Trichotillomania (TTM) is a disorder prone to chronic, relapsing course, which is characterized by a pathological desire to pull out (auto-depilate) hair on various parts of the body.
Despite the fact that TTM has been discussed in the medical literature for more than a century, and was first described in 1889 by the French dermatologist François Henri Allopeau, it has not been included in national and international diagnostic systems such as ICD-10 or DSM-5 for a long time. More than 100 years later, the actual prevalence, causes, and effective treatments for trichotillomania remain poorly understood, as does the question of whether TTM is an independent disease, or whether it is a component or a special form of other mental disorders. There is no reliable information about the prevalence of TTM, which can be explained by the reluctance of people suffering from TTM to seek help, because Often, hair pulling is considered by them as a “bad and shameful habit.” According to some available data, TTM occurs in approximately 2% of the population. The inability to estimate the real number of patients with trichotillomania is also due to the fact that when contacting dermatologists, patients present their problem as “simple hair loss,” hiding the fact that hair loss is associated with auto-depilation.
The onset of TTM usually coincides with early adolescence, between 10 and 14 years of age, although the disease can debut at any age. In general, TTM affects women more often than men in a ratio of 4:1, while no such difference is observed in childhood. This is partly due to the fact that women seek medical help more often than men, which leads to distortion of data on the actual prevalence and gender relationships of many diseases. About 40% of people suffering from TTM never seek help, while 58% have never received treatment (Cohen LJ et al., 1995).
Below are the diagnostic criteria for T.
- Noticeable loss of hair due to periodic inability to resist the urge to pull out hair.
- Repeated and usually unsuccessful attempts to reduce and stop hair pulling.
- Hair pulling is usually preceded by increasing tension, and after it, a feeling of relief and satisfaction is experienced.
- Hair pulling causes clinically significant impairment in social, occupational, and other important areas.
- Hair pulling or hair loss is not associated with another dermatological disease or attempts to correct a perceived flaw in appearance.
Trichotillomania should be distinguished from the so-called “Body-Focused Repetitive Behavior (BFRB)”, the manifestations of which are extremely varied, and are often a variant of the norm, helping to reduce stress and tension. BFRP becomes a mental disorder when the behavior results in significant social consequences for the individual.
Examples of BFRP include dermatillomania (scratching, rubbing and picking at the skin), dermatophagia (biting and eating one's own skin, most often around the fingers), onychophagia (obsessive nail biting), onychotillomania (desire to damage the nail bed and cuticle with the purpose of destroying the nail plates), rhinotillexomania (compulsive picking of the nose to remove dried mucus), trichothemmania (compulsive hair cutting), biting the cheeks, the inner surface of the lips and tongue.
Reasons for the development of trichotillomania
An important component of the development of TTM is positive reinforcement associated with satisfaction and positive emotions as a consequence of autodepilation, strengthening and consolidating such behavior in the future. The tension and anxiety that patients experience before hair removal is completely relieved by the act of auto-depilation and is accompanied by a feeling of “duty accomplished.” In this regard, trichotillomania is considered as a kind of “coping strategy” (a strategy for coping with crisis situations), aimed at eliminating and reducing the intensity of stress through positive reinforcement through the neurotransmitter dopamine.
Among the so-called triggers - triggering mechanisms of auto-depilation, which, as a rule, precede the act of hair pulling and are directly related to them, there are emotional, sensory and cognitive. Emotions such as sadness, anxiety, boredom, anger, irritation and disappointment are emotional triggers. Unpleasant, subjectively extremely painful sensations in the projection of the autodepilation site associated with the thickness, size and location of the hair are designated as sensory triggers. Cognitive mechanisms of provocation reflect the content of the thinking of patients with TTM, namely the emergence of automatic thoughts about the appearance of hair, a supposed aesthetic defect, with subsequent attempts to correct the supposed defect.
Multiple mutations of the SLITKR1 gene, found with increased frequency in families of individuals suffering from trichotillomania, suggest a genetic nature of the disease. However, like other mental disorders, trichotillomania should be considered within the framework of a biopsychosocial model, which postulates the multifactorial development of the disease with the obligatory interaction and mutual influence of the biological substrate (hereditary predisposition, neurotransmitter disorders, organic brain damage), social and psychological stressors.
What is rhinotillexomania
The term rhinotillexomania refers to the phenomenon of nose picking.
Photo by RODNAE Productions: Pexels
Moreover, here we are not talking about the physiological need to remove mucus that has dried during the day from the nostrils, because moderate picking is not evidence of any disorders. We will talk about rejecting the natural cleansing process, when the desire to “clean your nose” becomes obsessive and very difficult to give up. It's a kind of nose-picking mania.
