cortices. A recent study has shown the dampening of the nucleus accumbent response to reward anticipation.

Another study showed the disorganization of white matter tracts involved in the motor generation and suppression in both conditions. Neurophysiological studies have shown that cognitive ability deficits are linked to frontal lobe functions and frontal-subcortical structures like deficits in functioning, motor impulsivity, and cognitive behavioral flexibility.

What Is the Etiology of Trichotillomania and Excoriation Disorders?

Negative emotions like anxiety, sadness, and tension precede the actions of these two disorders. Picking and pulling behavior may function as a means to overcome specific negative experiences. Studies have shown that there is difficulty in the regulation of emotions among affected individuals with these disorders. In the same way, boredom also plays a role in triggering these conditions.

Some researchers have hypothesized that these picking and pulling actions help in adjusting negative emotions caused due to perfectionism. The feeling of perfectionism creates frustration, impatience, and dissatisfaction due to not meeting the standards or expectations. These actions help in releasing tension caused by these negative emotions.

How to Diagnose Trichotillomania and Excoriation?

Diagnosis is essential for treatments to be planned. Generally, these two conditions are usually misdiagnosed as OCD, anxiety disorder, and drug addiction. Treatments of these disorders differ from the treatment of trichotillomania and excoriation. Hence accurate diagnosis is to be done.

Trichography: Microscopic examination of plucked hair may help diagnose trichotillomania.

SPRS (Skin Picking Reward Scale): This scale evaluates skin picking and defines the wanting and liking of skin picking.

Blood Examination: Complete and differential blood counts help diagnose skin picking.

What Is the Treatment for Trichotillomania and Excoriation?

Treatments of these two conditions include

Psychotherapy: Behavioral therapy called HRT (habit reversal therapy) is used for trichotillomania; other components like acceptance, commitment, and dialectical treatment are also included. Regarding skin picking, HRT and cognitive behavioral therapy are used.

Pharmacotherapy: No pharmacotherapy has been accepted currently. Clomipramine has demonstrated some effect in trichotillomania. Other agents like SSRI (Selective Serotonin Reuptake Inhibitors), Glutamatergic agents, NAC (N-acetylcysteine) were used.

Sequencing treatment: Psychotherapy and pharmacotherapy together were used for effective therapies.

Conclusion:

Trichotillomania and excoriation are two different entities that are psychiatric conditions. If left untreated may show severe symptoms and become chronic. Hence it is essential to know about these conditions, causes, symptoms, diagnoses, and treatments. Knowing helps achieve early diagnosis and effective treatment. This, in turn, helps achieve a good quality of life.

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Frequently Asked Questions

Trichotillomania is a disorder that can vary in intensity throughout people and does not always go away with time. While some people may go into remission, others may find it to be a lifelong struggle that requires constant care and coping mechanisms to lessen its effects on day-to-day functioning and mental health. A thorough, individualized treatment plan for each patient and early intervention can greatly enhance quality of life and long-term results.

For those afflicted, trichotillomania is a lifetime problem that needs constant care and assistance. Nonetheless, suppose they get the right therapies and coping skills. In that case, people can learn to effectively control their symptoms and enhance their quality of life by reducing the frequency and intensity of bouts of hair-pulling. Creating a solid support system and practicing self-care regularly may strengthen resilience and make managing the illness easier.

Yes, there are recorded instances of people with trichotillomania conquering the condition using different therapeutic modalities and coping mechanisms. Depending on the requirements and circumstances of each individual, they may include medication, lifestyle modifications, counseling, and support groups. Along with a readiness to investigate and embrace new coping techniques, persistence, patience, and a supportive environment are frequently important components in the healing process.

In trichotillomania-afflicted regions, hair can regenerate with appropriate care putting an end to the hair-pulling activity. The length and intensity of the tugging behavior and individual variations in hair growth patterns can affect how quickly and effectively this renewal process occurs. In addition to treating the underlying psychological causes of the illness, consistent commitment to therapy and good scalp hygiene help promote optimum regrowth.

