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Final
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
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Final
Psychological concepts, Symptoms and behaviors of the patient
The patient presents symptoms of plucking her eyelashes when she was a child in seventh
grade because she describes her parents as complex and always wanting to be overinvolved in
her activities. She explains that she has always been nervous about things and would pluck her
eyelashes when she was highly stressed out. In college, she relapsed but pulled her hair instead
when she underwent a break-up with her first boyfriend. She could not take in the frustration of
being left with no explanation.
Matches of the patient’s symptoms to DSM-5 criteria manual
According to DSM-5, the Hair-pulling condition, also known as trichotillomania,
comprises both compulsive hair-pulling with unsuccessful trials to curb the behavior (Edition,
2013). The patient’s symptom matches the trichotillomania under obsessive-compulsive
disorders in DSM-5. Though anxiety and boredom are often precursors to the body-focused
repetitive behaviors that characterize this disease, obsessions and preoccupations are not the
direct cause of these behaviors. Hair-pulling is a common stress reliever but can also come after
a period of heightened anxiety (Edition, 2013). Some people with these conditions appear to be
fully aware of their actions while they are taking place, with tension building up and then
releasing.
Hair pulling causes occupational and social impairment, where individuals use wigs to
cover those areas in an attempt to stop. Hair-pulling behavior only occurs in the presence of
close family but not among strangers (Edition, 2013). Hair pulling causes embarrassment and
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shame. In contrast, others appear to be acting more automatically, with the behaviors occurring
without full awareness.
Suzanne fits this description because she pulled hair in different parts of her body: her
eyelashes and her head. She describes that the hair-pulling behavior caused her relief from
distress. She believed her eyes were irritated and sore, so she needed to pluck her eyelashes,
which she believed had bacteria wiggling around her skin. She plucked her eyelashes in front of
her parents during dining hours on which her mother noticed that even the eyelashes were almost
not there anymore. Hence, she had to remove them to feel better, but it was mainly a way to
evade feeling guilty over her behavior.
Validity and limitations of the DSM-5 diagnostic manual
The DSM-5 is based on criteria on which mental disorders are diagnosed, coupled with a
lengthy accompanying fully referenced text for the first time in the electronic version of the
DSM (Regier, 2013). Using an enlarged set of “validity criteria” from those first proposed in
1970 by Guze and Robins, a series of analyses and publications were generated in an
international psychiatric journal (Regier, 2013). It was later confirmed that applying such
“validators” was more meaningful for disorder spectra or group disorders than for specific
category diagnoses. A new organizational structure for the DSM-5 was the result of this decision.
However, a deeper look at the DSM-5 indicates that its diagnoses of mental diseases are
inaccurate representations and are not always helpful in choosing the most appropriate treatment
methods (Regier, 2013). It is easy for clinicians to disregard the DSM-5’s warning, which states
that the manual should not be used as the primary foundation for planning treatment and instead
advises evaluation in full.
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The theoretical orientation of trichotillomania
Based on neurobiology, trichotillomania is caused by neurochemical and
neuroanatomical. Their features of how they result in trichotillomania behavior have been
documented in several studies. Researchers at Swedo University were among the first to find a
connection between hair-pulling and low serotonin levels in the brain (Dixon, 2016). According
to the results of these investigations, brain chemistry and structure issues have been linked to
trichotillomania.
Neuroanatomical
Recent research on trichotillomania’s pathophysiology has white matter disorder that
tracts involved in motor habit suppression, generation, and affective regulation (Dixon, 2016).
Researchers have looked into trichotillomania patients’ brains a little; brains of people with
trichotillomania showed reduced left putamen volume compared to controls, which may indicate
changes in frontostriatal motor circuitry and a correlation between the intensity of
trichotillomania symptoms and a lower cerebellar volume (Dixon, 2016). When comparing the
brains of people with and without trichotillomania using magnetic resonance imaging (MRI),
researchers found that those with trichotillomania had a considerably smaller left inferior frontal
gyrus volume and a larger volume in the right cuneal cortex. Those with trichotillomania have
been found to have elevated glucose metabolism in the superior parietal region on the right and
the right cerebellum and left superior parietal regions compared to those without the disorder
(Dixon, 2016).
In a new study, researchers looked at what happens to the brain over time due to stress.
One hundred healthy individuals’ brains were scanned while answering questions regarding
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stressful life experiences (Dixon, 2016). The cumulative impacts of trauma, they said, have a
profound influence on brain volume. Tragedies profoundly affect the parts of the brain that
regulate emotion and behavior, distorting the way we process and respond to pleasure and
reward. Reduced brain volume in these regions has been associated with anxiety and depression.
