It is not uncommon for people who suffer with a mental health disorder to struggle with more than one condition. Sometimes the illnesses spring from a similar cause, whether biological or environmental, and sometimes the occurrence or treatment of one condition will lead to the development of a secondary disorder. Hair-pulling, body image disorders and depression are independent conditions that sometimes interrelate and co-occur.
The urge to pull out one’s hair is known as trichotillomania. Most commonly people pull the hair from their scalp, eyelashes, or eyebrows, but hair anywhere on the body may be targeted. Trichotillomania is classified as an impulse control disorder, a condition in which people realize that a behavior is unwise or counterproductive but are unable to control their impulses to engage in it. The website MedLine Plus notes that symptoms usually begin before age 17 and that women are four times more likely to be affected than men.
The medical website WebMD states the following about trichotillomania:
- People with the disorder may feel a sense of tension before pulling their hair and a feeling of relief, satisfaction, or pleasure afterwards.
- Both biological and behavioral factors are apparently involved. Impulse disorders are often related to imbalances of neurotransmitters, but sometimes behaviors are continued because of habit.
- There is a slightly higher risk of developing the condition in people who have relatives who suffer from it.
- Stress may trigger the behavior.
- The condition may co-occur with depression or anxiety.
The Co-occurrence of Trichotillomania and Other Psychiatric Conditions
A 2007 article in the American Journal of Psychiatry reports that a study of trichotillomania sufferers found that 82 percent had another current or past psychological illness diagnosis. The most common co-occurring conditions were major depression, anxiety disorders and substance abuse. Close to a quarter of the patients met the diagnostic criteria for depression. In a question and answer site associated with Columbia Health, a question responder noted that the condition may also coexist with eating disorders and may be associated with low self-esteem and poor body image.
The relationship between hair pulling and body image may be cyclical with a poor body image contributing to trichotillomania and the effects of trichotillomania (bald spots and thinning hair) contributing to a worsening perception of the body. A 2013 article in the International Journal of Trichology reported on the case of a 12-year-old girl with bright red hair. Trichotillomania developed because her classmates teased her and called her “carrot head,” which caused her to develop body dysmorphic disorder (BDD), a preoccupation with a perceived body defect. The authors note that hair is often a focus for adolescents with BDD.
The Co-occurrence of Body Dysmorphic Disorder and Other Psychiatric Conditions
As is the case with trichotillomania, BDD also commonly coexists with other disorders. A 2003 article in the journal Comprehensive Psychiatry notes that most patients with BDD appear to have at least one other co-occurring condition. A study of 293 BDD patients found that the most common co-occurring conditions were major depression, obsessive compulsive disorder, social phobia and substance abuse. The authors note that social phobias generally preceded the development of BDD, but depression and substance use disorders tended to arise after BDD had already developed.
Treatment for Trichotillomania
When treating co-occurring mental health conditions, integrated treatment, in which all disorders are addressed simultaneously, generally leads to the best treatment outcomes. Hair pulling is often treated with habit reversal training (HRT). HRT teaches patients to recognize and redirect their impulses using relaxation and competing responses. Other possible psychological treatments include Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), biofeedback and hypnosis.
A number of medications may be used to treat trichotillomania including certain antidepressants. An over-the-counter supplement may also be helpful. A 2009 article in Time magazine reported on a study of the antioxidant N-acetylcysteine. In a small trial more than half of the participants who took the supplement saw symptom improvement compared to 16 percent of people taking a placebo. N-acetylcysteine is thought to work by reducing the release of glutamate in the brain. As with trichotillomania, depression and body dysmorphic disorder are also often treated with a combination of medication and counseling.
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