Trichotillomania and Defining Subtypes: The Latest Research

When it comes to Trichotillomania (TTM), not all hairpulling is the same. While hair pulling is the dominant feature of TTM, new research published in The Journal of Psychiatric Research suggests that there’s much more to the clinical picture. These results have significant implications for diagnosing, categorizing, and treating TTM.

The Need for Better Data

A relatively common disorder, TTM affects about 3% of the population. Despite its prevalence, TTM remains under-represented in the research literature and often goes untreated.

One of the things we know about TTM is that it creates significant impairment in a person’s physical, emotional and social functioning. While no one knows the exact cause, studies have pointed to factors such as boredom, emotional reactivity, stress and anxiety, problems in perceptual sensitivity, dissociation, and trauma. Some studies have looked to neurocognitive factors such as memory, attention, and cognitive flexibility. Other research has even looked at brain structure for clues. But, so far, the root cause remains elusive.

For those who do seek help, treatment tends to be only partially successful in symptom reduction and relapse is common. There is currently no “best” way to treat TTM. A barrier to the development of successful treatments has been a lack of clear scientific data to guide treatment protocols. Why do some things for work some people and other things don’t? The answer seems to be, at least in part, the way TTM is defined.

Some research, and anecdotal evidence, has long supported the belief that there are distinct differences in causality and in just how the disorder manifests. Some people seem to pull intentionally. Others seem to do so randomly or automatically without much awareness at the moment. Still, others seem to be driven by uncontrollable urges. However, research on various dimensions of the disorder yielded mixed results.

This new study has taken a closer look to see if there really differences are in how TTM can present and why. The results suggest that there are three distinct sub-types of TTM, each one with a unique set of features and implications for classification and treatment. The study also included another body-focused repetitive behavior, Excoriation or Skin Picking Disorder (SPD).

Why Subtypes Matter

TTM is more than just hairpulling, even intense hair pulling. TTM is a distinct set of symptoms that come together to create distress for a person in one or more areas of functioning. According to the APA’s Diagnostic and Statistical Manual, (DSM-5), the following criteria for a TTM diagnosis must be met:

• Recurrent pulling of the hair, resulting in hair loss
• Repeated attempts have been made to reduce or stop the hair pulling
• The hair pulling causes significant distress or impairment in areas of occupational, social, or other important areas of functioning.
• The hair pulling cannot be better attributed to another medical condition.
• The hair pulling cannot be better explained as a symptom of another mental disorder.

While these criteria are necessary for the diagnosis to be made, they don’t delineate between the ways TTM can present clinically. For example, some people are very focused and intentional when engaging in hair pulling. Others may pull in a way that looks almost automatic or impulsive. But, the criteria alone don’t tell the whole story. While two people might meet the criteria for TTM, the factors underlying their TTM and the dynamics of their may be very different. That has significant implications for treatment.

What’s also worth noting here is that other disorders are often seen occurring along with TTM. Some of the more common co-occurring disorders are major depressive disorder, anxiety disorders, and substance use disorders. The presence of a co-occurring disorder can impact treatment as well.

The study looked at TTM along multiple dimensions to seek a better definition of TTM and how it can manifest.

Three Subtypes of TTM

Using what’s considered the “gold standard” in assessment tools to assess symptoms of TTM and a method is known as mixed modeling, researchers identified three distinct sub-types of TTM. These sub-types were identified as:

• Subtype 1: Sensory-sensitive Pullers
• Subtype 2: Low Awareness Pullers
• Subtype 3: Impulsive/Perfectionist Pullers

Each of these subtypes has a unique set of clinical characteristics.

Subtype 1: Sensory-sensitive Pullers

This subtype is characterized by highly focused pulling behavior. The pulling tends to be very intentional. Urges to pull tend to be infrequent. When urges do occur, they tend to not be overwhelmingly intense.  The frequency of pulling tends to be lower than in other subtypes.

Individuals in this subtype score high in sensory sensitivity. Sensory sensitivity refers to how aware someone is of their sensory input: sight, sound, taste, smell, touch, and pain. Highly sensitive individuals tend to react strongly when something is highly stimulating. There is a moderate disturbance in mood.  Impairment due to the pulling is moderate.

Subtype 2: Low Awareness Pullers

This subtype is the most common manifestation of TTM via the study. These individuals tend to engage in automatic pulling. Their pulling is more often the result of emotional triggers while urges to pull are generally low. Some degree of impairment is present.

While they may sometimes experience some disturbance in mood, people with this subtype tend to present with symptoms of ADHD and a degree of impulsivity.