It is plausible that ripping out one’s hair repeatedly over many years represents a traumatic event
in one’s life that adds to the development of anxiety and depression.
Behavioral theory
Several scholars have proposed that mimicked behavior has a role in the development of
trichotillomania. The hair in this context symbolically represents an individual’s emotional
content. Target actions are not seen as particularly problematic in behavioral theories, and hair-
pulling is seen as a problematic behavior rather than an underlying conflict symptom. Behavioral
models investigate the environmental and emotional cues that lead to hair-pulling and the
reinforcement processes that keep the action going (Dixon, 2016). Since there is a shortage of
literature on hair-pulling behavior in models, more investigation into this potential prelude to
trichotillomania is warranted.
Psychoanalytic theory
Based on the psychoanalytic theory, psychological factors are involved in hair pulling
based on the idea that appendages and tactile stimulation of the skin during infancy affect future
and present development in physical and emotional aspects (Dixon, 2016). Hair-pulling can be
triggered or made worse by stressful situations analogous to repressed tensions. According to one
psychoanalytic theory, pulling one’s hair is a coping mechanism to deal with anxiety over
possibly losing an important external focus of attention.
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Hair loss can be upsetting since it represents much more than an inconvenience. If a child
has a conflicted relationship with one or both of their parents in the first two years of their
existence, the youngster may develop trichotillomania (Dixon, 2016). Hair-pulling is a coping
mechanism for anxiety and conflict resulting from dysfunctional familial interactions. According
to these ideas, sufferers with trichotillomania are held responsible for their condition. Some
researchers believe pulling one’s hair is a coping mechanism for dealing with conflicting
emotions, such as the desire to show affection to one parent while harboring competitive
resentment toward the other (Dixon, 2016). Ripping out one’s hair may be a form of penance for
the “forbidden longing for self-gratification.” Some psychoanalytic perspectives hold that sexual
abuse or trauma probably plays a role in the onset of trichotillomania. The lack of empirical
validation is a feature shared by most psychoanalytic hypotheses.
Comorbidity
From the case study, two distinct mental disorders appear to be involved.
Trichotillomania dominates the patient, but there are symptoms of major depressive disorder.
The criteria for depressive disorder include feelings of worthlessness that have been present for
two consecutive days and occurring at least every day—difficulty concentrating, thinking and
making decisions (Edition, 2013). Distress is significant clinically and impairs social and
occupational functioning. Psychomotor changes, which include hair pulling and Suzanne’s
trichotillomania disorder, may be associated with a major depressive episode, where she
mentions she always felt undesirable. Jon breaking up with her made those feelings intensify.
She also mentions feeling depressed. She lost her thinking and decision-making until she failed
two of her classes. Her symptoms caused clinically significant distress, which led her to relapse
from pulling her hair, which she only noticed mid through her semester.
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Symptoms evaluation with theoretical orientation
Psychoanalysts once thought that rage turning to self-hatred was what created sadness.
To further clarify this notion, it is helpful to give an example of how this transition is imagined
to occur typically (Dixon, 2016). An unpredictable, hostile environment is created for a child by
inconsistent neurotic parents (demanding and overindulging), lacking warmth, insensitive,
furious, or motivated by their selfish wants. The child consequently feels abandoned, perplexed,
helpless, and angry. The kid is aware that strong parents are the only ones who can keep them
alive, in any case. Thus, the child suppresses anger at the parents and channels it inward so that it
is rage aimed at themselves out of fear, love, and guilt (Dixon, 2016). The youngster develops a
“despised” self-concept and finds it relaxing to believe phrases like “I have always been
undesirable.”
Cognitive behavioral theory is the interplay between cognition, emotion, and behavior.
Our thoughts drive our emotions and actions. We can experience mental anguish and external
difficulties directly from dwelling on the negative and unrealistic (Dixon, 2016). Psychological
anguish distorts one’s perceptions and attitudes, which have unfavorable consequences on
behavior.
Prevalence of trichotillomania based on age, gender, sexual orientation, ethnicity, and
socioeconomic factors.