In the United States, scientists Thompson and Jefferson conducted a study in 1995, during which an anonymous questionnaire was compiled, “Inserting a finger or other object into the nose to eliminate dried nasal discharge,” sent by mail. After processing, the following data was found:
- 91% of respondents pick their nose;
- 75% pick their nose daily;
- 22% pick their nose several times a day, of which:
- 55% devote 1 to 5 minutes a day to this activity;
- 23% - from 5 to 15 minutes a day;
- 2 people – from 15 to 30 minutes a day;
- 1 person spends 2 hours on this.
In psychology, rhinotillexomania does not refer to bad habits, various diseases and pathologies, as you might think, but to unhelpful actions. The latter are not usually considered as a disease or addiction, but they arise against the background of an imbalance in the nervous system.
Why do people eat boogers? Rhinotillexomania.
Interesting! Rhinotillexomania affects boys more often than girls.
Clinical manifestations of trichotillomania
In TTM, hair pulling can occur in any area of the body, but the most common sites are the scalp (up to 73%), eyebrows and eyelashes (56%), and pubic area (51%). Less common is auto-depilation of the armpits, chest, abdomen and limbs. It is more common to pull out hair one at a time rather than in strands.
Hair pulling, as a rule, occurs daily, taking from several minutes to several hours, often representing a whole ritual - the hair is twisted in a special way around the finger and pulled out. If the hair is short, then it is clamped in a certain way, then extracted, after which it is held between the teeth in order to bite off the bulb and make sure that the hair is completely removed. Many people use devices such as tweezers or scissors for auto-depilation. Hair pulling during TTM is centrifugal - you can always find a “starting point” from which, like waves, foci of auto-depilation with hairs of different lengths diverge in different directions.
There are two types of trichotillomania – automatic and focused. In the automatic version of TTM, autodepilation is carried out without consciousness control, in a “trance-like” or dissociative state. This form of trichotillomania is associated with more severe consequences and is manifested by more dramatic symptoms - extensive and multiple foci of alopecia. The focused type of trichotillomania is accompanied by a purposeful and conscious desire for auto-depilation, while all the subject’s attention is focused on the process of pulling out hair.
The environment is an important factor influencing the frequency and intensity of auto-depilation. A sedentary lifestyle and spending long periods of time in a relaxing, comfortable environment, such as lying in bed before going to bed, have been shown to promote hair pulling.
Over time, the consequences of TTM become obvious to others, causing patients to experience feelings of shame and guilt, which only worsens their condition. It happens that a person denies the problem, tries to rationalize his own behavior, explaining auto-depilation by skin itching, injury, burn or “mere accident”, demonstratively engaged in “searching” for lost hair in the apartment, while showing bewilderment and indignation.
A peculiarity of the course of TTM in women is the connection between the “craving” for auto-depilation and the ovarian-menstrual cycle. According to one study (Ketheun NJ, 1997), in approximately half of the women observed, in the week before menstruation, the “urge to pull out hair” became more frequent and intense, and the ability to resist it significantly decreased.
The danger of habit
During an exacerbation of colds, the discharge becomes liquid. Doctors warn that eating snot is strictly prohibited. It's all about the infection in them. Especially if the slippery contents of the sinuses take on a greenish tint. Bacteria, when ingested, provoke even greater complications for the body. Of course, no one died from this, but increasing the duration of the disease clearly does not improve immunity. Especially if it could have been avoided.
Adults are also susceptible to this habit. Naturally, loved ones have no idea about this. Rarely did anyone notice a girl or woman behind this unaesthetic process. One way or another, snot gets into the body, if only because it flows down the nasopharynx.
To minimize the danger when a runny nose occurs, you should immediately start dripping vasoconstrictor drugs into your nose. And regularly empty the contents of the nose using a slightly salted or sea solution.
Features of trichotillomania in childhood
It is assumed that the development of trichotillomania in children is preceded by physical or psychological trauma: dysfunctional parenting models, rough treatment and attention deficit, forced separation from loved ones, physical and sexual violence, change of place of residence. In adolescents, in addition to the costs of education, trichotillomania is provoked by a tense environment in the school community and problems in communicating with peers. Although these stressors themselves are not the direct causes of the development of TTM, they are certainly the provoking factors that contribute to the manifestation of the disease.
In childhood, the disease usually manifests itself after 3 years. Children carry out auto-depilation uncontrollably, as if automatically: while playing, watching cartoons, and also in situations of stress. The child, unlike adults, does not seek to hide the pathological actions and consequences of TTM.
Why does rhinotillexomania occur?