Subtype 3: Impulsive/Perfectionist Pullers

Pulling behavior for this subtype is driven by a need to control unpleasant emotions. These individuals experience uncontrollable urges to pull. Distress tolerance, the capacity to cope with negative emotional or other aversive situations, is poor and they can be easily overwhelmed.

People with this subtype of TTM tend to present with high degrees of both perfectionism and impulsivity. There is significant mood disturbance and impairment.

Two Subtypes of Excoriation (Skin Picking Disorder)

Along with TTM, the researchers also included another body-focused repetitive behavior, Skin Picking Disorder (SPD), in the study. Using similar assessment tools, they found evidence for two distinct subtypes of skin picking as well.

Subtype 1: Emotional/Reward Pickers

This subtype is the most common type of SPD. It is characterized by intense and frequent urges to pick. Urges are triggered by negative emotions. Automatic picking may also be present. Individuals in this subtype tend to score high on measures of ADHD and report a high degree of perfectionism.

Subtype 2: Functional Pickers

This subtype is characterized by milder symptoms of SPD and lower urges to pick. People in this group tend to experience some degree of sensory sensitivity and a lowered tolerance to stress. Impairment is generally low.

The researchers noted that these subtypes may be less distinct subtypes and more opposite ends of the SPD continuum. More research is needed but clinicians should be aware of the different manifestations of the disorder.

What The Findings Suggest

The findings of the study support the idea that TTM indeed consists of distinct subtypes, each with its own profile and constellation of symptoms. Understanding the distinct differences in each subtype may lead to better classification of TTM and in turn, more targeted treatments to address the needs of each.

These findings suggest that clinicians need to be mindful of not just the main diagnostic criteria for TTM but to also be mindful of the various ways in which the disorder can present and what drives that presentation. Better assessment can mean better treatment planning.

Treatment Implications

There is currently no single “best treatment” for TTM. Current treatments for TTM consist primarily of psychotherapy and medication management. Effectiveness is highly variable.  

For psychotherapy, the most common and most empirically-supported therapeutic approach to treating TTM is behavioral therapy, primarily Habit Reversal. Habit Reversal is particularly flexible and can be used in-person, online, or as self-help. Other approaches that may be used alone or in combination with Habit Reversal include Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy(ACT), or Dialectical Behavior Therapy.

There are currently no “first line” medications for TTM. Some studies have explored the effectiveness of certain antidepressant medications but the results are not clear. More often, medication may be used to treat the co-occurring conditions that may accompany TTM like anxiety or depression.

So, why does knowing about subtypes matter? Having knowledge of the TTM subtypes offers clinicians more information to work with. Knowing someone shows the profile of a Subtype 2: Low Awareness Puller, that they generally don’t experience significant mood disturbance vs. a Subtype 3: Impulsive/Perfectionist Puller who can have significant mood impacts can enable the clinician to better develop a plan of treatment for that individual. Instead of a general treatment approach, clinicians can zero in on those factors most involved in driving the TTM behavior. A more targeted approach may result in a more satisfactory outcome.

As researchers continue to better define and understand this disorder, treatment protocols will follow. For now, while there is no definitive treatment for TTM and other body-focused repetitive behaviors, there is hope. Current treatments can offer some relief to people living with disorders like TTM and SPD.

The important first step to getting help is to seek out a clinician who is experienced in working with body-focused repetitive behaviors like TTM. Support from family and friends is also critical. Reach out to the people who care about you and ask for their support. Remember that a disorder does not define you and, with treatment and support, you can take control of your mental health and well-being. 

References

1. Grant, J. E., Peris, T. S., Ricketts, E. J., Lochner, C., Steins, D. J., Chamberlain, S. R., … Keuthin, N. J. (2020). Identifying subtypes of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder using mixture modeling in a multicenter sample. Journal of Psychiatric Research, in press. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0022395620310578?via%3Dihub
2. Grant, J. E., & Chamberlain, S. R. (2016, September 1). Trichotillomania. Retrieved from https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2016.15111432
3. Snorrason, I., Ólafsson, R. P., Flessner, C. A., Keuthen, N. J., Franklin, M. E., & Woods, D. W. (2012). The skin picking scale-revised: Factor structure and psychometric properties. Journal of Obsessive-Compulsive and Related Disorders, 1(2), 133-137. doi:10.1016/j.jocrd.2012.03.001
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5. Chamberlain, S.R., Harries, M., Redden, S.A., Keuthen, N.J., Stein, D.J., Lochner, C., et al., 2018. Cortical thickness abnormalities in trichotillomania: international multi-site analysis. Brain Imaging Behav 12 (3), 823–828.