A total of 10,169 persons participated in the study. 1.7% of the sample, or 175 people,
reported suffering from trichotillomania (Grant, Dougherty & Chamberlain, 2020). The rate in
the lifetime for trichotillomania was 2.5%. In a recent study, trichotillomania prevalence in the
general population in males was 1.8%, and in females, 1.7%. Lifetime prevalence rates for
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trichotillomania were in males 2.5% and 2.4% in females, with no significant difference between
the sexes. There was no statistically significant difference in trichotillomania prevalence by
income, education level, race, or ethnicity. Among people aged 30–49, there was a significant
gender gap in the prevalence of trichotillomania. The incidence of trichotillomania appears to be
highest (2.2–2.6%) among those younger than 50 (Grant, Dougherty & Chamberlain, 2020).
Of the 175 people who self-reported having trichotillomania at the time of the survey,
110 (62.9% of the total) said that a medical expert had diagnosed their condition. When a more
conservative estimate of actual prevalence was genuine, 0.98 percent of people have active
trichotillomania and have sought medical help for it in the past year. Most of these
trichotillomania subjects were male (Grant, Dougherty & Chamberlain, 2020). For the 175
people with active trichotillomania, the mean age of onset was 17.7 years old (range 1-61 years).
A statistically significant difference between the average ages of onset in males mean of 19.0
years and 14.8 years for females was recorded.
On a scale from 1 to 7, with 1 being hardly detectable and 7 being significantly so, the
mean score for the 175 people with active trichotillomania was 4.3, indicating that their hair loss
was moderately noticeable (Grant, Dougherty & Chamberlain, 2020). Concern about their hair-
pulling, measured on a scale from 0 to 7 (7 being the most disturbing), was, on average, 5.1. On
average, participants rated their hair-pulling behavior as 4.4 at the time of diagnosis, 5.2 at the
time of their worst episode, and 4.1 at the time of their best episode. When comparing the effects
of hair-pulling by gender, women were more likely to report “severe” anguish (42%) and
“substantial impact” (32%), whereas men were less likely to report either (18%) or (12%).
Sexual orientation prevalence indicated that of the males and females screened, 11 and 9
identified as transgender males and females, respectively. According to Grant, Dougherty &
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Chamberlain (2020), on the ethnicity scale, Alaska Native or American Indians have a 1.1%
TTM prevalence rate, Asians, 2.0%, native Hawaiians, 2.0%, Black Americans, 1.7%, and
whites, 1.7%. In the socioeconomic category, individuals with lower household incomes of less
than $25,000 have high TTM prevalence compared to households with higher socioeconomic
status with an annual income of more than $125,000.
DSM-5 diagnostic manual proves to be valid because, on the comorbidity of
trichotillomania, the patient matches some of the major depressive disorder criteria (Regier,
2013). The validity of a statistical conclusion is measured by the precision, consistency, and
generalizability of the numbers drawn from research or a series of studies. There are nine
standards for evaluating the reliability of statistical findings. Each first five is associated with a
separate study, while the latter four are collective nouns (Regier, 2013). This includes, but is not
limited to:Kthe study’s sample method, Quantity Represented in the sample, and all of the
variables in theKstudy havingKhigh levels of dependability in their measurements.K
Risk factors of trichotillomania
Hair-pulling itself may not hurt, but the physical effects can. Some people may
experience moderate to severe physical impairment from pulling their hair. TTM’s physical toll
has been related to redness, itching skin, and other health problems (Woods & Houghton, 2014).
Some people who have TTM say they experience satisfaction during and after instances of
pulling, whereas some suggest a decrease in stress, boredom, unhappiness, and tension. Most
trichologists will not consider social isolation because they cannot form close personal
relationships for fear of revealing their secret.
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Results from this study pointed to a need for impairment in academic, social, or
interpersonal functioning for teens with TTM who also have significant depression and anxiety
symptoms (Woods & Houghton, 2014). TTM is typically accompanied by negative feelings,
including unattractiveness, secrecy, irritability, depression/bad mood, embarrassment, low self-
esteem, and arguing. Participants reported high rates of clinically severe despair and anxiety.
People affected by trichotillomania are more likely to withdraw from social activities, seek
professional help, and have lower incomes (Woods & Houghton, 2014). The habit of ripping out
one’s hair adversely affected one’s school performance (in the form of absenteeism, problems
concentrating, and linguistic fluency). Economically, due to absences, trichotillomania greatly
influences schools (Woods & Houghton, 2014). We lose out on that sum of money. Several
respondents said they had to abandon their studies and had work interrupted. Products to cover
hair loss could have a substantial economic impact.
