Academic journal article Journal of Counseling and Development : JCD

Trichotillomania: Assessment, Diagnosis, and Treatment

Academic journal article Journal of Counseling and Development : JCD

Trichotillomania: Assessment, Diagnosis, and Treatment

Article excerpt

This article focuses on trichotillomania as described in the Diagnostic and Statistical Manual of Mental Disorders, text revision (DSM-IV-TR; American Psychiatric Association [APA], 2000). Trichotillomania is defined in the DSM-IV-TR (p. 674) as the recurrent pulling out of one's own hair that results in noticeable hair loss. Trichotillomania involves an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior and pleasure, gratification, or relief when pulling out the hair (APA, 2000). For the diagnosis of trichotillomania to be applied, the client must experience clinically significant distress from the hair pulling or impairment in social, occupational, or other important areas of functioning secondary to the behavior.

Trichotillomania has been estimated to affect 2.5 million people in the United States and to have a 1% prevalence rate (Diefenbach, Reitman, & Williamson, 2000). The prevalence of trichotillomania may be underestimated because it is sometimes overlooked, particularly when it is comorbid with other mental disorders (Mulinari-Brenner & Bergfeld, 2001). Previous underestimates of the occurrence of trichotillomania may also be partly due to the secretiveness of individuals who have this disorder (Stein, Christenson, & Hollander, 1999). Many people with trichotillomania often go to great lengths to hide their behavior from others for fear of how they will be perceived. Despite an ostensible rise in the incidence of trichotillomania (Diefenbach et al., 2000), many clinicians have had little or no experience working with this population. Counselors have an obligation to become educated about the assessment, diagnosis, and treatment of trichotillomania.

Trichotillomania typically begins in late childhood or early adolescence and, if untreated, continues chronically throughout life with waxing and waning symptoms (Simeon et al., 1997; Stein et al., 1999; Walsh & McDougle, 2001). Thirteen years is the average onset age of trichotillomania (Christenson, Mackenzie, Mitchell, & Callies, 1991; Stein et al., 1999). Because individuals with trichotillomania often believe that no one else experiences this disorder, they are often socially isolated (Diefenbach et al., 2000). Isolation ranges in severity from feelings of discomfort in social settings to avoidance of all social activities (Mansueto, Townsley-Stemberger, McCombs-Thomas, & Golomb, 1997; Watson & Winter, 2000). Trichotillomania is sometimes associated with low self-esteem, depression, and anxiety (Diefenbach et al., 2000; Stein et al., 1999), as well as mood disorders, anxiety disorders, and substance abuse (Walsh & McDougle, 2001).

ETIOLOGY OF TRICHOTILLOMANIA

The etiology of trichotillomania is multidimensional and complex. There is little agreement on the cause of trichotillomania, yet many hypotheses have been suggested (Diefenbach et al., 2000; Stein et al., 1999). Trichotillomania is considered by some clinicians to be a form of obsessive-compulsive disorder (OCD; Simeon & Favazza, 2001; Swedo & Leonard, 1992) because individuals with trichotillomania feel compelled to execute the impulse of hair pulling and wish to resist it, but with varying levels of success. In one sample of clients with trichotillomania, 15% had a lifetime history of OCD and an additional 18% had OCD-related symptoms (Christenson, Mackenzie, & Mitchell, 1991). Similar to obsessive-compulsive dynamics, the experience of increasing anxiety and subsequent tension release is commonly described. However, unlike OCD, hair pulling most often occurs when the individual is engaging in sedentary activities and is not usually characterized by obsessive thoughts (a central feature of OCD) about hair pulling (Stein et al., 1999). A study by Tukel, Keser, Karali, Olgun, and Calikusu (2001) indicated that clients with trichotillomania had an earlier age of onset than did those diagnosed with OCD and that Axis II personality disorders were more common among clients with OCD. …

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