Impairment in Trichotillomania sufferers
Trichotillomania, or hair pulling disorder, involves the obsessive compulsion to pull out ones hair. The focus area of hair pulling varies and can be anywhere on the body where there is hair. Pulling at the hair on the scalp is most common and often automatic. For some people hair pulling is just a bad habit which does not affect them negatively in any way. In this case the hair pulling is not considered a disorder. According to the DSM5, trichotillomania is most commonly characterized by:
- Recurrent pulling out of one's hair, resulting in hair loss.
- Repeated attempts to decrease or stop hair pulling.
- The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
- The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).
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How does trichotillomania impact functioning?
As shown, impairment in functioning is an important criterion in the diagnosis of hair pulling as a disorder. However, even when diagnosed as a disorder according to the DSM5, the level of impairment caused by trichotillomania varies from one individual to the next. Research studies such as the Trichotillomania Impact Project examined the impact of trichotillomania on functioning and have reported mild to moderate life impairment in social, occupational, academic, and psychological functioning for the entire sample of 1697 participants. In this study, the impact of trichotillomania was evaluated across the domains of social interference, occupational/academic interference, and psychological interference. Respondents were asked about the amount of interference hair pulling had on daily functioning within these domains. Within the 12 months leading up to the study. While interference was prevalent among all participants the extent of interference differed greatly between respondents. The impact on functioning was predominantly attributed to the amount of time spent engaging hair pulling which takes away from day to day tasks within the different domains, as well as avoidance of situations where the consequences of hair pulling would be visible to others.
Under the social domain of the study, respondents reported that hair pulling interfered with home management tasks, maintaining close relationships and having a quality social life. This was due to respondents avoiding social or group activities and events and recreational activities. Respondents also spent varying amounts of time in concealment behaviour, trying to cover up the evidence of their pulling.
The compulsion to engage in hair pulling can often result in being late for work or school and many respondents of the study indicating that hair pulling interfered with quality of work as well as confidence to pursue advancement in career. In terms of academic performance, the urge to pull often also resulted in difficulty concentrating on studies and avoiding further educational opportunities.
While the act of pulling provides relief, tension release and even satisfaction, the aftermath of the damage caused to the site of hair pulling leads to feelings of shame, guilt and embarrassment. The use of alcohol, illegal substances and tobacco has been found to be used to relieve the negative feelings associated with pulling, and sometimes in an attempt to reduce the urge to pull. A high proportion of respondents from the impact study also felt that trichotillomania directly contributed to the development of an additional emotional disorder such as depression or anxiety disorder.
Apart from the obvious physical damage to the hair at the site of pulling, the feelings of shame mentioned above also leads to some individuals avoiding vital medical care such as dermatology or gynaecology, for fear of being exposed. Hair pulling can also lead to repetitive strain injuries, whereby the repetitive motion of specific muscle groups used to constantly pull at hairs become strained and painful.
Like so many other mental health disorders, trichotillomania is a long term condition. When an individual does not seek help and suffers in silence, a large amount of time and sometimes expense is spent trying to cover up hair loss. In contrast those who do seek help are often faced with the cost of seeking treatment that works for them.
Still the severity of impact on each individual trich sufferer varies greatly. Minimal impairment is described as experiencing some feelings of shame or embarrassment and has tried to stop, but rarely thinks about it as a problem. Mild impairment is when there is a preoccupation with the urge to pull hair, and the person feels conscious about appearance due to a small area of balding that occurs. The person thinks about quitting more often and finds that the behaviour is starting to interfere with some activities. Moderate to severe impairment is when the effects of pulling becomes obvious to others either because of time spent pulling, or because of the appearance of large balding spots. In the severe form the person is as preoccupied with thoughts about stopping as they are preoccupied with the urge to pull.