Comparison of Evidence and non-evidence-based treatments
Traditional methods of treating trichotillomania have involved some form of cognitive
behavioral therapy of coping mechanisms by unlearning the hair-pulling behavior. However, in
Adrenalin hypnotherapy, hypnosis has been used in some cases (Melo, 2022). Combined with
cognitive behavioral approaches, hypnosis is founded on the hypothesis that trichotillomania is
more than just an annoying habit and that the individual may benefit from the condition by
relieving stress (Melo, 2022). Hypnosis, on the other hand, is beneficial for more than only
eliminating symptoms and changing behaviors; it may also be used to facilitate relaxation and
address emotional concerns.
Established Treatments
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Traditional behavioral treatments for TTM have focused on three central tenets: first,
training on awareness, in which self-monitoring techniques are implemented to increase the
awareness of the patient’s hair-pulling behavior and, more ideally, the urge that precedes pulling
Franklin, Zagrabbe & Benavides, (2011); stimulus control, in which several methods are used
triggers to decrease the likelihood of hair-pulling behavior beginning; and, competing response
training, in which the patient is taught alternative behaviors to the problematic one. Although
some procedures of habit reversal training have techniques included, the foundations of modern
behavioral treatment were laid by developing and testing these essential methods (Franklin,
Zagrabbe, & Benavides, 2011). For instance, cognitive strategies and relaxation training to
address precipitation pulling from dysfunctional thoughts.
Annotated Bibliography
Dixon, M. M. (2016).KTrichotillomania: A journey of personal empowerment: A qualitative study
of women who engage in chronic hair pulling. The University of Utah.
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Melissa Marie Dixon studies trichotillomania broadly. She illustrated vast knowledge in
theoretical explanations of trichotillomania, impacts and therapies for the disorder.
Franklin, M. E., Zagrabbe, K., & Benavides, K. L. (2011). Trichotillomania and its treatment: a
review and recommendations.KExpert review of neurotherapeutics,K11(8), 1165-1174.
Franklin and colleagues conducted a broad study of trichotillomania and its treatments.
The study suggests cognitive behavioral therapy combined with medication effectively
treat the disorder.
Grant, J. E., Dougherty, D. D., & Chamberlain, S. R. (2020). Prevalence, gender correlates, and
comorbidity of trichotillomania.KPsychiatry Research,Kp. 288, 112948.
Grant and colleagues conducted an extensive study in 2020 to assess the prevalence of
trichotillomania in different demographics. The study found that prevalence varies with
age, gender, sexual orientation, socioeconomic status, and ethnicity.
Melo, D. F., dos Santos Lima, C., Piraccini, B. M., & Tosti, A. (2022). Trichotillomania: What
Do We Know So Far?KSkin Appendage Disorders,K8(1), 1-7.
Melo and colleagues explored the evidence and non-evidence treatments of
trichotillomania. They argue that most patients do not like CBT, so they suggest
hypnotherapy focusing more on relaxation techniques that help patients do away with the
thoughts that trigger hair-pulling.
Woods, D. W., & Houghton, D. C. (2014). Diagnosis, evaluation, and management of
trichotillomania.KPsychiatric Clinics,K37(3), 301-317.
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Woods and Houghton conducted broad literature on the diagnosis, evaluation and
management of trichotillomania. They argue that the disorder can be managed and treated
with the correct diagnosis. The nature of trichotillomania is discussed in depth. The
article uses animal models to try and understand trichotillomania’s pathology.
References
Dixon, M. M. (2016).KTrichotillomania: A journey of personal empowerment: A qualitative study
of women who engage in chronic hair pulling. The University of Utah.
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Edition, F. (2013). Diagnostic and statistical manual of mental disorders.KAm Psychiatric
Assoc,K21(21), 591-643.
Franklin, M. E., Zagrabbe, K., & Benavides, K. L. (2011). Trichotillomania and its treatment: a
review and recommendations.KExpert review of neurotherapeutics,K11(8), 1165-1174.
Grant, J. E., Dougherty, D. D., & Chamberlain, S. R. (2020). Prevalence, gender correlates, and
comorbidity of trichotillomania.KPsychiatry Research,Kp. 288, 112948.
Melo, D. F., dos Santos Lima, C., Piraccini, B. M., & Tosti, A. (2022). Trichotillomania: What
Do We Know So Far?KSkin Appendage Disorders,K8(1), 1-7.
Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013). The DSM‐5: Classification and criteria
changes.KWorld Psychiatry,K12(2), 92-98.
Woods, D. W., & Houghton, D. C. (2014). Diagnosis, evaluation, and management of
trichotillomania.KPsychiatric Clinics,K37(3), 301-317.
