Male vs Female Presentation of Trich

Trichotillomania or simply just “trich” is an disorder on the Obsessive Compulsive Disorder Spectrum and is characterized by the irresistible urge to pull out one’s hair and is usually persistent and difficult to treat. This usually leads to hair loss or balding (depending on the affected area of pulling), distress and in many cases, functional or social impairment. This hair pulling disorder affects just a small percentage of the general population (1% to 4%) but unfortunately, it is often a mistreated and underdiagnosed disorder. Although it is usually thought to be a disorder that primarily affects women; the male patients’ clinical presentation may be unique. When assessing and treating this disorder, sex difference may be a major factor. In most cases, there are many similarities in male and female patients of trich, but there are important differences to note as well.

Age of Onset 

According to research, the age of onset of the disorder is variable with the peak prevalence being between the ages of 9 – 13. Although trich seems to be more common in children compared to adults, severity of the presentation seems to be higher during adolescence and the prognosis is getting poorer as the age for onset approaches adulthood. This implies that sufferers from adolescence to young adults have a more long-lasting form of the disorder and therefore do not respond well to treatment. Age of onset also varies between the sexes with 70 – 93% of adolescents and young adults being female even though it affects both boys and girls equivalently in early childhood. Studies show that females usually tend to outnumber their male counterparts with the overall female predominance of 10 to 1.   
However, these studies could only show that gender disparity does not result because of the disorder but rather, it can be a reflection of the fact that more women seek medical attention compared to their male counterparts. This is because of all the ones who seek treatment more than 70% are usually women.  

Causes 

It is important to know that trichotillomania can affect any person from all walks of life. Therefore, physicians should have a high index of suspicion so as to obtain an effective history. Trich is often comorbid with obsessive-compulsive disorder, anxiety, depression and stress, with the latter thought to be common triggers for onset. This implies that the behavior is a way of coping with the negative feelings associated with those conditions. These conditions that may increase suspicion towards trich diagnosis include psychiatric disorders such as obsessive-compulsive disorder, attention deficit disorder, mood disorder and body-focused repetitive behaviors such as nail biting, skin picking or lip biting. Another cause can be linked to the same characteristics as that of addiction. This means that the more an individual pulls out hair, the higher the need to repeat the action gets. There two ways of pulling namely automatic and focused. Automatic is the involuntary pulling without premeditated intent while focused pulling is when the person knowingly decides to pull. In automatic pulling, it can happen when the individual is engaged in other tasks or is absorbed in thoughts. About 75% of adult trichotillomania patients engage in automatic pulling. Also, patients who engage more in focused pulling rather than automatic pulling may develop other associated disorders such as skin picking. 

Symptoms 

• Hair pulling: the behavior is usually confined to one or two places but can also involve multiple places. The primary pulling site is usually the scalp followed by the eyebrows and eyelashes, face and the limbs. Other less common areas include the pubic areas, and underarms. The male individuals who suffer from this disorder tend to pull more from their faces, arms as well as torso and are more vulnerable to suffer from coexisting substance use disorder. Children are more likely to concentrate on the scalp compared to other areas.
• Denial of hair pulling: this is usually common among children because usually, they do not do the action in front of adults.
• Avoiding social situations: patients with trich tend to have low self-esteem as a psychological effect of the disorder due to fear of socializing because of appearance and fearing how people will perceive them. Stress and embarrassment can make the individuals isolate themselves from the world.
• Gastrointestinal problems: another possible co-occurring disorder associated with trich is trichophagia which is the compulsive eating of the hair after the act pulling which in rare but extreme cases, can lead to a ball of hair also known as trichobezoar. In the extreme form of trichobezoar known as Rapunzel syndrome can occur when the hair ball extends through to the intestines. The hair ball can lead to abdominal pain, constipation, nausea, and vomiting or other symptoms of bowel obstruction. If the diagnosis is not made early it can be fatal.
• Physical Examination: Some of the physical signs of trich include: areas of hair loss which range from barely noticeable places to complete baldness, areas of hair loss with broken hairs of different lengths usually arranged in a circular manner surrounded by unaffected hair and hair abnormalities such as empty or damaged hair follicles, broken hairs, wavy or wrinkled hair shafts.

Treatment 

A person’s age is usually a major factor in treatment. Most preschool kids overcome the disorder if it is managed early on with the support of a good child mental health professional and the parents. In young adults, the use of behavior modification programs might be considered. When other methods fail, referral to psychiatrists is considered. If the disorder begins in adulthood, it is normally identified with other forms of mental disorders. Therefore, the best treatment is a referral to a psychiatrist. According to studies, unlike women, about 70% of men prefer psychotherapy over medication or even no treatment, preferring to wait and see what happens. Therefore, men are advised to consider individual therapies to encourage treatment rather than avoid it.
 

Sources

http://emedicine.medscape.com/article/1071854-clinical#showall
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https://en.wikipedia.org/wiki/Trichotillomania