Often there is a disgusted reaction to picking your nose. What could it be connected with? Urine, feces, earwax, “boogers” in the nose, mucus - this is unpleasant against the backdrop of the body’s protective reaction.
After all, the body has excreted it, it is already toxic, it is already harmful to take it back. Although, as a result of the above study, it was found that 8% of those who pick their nose every day eat the extracted product. Disgust is a protective reaction against poisoning.
Nose picking can be caused by reasons such as:
- hyperactivity;
- attention deficit;
- neurosis-like conditions;
- neurotic conditions.
You probably picked your nose yourself as a child, only some people stop at some stage of growing up, while others continue to do this throughout life. Let's see why.
- While inserting his finger into the nasal passage and picking there, a person plunges himself into a light trance, renounces reality, and goes into another dimension.
- When picking, an unconscious attempt is made to complete something unfinished and a desire to come to peace.
- It is also a way to free yourself from something, to relieve yourself.
Note that if a person is not bothered by picking his nose, and as a rule, this does not bother him, he should look at where this attempt to immerse himself in another reality is coming from. It makes sense to understand this condition more deeply.
Consequences of trichotillomania
Trichotillomania can lead to undesirable medical consequences, primarily – damage to the skin when using sharp “instruments” for autodepilation - tweezers or scissors. At the beginning, the so-called non-scarring, non-inflammatory alopecia associated with damage to the hair follicles, manifested by clear, limited areas of hairlessness without signs of skin lesions. With continuous auto-depilation, this type of alopecia can lead to inflammatory changes in the skin caused by infection. This leads to irreversible damage to the hair follicles (atrophy) and the appearance of connective tissue in their place - scars, while the only way to treat cicatricial alopecia is the surgical method.
Trichophagia (i.e. eating one's own hair) is observed in approximately 20% of patients with TTM, so another important consequence of this disease is the formation of so-called trichobezoars - tight junctions in the stomach, consisting of ingested hair, food debris and gastric mucus. The sizes of trichobezoars vary from a few millimeters to several tens of centimeters, and the weight sometimes reaches 4-5 kg! Ultimately, this leads to the development of gastric obstruction, accompanied by severe pain, as well as digestive disorders. An extreme variant of trichophagia is Rapunzel syndrome, when a hair strand extends from the stomach to the intestines. In such a situation, the only way to help the patient is surgery to remove the trichobezoar. Symptoms such as frequent vomiting, unexplained weight loss, pain in the epigastric region, prolonged constipation or, conversely, diarrhea, change in stool color should cause concern and require immediate medical attention.
When the focus of autodepilation is localized in the area of eyelashes and eyebrows, frequent complications are inflammation of the eyelids (blepharitis) and the mucous membrane of the eye (conjunctivitis), the development of furunculosis and traumatic injuries to the eyeball.
In addition to medical consequences, TTM significantly affects a person’s quality of life and leads to problems in the social and professional sphere. One study demonstrated that trichotillomania is associated with lower self-esteem, significant difficulties in career advancement, and avoidance of social interactions. Patients, realizing the absurdity of their behavior, are forced to hide the pathological inclination and unattractive consequences, often showing extraordinary ingenuity - they style their hair in a special way, wear wigs, constantly use hats and glasses, resort to makeup and false eyebrows and eyelashes.
It is worth noting that society is poorly aware of the problem of trichotillomania, so an “unevenly bald” person with so-called bald spots, without eyebrows or eyelashes, involuntarily causes bewilderment and sarcasm from others. As a result, this forces trichotillomaniacs to isolate themselves from people, which ultimately threatens complete self-isolation and the destruction of social connections.
Stages of formation of rhinotillexomania
Stages of transition from normal elimination of mucus from the nostrils to rhinotillexomania:
- At the initial stage, the child simply cleans his nasal cavity. Nothing special is happening here yet. This is a normal, harmless process.
Giphy
- A habit is formed. Prolonged exposure to this activity indicates a mental disorder or nervous shock. Due to improper care of the mucous membrane, the issue becomes aggravated.
- Worsening of the habit. This stage is formed against the background of an incorrect reaction from adults. They, as a rule, shame the child, scold him, laugh at him.
As a result of rash actions of adults in tandem with psychological factors and poor hygiene of the nasal cavity, an undesirable consequence occurs. Simple cleansing of the nostrils already turns into rhinotillexomania.
Trichotillomania and other mental disorders
Trichotillomania is quite rare in its “pure form”. As a rule, it is associated with a number of mental disorders, which further aggravate the patient's problems. The most common comorbid (coexisting) diseases are depression (up to 65% of patients) and anxiety disorders (up to 55% of patients). In addition, up to 20% of patients with TTM abuse psychoactive substances and alcohol (especially men) to relieve the negative feelings associated with autodepilation.
