Do you know a trichster when you see one?

Those suffering from trichotillomania pull out hair from their scalp, lashes and brows. But instead of seeing a dermatologist for balding patches, sufferers would be better off seeking psychological help

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“I knew it wasn’t something I should be doing. But I didn’t know how to stop it,” says Aneela Idnani Kumar. “I remember seeing a video in school about microscopic living things. There was a segment about mites that live in eyebrows and eyelashes. It grossed me out beyond belief and brought attention to this area for me. I started pulling at my bushy eyebrows and went from beautiful, thick, long lashes to nothing.”

Aneela was 12 when she first started plucking out her eyebrows and eyelashes. Hormonal changes at puberty and stress arising due to her father suffering from leukaemia meant that the subconscious action of twirling and pulling hair soon turned into a habit, one that eventually became compulsive, repetitive behaviour that led to relief from stress. At its peak, Aneela, who says she was “pretty much always pulling” her hair out, found herself without any lashes and gaps in her brows. Still a teenager, she started using make-up to fill up the space in her brows. It was only in her 20s that she learnt that this “soothing mechanism” was, in fact, a medical disorder. Trichotillomania, say, clinical psychologists, is a mental health condition on the Obsessive-Compulsive Disorder (OCD) spectrum. Trichotillomania or hair plucking to the extent that it leads to alopecia, as well as constant nail biting, hand washing or skin picking are all categorised as Body-Focussed Repetitive Behaviours (BFRBs) wherein prompted by an impulse, the action of plucking, biting, washing or picking alleviates stress build-up and relieves anxiety. 


Not uncommon but poorly understood

Dr YC Janardhan Reddy, a professor of psychiatry at the National Institute of Mental Health And Neurosciences (Nimhans), says there is no community-based data on the prevalence of trichotillomania in India but prevalence rate in western countries is under 1 per cent. “Trichotillomania and OCD are related disorders, therefore about three percent of those with OCD may also have trichotillomania,” he says. “Many patients consult dermatologists thinking it to be hair-related problem whereas it is actually a psychiatric problem.”

At the ESIC Medical College and Hospital in Faridabad, NCR, Dr Ankur Sachdeva says he sees one new patient every two months. “Trichotillomania is not uncommon, and most trichsters we've seen are children and adolescence. But it’s not unusual even among adults,” says Dr Sachdeva, who had, in 2009, documented the case of a nine-year-old girl in Delhi, who not only suffered trichotillomania, but also the related condition, trichophagia – the ingesting of hair pulled from one’s body.


Understanding trichotillomania

  • Trichotillomania is a condition in which a person feels an intense urge to pull out hair from their scalp, eyebrows, eyelashes, pubic area or any other part of the body. Over time, this results in bald patches and hair loss.
  • While trichotillomania is commonly seen in teenagers and adolescents, adults too may go through this OCD-spectrum condition during times of stress.
  • Sufferers may be of two types, says clinical psychologist Dr Sudhir Paulomi of Nimhans. Those who are not consciously aware that they are pulling their hair while doing routine activities like watching television, or during stressful periods. “And those who are focused pullers, who experience pain, pleasure and relief after the pulling because it releases the physical build-up of tension.”
  • Sufferers invariably seek help for bald patches without realising that the urge to pull is linked to one’s mental health condition. Considering not all dermatologists are aware of trichotillomania, while the hair may regrow, the root condition may remain untreated. 




Dr Reddy adds that in general, trichotillomania is more common in women than men, with occurrence ratio in adult female to male being 4:1. He adds that the condition is very often perceived “as a bad habit”. “There is often shame and embarrassment with resultant low self-esteem and social avoidance. Depression is common among those who have trichotillomania.”

His colleague and professor at Nimhans' department of clinical psychology, Dr Paulomi Sudhir, says, “Trichsters and those suffering other BFRBs are unable to regulate their behaviour and urges. Why someone experiences such intense urge depends on a host of biological and psychological factors.”

Causes and treatment

Dr Reddy says that there is no clearly established cause for trichotillomania but there can be several factors. “It can be familial with relation to OCD and body dysmorphic disorder (imagined ugliness). There is also preliminary evidence to suggest structural and functional abnormalities in the brain. Emotional dysregulation, stress, boredom, need for perfectionism can also contribute to hair pulling,” he says.

Fortunately, sufferers can overcome the condition. “The real challenge is to get them involved in treatment,” says Dr Reddy. “A type of behaviour therapy called habit reversal therapy (HRT) is most effective and should be tried first when facilities are available.”

Dr Sachdeva recommends a combination of therapy and medication. “Medication primarily involves a class of drugs that reduce impulsivity and the urge to pull, as well as anti-anxiety drugs,” he adds.

Aneela, who is based in the US, went for therapy but found lasting solution when she and her husband consciously thought of ways that could serve as “notifications” everytime she felt the urge to pull. After experimenting with a few ideas, the couple came up with a smart bracelet, called Keen by HabitAware, that paired with an app on a smartphone, sends a vibrating signal each time the sufferer feels the urge to pull and raises his/her hand to do so. “In using Keen, I have heightened my awareness of my urges and pulling,” says the 36-year-old mother of two. “I have now put trichotillomania behind me. That is not to say that I don’t still have urges, nor is it to say that I have stopped pulling. What it means is that trichotillomania no longer has a hold on me.”

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