Cognitive-behavioral therapy (CBT), acceptance and commitment therapy (ACT), habit reversal training (HRT), and mindfulness-based therapies are effective methods for attaining long-term recovery from trichotillomania. These methods seek to challenge erroneous ideas and attitudes connected to the behavior, create alternative coping strategies, and raise awareness of the triggers that cause hair pulling.

After treating trichotillomania, hair growth varies in duration and might take several months to a year. The length of recovery can be affected by variables such as the degree of hair loss, regrowth patterns, and each patient's reaction to therapy. Promoting hair regrowth and avoiding relapses requires perseverance and patience while following treatment suggestions.

Following trichotillomania therapy, the recovery period for hair growth varies depending on the severity of the problem and each patient's reaction to treatments. Some patients may recover noticeably within a few months of starting therapy, while others may take longer to observe appreciable benefits. Adhering to treatment recommendations and regular follow-ups with healthcare experts can facilitate the ongoing development and maintenance of recovery.

After being impacted by trichotillomania, hair can recover if pulling is stopped and the scalp is properly cared for. When people stop having hair-pulling episodes, their damaged follicles can repair and produce new hair. A healthy scalp may be achieved by implementing good hair care habits, such as frequent washing, conditioning, and shielding the scalp from additional stress.

Trichotillomania may have long-term consequences for the health of the hair and scalp, including hair loss, scarring, and texture changes. Hair follicles and surrounding tissues may sustain irreversible damage from persistent or severe hair-pulling activity, manifesting as observable changes in hair density and appearance. Preventive treatments and addressing underlying psychological problems that contribute to trichotillomania can help lessen the long-term effects on the health of the hair and scalp.

Ignoring trichotillomania can have detrimental effects on mental health, exacerbate symptoms, and increase hair loss. Without successful intervention, people may face increased discomfort and impairment in several daily living domains and a steady decline in functioning and quality of life. Recovery can be aided by seeking expert assistance and making use of the right therapy options to stop symptoms from getting worse.

Trichotillomania may negatively affect brain function, especially reward processing, impulse control, and emotional regulation. Changes in brain circuits related to habit formation and self-regulation by long-term hair-pulling activity may result in persistent maladaptive behavior patterns. Comprehending the neurological foundations of trichotillomania can facilitate the creation of focused therapies intended to regulate brain activity and alleviate symptoms.

Treatment for trichotillomania has varying success rates, but with the right interventions, many people see great recovery. Empirical evidence indicates that the most effective strategies for managing symptoms and promoting sustained recovery involve a multimodal strategy that integrates psychotherapy, medication, and lifestyle adjustments. Treating co-occurring illnesses and customizing treatments to meet each patient's requirements can decrease relapse risk and increase treatment efficacy.

In extreme cases, scarring may continue, although the skin condition may improve if compulsive picking habits stop. Skin lesions can heal and not return if treatment instructions are followed consistently, such as avoiding triggers, using stress-reduction strategies, and taking good care of wounds. Working with medical practitioners to address underlying psychological reasons leading to obsessive picking habits is crucial for long-lasting improvements in skin health and general well-being.

Genetic, environmental, and psychological factors, many of which are connected to impulse control, mood management, and sensory processing, combine to form the underlying processes of trichotillomania. Hair-pulling symptoms may arise due to dysregulation in brain circuits related to reward-seeking behavior, habit formation, and stress response. Determining these fundamental processes might help focus therapies to break through maladaptive behavioral patterns and encourage adaptive coping mechanisms.

Serotonin, dopamine, and glutamate are some neurotransmitters hypothesized to be involved in developing and expressing trichotillomania. The underlying neurobiology of the condition may be influenced by dysregulation of neurotransmitter systems or imbalances in neurotransmitter levels, which can affect several aspects of behavior, mood, and cognition. Treatment options for promising trichotillomania include pharmaceutical or behavioral therapies targeting particular neurotransmitter pathways to modify neurotransmitter activity.

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Dr. Vipul Chelabhai Prajapati from iCliniq
Dr. Vipul Chelabhai Prajapati

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