In women, trichotillomania is often accompanied by onychophagia (nail biting), body dysmorphic disorder (excessive concern about an imaginary defect in appearance), auto-aggressive (self-harming) behavior, including excoriation disorder (dermatillomania) - compulsive self-harm of the skin by scratching and picking.
Men more often suffer from concomitant tic disorder (Tourette's syndrome), hypochondria, as well as obsessive-compulsive disorder, the prevalence of which among male trichotillomaniacs reaches 27%, with an average population level of 0.5-2.0%.
Why do boogers grow in my nose and snot appear?
Where do boogers come from?
Snot is an extremely important thing for the body. Our nose and throat are literally lined with special glands that produce 1 to 2 liters of mucus every day, which needs to go somewhere. A small part of it comes out of the nose, or through the pharynx passes into the respiratory tract - the trachea, bronchi and lungs, and we swallow the bulk without even knowing it.
Absolutely everyone swallows snot - you, the reader, and all your close relatives and acquaintances, and our domestic president, and the overseas one, all the actors, writers, artists and other fashion models, brutal macho men and glamorous pussies.
When we get sick or have an infection in our sinuses, the body produces even more of it than usual because the body is trying to get rid of bacteria or viruses and push them out.
Are snot and boogers the same thing?
Dry boogers in the nose are a very small part of the snot we produce, which has dried up and collected everything that tried to enter the nose with air. Of course, not everything can be retained, and tiny particles still get inside, but a considerable part of the harmful substances still settles on the mucus, which we blow our nose out - or take out with our finger, as you like.
Trichotillomania, obsessive-compulsive disorder and Tourette's syndrome
Until recently, TTM was classified as a disorder of impulse control and impulse control, along with pyromania (an irresistible urge to set fires and watch flames), gambling disorder (pathological urge to gamble) and kleptomania (a morbid urge to commit thefts), which was due to the similarity of manifestations these pathological conditions: an irresistible attraction to a certain action, accompanied by increasing internal tension, and ending with a feeling of relief and relaxation after its completion.
With the release of the new DSM-5 manual in 2013, TTM, along with obsessive-compulsive spectrum disorders (OCD), were classified under the same rubric, which was and is disputed by many experts. Apart from an irresistible compulsion to perform an unwanted action, TTM and OCD have little in common, differing in preferred age of onset, gender ratios, frequency and range of comorbidities, presumed neuroanatomical basis, and treatment effectiveness. And some researchers propose to classify trichotillomania, which began in childhood, as an independent disease (Chamberlain SR et al., 2007).
More and more evidence is emerging about the biological and essential affinity of trichotillomania with tic hyperkinetic disorder, better known as Gilles de la Tourette syndrome. A study conducted by Zuchner S. et al., 2006, demonstrated an increased incidence of SLITKR1 gene mutations in patients suffering not only from TTM, but also from Tourette's syndrome.
How to help patients with trichotillomania
The course of trichotillomania without therapy is usually chronic and undulating, with periods of decreasing and increasing symptoms. Spontaneous cessation of autodepilation is observed only in 15% of cases.
Seeking help from a psychiatrist or psychotherapist is quite rare. According to a study by Woods DW et al. (2006), out of 1048 people suffering from TTM, only 39.5% sought help from general medical specialists (therapists), and only 27.3% sought treatment from a psychiatrist.
Official recommendations for TTM therapy have not yet been developed, and treatment is based, as a rule, on individual studies with a limited evidence base. However, the use of an integrated approach that combines medicinal and psychotherapeutic methods can significantly reduce the severity of trichotillomania.
Psychotherapy
Of the psychotherapeutic techniques used to treat TTM, the most convincing evidence is the so-called Habit Reversal Therapy (HRT). The essence of this approach is, firstly, to increase awareness of what trichotillomania is, which may be associated with the desire to pull out hair (identification of trigger mechanisms). This is followed by training in a competing response, when in response to a “trigger stimulus,” the patient is asked to carry out a competing behavioral act other than autodepilation. Of no small importance is the process associated with the organization of the environment (the so-called management of unforeseen circumstances), which consists in preventing exposure to conditions that contribute to the intensification of the desire for autodepilation. At the final stage of HRT, the patient is taught relaxation methods and summarizes the information received in a thesis form, evaluates intermediate results and carries out “work on mistakes.”
In addition to the above method, various variants of cognitive behavioral therapy, schema therapy, and acceptance and commitment therapy (ACT) are used.
