Perspectives - Vol. 5, No. 4 - The TricheeGary Brown, Ph.D. Updated: Sep 1st 2000 "Take off your hat," the father instructed the nine-year old boy. "And roll up your sleeves." Tommy L. did as he was told. He took off his NASCAR cap and rolled up his sleeves. Bald spots of various sizes covered his scalp and his arms were completely hairless. "The boy pulls out his hair," dad informed me of the obvious. "Have you ever seen anything like this?" I told Tommy and his daddy I'd seen one other case of trichotillomania, but that didn't mean it was rare. Some estimates say 7-8 million people in the U.S. suffer from trichotillomania. "Is it inherited?" dad asked. "Except in rare instances trichotillomania isn't found in more than one member of a family," I lectured "But another family member may have a related disorder such as nail-biting, skin-picking, or obsessive-compulsive behavior. (I didn't mention an early psychodynamic theory that said trichotillomania was caused by incest.) Tommy began squirming around in his seat. He glanced at his dad. "I got on the Internet one night and found out some stuff about this tricotillomania," he said nervously as he looked at the floor. "Lots of stuff." "Why didn't you tell me what you found," dad snapped. I held up my hand to try and stop dad's little tirade before it went any further. "What did you find out Tommy?" I inquired. "There's a whole bunch of us," he replied after taking several deep breaths. "We're called trichsters or trichees." I noticed Tommy's hands went to this head several times and lingered on the bald spots. "I imagine there's lots of support groups and chat rooms," I added. "And lots of confusing information." "Yeah," Tommy confirmed. "I don't think anybody knows what's going on with this disorder. I'm not in a trance or stressed out when I pull out my hair like some of the people logging on." "I think the disorder has biological and behavioral components like a phobia," I explained. "Combining medication and a behavioral program produces the best results." After several minutes of general discussion I began to take Tommy's history. He told me that he didn't remember exactly when he started pulling out his hair, but he could remember pulling out his hair and sucking his thumb when he was a toddler. Some kids pull out their hair in tufts when they tantrum or stressed. Other kids are bored and when they pull out their hair they seem comforted. Tommy had some stress in his life, but I had a hunch he fell in the latter category.  I asked Tommy what he did with the hair when he pulled it out and he said he twirled each hair between his fingers for several minutes and then he meticulously examined the root before throwing it away. He did not bite his nails or engage in any other obsessive-compulsive behaviors. And he didn't suck his thumb anymore. (Some patients with trichotillomania eat the hair after it is pulled out. This disorder is called trichophagia. If enough hairs are eaten a hair ball or trichobezoar is formed in the stomach. The trichobezoar causes stomach pain and it must be surgically removed.) Dad interrupted. "Can you cure the boy or not?" "He's young and he's a male," I answered. "So that increases his odds." I finished taking Tommy's history, and then I discussed a behavioral intervention to condition a competing response to his hair pulling habit such as squeezing the fist. I also told them I would call Tommy's pediatrician and ask him to prescribe one of the selective serotonin reuptake inhibitors (SSRI). These drugs have been shown to be effective for short-term treatment in approximately 25% of the cases. In addition to a behavioral plan and SSRI drugs it is recommended that the hair of a trichee be cut extremely short (easier to do with boys) and a mousse kept on it. (Baby oil can be kept on the forearms and eyebrows. Pulling short greasy hairs is not easy.) Next I took out a ruler and measured the bald spots on Tommy's head. If they decreased each week then dad would see that he would get a special treat on Saturday. Neither Tommy nor his dad were very excited about what I'd proposed. Everything went just fine for a month. Tommy's pediatrician prescribed Prozac and the behavioral program was being followed. Each week when they came in for their appointment I measured the bald spots on Tommy's head and they were getting smaller. Hairs began to appear on Tommy's forearms. Trichotillomania is difficult to treat and I was keeping my fingers crossed. And then they didn't show up for their next appointment. I called the next day and step mom answered the phone. She told me she was divorcing Tommy's dad and moving to Chicago. And she added that Tommy had stopped taking his Prozac and following the behavioral program. I ran in to Tommy and his dad at a basketball game several months later. They spoke briefly and hurried to their seats. It was winter and everyone, including Tommy, was wearing hats and long sleeves and I couldn't see how much hair was being pulled out of his scalp or his arms. But I could see that Tommy's eyebrows were missing now so I guess he's still a trichee.* Notes: Bordnick, Thyer, and Richie (1994) present an avian model of trichotillomania based on feather picking disorder in birds. Like humans birds tend to pluck out their feathers at times of stress or boredom. The behavioral and drug interventions used to treat trichotillomania in humans are effective in treating feather picking disorders in birds. (J. Behav. Ther. & Exp. Psychiat. Vol. 25, No3, pp. 189-196.) Reference
Rice, Ralph (2000). Downstream: A Parable for Schizophrenia. [Online]. Perspectives. [2000, July 1]. | 
