Magazine article Clinical Psychiatry News

Trichotillomania: Finding Solutions

Magazine article Clinical Psychiatry News

Trichotillomania: Finding Solutions

Article excerpt

Some years ago, I treated a woman who had been diagnosed with trichotillomania. This patient, who made her living as a trial attorney, had become courtroom phobic after she began pulling the hairs out of her eyebrows and feeling self-conscious about the awkward look of her face without them.

She thought of penciling in eyebrows, but instead started sending in associates to handle court appearances. Her career was suffering, and this seemingly uncontrollable habit began to damage her self-esteem.

As a pragmatic litigator, she approached the problem in a specific, direct manner. "There must be a medication to help me stop pulling out my eyebrows," she said. Indeed, she was right. A well-respected psychiatrist prescribed a selective serotonin reuptake inhibitor (SSRI).

The psychiatrist theorized that the eyebrow pulling was a compulsion disorder (not an impulse disorder, as put forth in DSM-IV), which was the rationalization for this pharmacologic intervention. The psychiatrist knew current evidence suggested that medications that alter central serotonin turnover had been effective in treating this disorder. "Concise Textbook of Clinical Psychiatry." Harold Kaplan and Benjamin Sadock, (Philadelphia: Lippincott Williams & Wilkins, 1996, p. 297).

Furthermore, in this patient's history, it was possible to identify periods of depression before the eyebrow pulling started, if you "looked hard," according to the treating psychiatrist. The psychiatrist thought the patient had an underlying depression, but she was certain, as was the patient, that this trichotillomania disorder was causing the patient to be depressed, rather than an earlier, undiagnosed depression.

The medication regimen and insight-oriented psychotherapy proved to be helpful. The patient's depressed mood was less pronounced and the eyebrow pulling behavior was reduced, but the behavior was still occurring to the point that her eyebrows were not growing in properly. The treating psychiatrist, realizing that she had gone as far as she could in the treatment of the patient's trichotillomania, suggested a different type of treatment and referred her to me for a short program of behavior modification. The lawyer, having had a good experience in psychotherapy, was more than eager to try something new.

For certain habit patterns, including this patient's hair-pulling behavior, I use what I call the LPA approach, which I developed over the years using education, emotions, relaxation, and behavior-modification techniques. The treatment plan involves three appointments: the Learning visit, the Philosophizing visit, and the Action visit.

In the Learning visit we explore the issues related to the habit on an educated, intellectual level and address theories of how the problem might occur and the various approaches to understanding why the person might have those behaviors.

Contributing factors include stress, anxiety, boredom, depression, neurochemical deregulation, impoverished childhood relationships, pathologic family relationships, the meaning of obsessive-compulsive disorder, lifetime losses, or any other idea that the patient might discover and name as important to her or him.

Too often, the patient is an outsider in the treatment. …

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