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Diplomat of the American Board
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Diplomat of the American Board
of Psychiatry and Neurology

561.842.9550

Trichotillomania

October 3, 2011 by Dr Mark Agresti Glossary, Impulse Control Disorders, Trichotillomania 0 comments

Trichotillomania is the compulsive urge to pull out one’s own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat.

Trichotillomania may be present in infants, but the peak age of onset is 9 to 13. It may be triggered by depression or stress. Due to social implications the disorder is often unreported and it is difficult to accurately predict its prevalence; the lifetime prevalence is estimated to be between 0.6% (overall) and may be as high as 1.5% (in males) to 3.4% (in females).

The name, coined by French dermatologist François Henri Hallopeau, derives from the Greek: trich- (hair), till(en) (to pull), and mania (“an abnormal love for a specific object, place, or action”).

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What is Schizophrenia? A man named Eugene Bleuler coined the term schizophrenia. If you break the word down to its parts, “schizo” and “phrenia,” it literally means split personality. But that’s not what schizophrenia is. There are so many misconceptions about schizophrenia that I want to explain more about it. Schizophrenia is a psychotic disorder, a severe and often debilitating brain and behavior disorder. It affects how a person thinks, feels, and acts, because they have breaks from reality. Basically, that means they have hallucinations and delusions, and can have trouble telling the difference between reality and fantasy. Their thought processes, behavior, and speech can become disorganized. Disorganized basically means abnormal. Disorganized speech is generally gurgly speech, it makes no sense. Disorganized behavior is basically a decline in daily functioning. This can range from a person not taking care of their hygeine, not bathing or brushing their teeth, to catatonia, where they are unable to move at all. They freeze and look like a statue, and this is called posturing. There can be something called “waxy flexibility” which is where their body can be placed in any shape in a fixed position, like a wax figure, hence the name. Disorganized thinking is basically when someone cannot “think straight.” They are unable to connect thoughts into logical sequences, so their thoughts become disorganized and fragmented. They often have unpredictable or inappropriate emotional responses, and hear imaginary voices and believe others are reading their minds, controlling their thoughts, or plotting to harm them. These are delusions and hallucinations; the two are very different. A delusion is a false fixed belief, often involving thoughts of others monitoring or threatening them or reading their thoughts. The most common type of delusion is a paranoid delusion. “The CIA is tracking me,” “The FBI is coming to get me,” “My neighbor is watching me.” These are common delusions in people with schizophrenia. Hallucinations cause a patient to hear, see, feel or smell something that is not there. The most common type of hallucination is an auditory hallucination, meaning the person hears something not actually there. These auditory hallucinations can be dangerous if they are what are called “command hallucinations,” because they can tell the person to kill themselves or someone else. Obviously, this is not good, and must be taken very seriously. Anytime you have someone experiencing hallucinations, it is in your best interest to explore these with a mental health practicioner to find out what they are and take appropriate measures. Schizophrenia can be cyclical. There can be remission and relapse cycles; a person can get better, worse, and then better again repeatedly over time. As a result, people with schizophrenia suffer from symptoms either continuously or intermittently throughout their entire lives, and they are often severely stigmatized by people who do not understand the disease. Contrary to popular belief, people with schizophrenia do not have “split” personalities or multiple personalities, and as long as they receive appropriate treatment and are compliant with medications, most pose no threat to others. However, the symptoms are sometimes so terrifying to those experiencing them that they can become agitated, withdrawn, and depressed. Sadly, people with schizophrenia attempt suicide more often than people in the general population, and it is estimated that up to 10 percent of people with schizophrenia will complete a suicidal act at some point within the first 10 years of the illness. This is particularly true in young men with schizophrenia. While schizophrenia is a chronic disorder, it can be treated with medication and psychological counseling, and this can substantially improve the lives of people with the condition. Schizophrenia can have very different symptoms in different people. The way the disease manifests itself and progresses in a person depends on the age of onset and the severity and duration of symptoms, which are categorized as positive, negative, and cognitive. Positive symptoms don’t mean symptoms that are good, they mean symptoms or actions which are added to the person’s behavior. Examples of positive symptoms are delusions and hallucinations, and these can be severe or mild. Negative symptoms don’t mean they are especially bad, they mean symptoms or actions which are taken away from the person’s behavior. They reflect a loss of functioning in areas such as emotion or motivation. Examples of negative symptoms are loss of motivation, aimlessness, poverty of speech, a blunted or flat affect, and inability to express emotion or find pleasure in life. They often lead to social withdrawl and apathy, and can be mistaken for laziness or depression. Cognitive symptoms involve problems with attention and memory, especially in planning and organizing to achieve a goal. These cognitive deficits are often the most disabling for patients trying to lead a normal life, as they make it very difficult to keep up with peers in the big wide world. All three types of symptoms- positive, negative, and cognitive- reflect problems in brain function. Schizophrenia affects men and women equally. Symptoms such as hallucinations and delusions usually start between the ages of 16 and 30, though men tend to experience schizophrenia symptoms earlier than women. Schizophrenia rarely occurs in children, but awareness of childhood onset schizophrenia is increasing in the psychiatric community. It can be difficult to diagnose schizophrenia in teens. This is because the first signs can include behaviors commonly exhibited by normal teenagers, such as a change in friends, a drop in grades, sleep problems, and irritability. Despite this, there are a combination of factors that can predict schizophrenia in up to 80 percent of youth who are at high risk of developing the illness. These factors include isolation, withdrawing from others, an increase in unusual thoughts, paranoia and unusual suspicions, and a family history of psychosis. Currently, schizophrenia is diagnosed by the presence of symptoms or their precursors for a proscribed period of time. There must be at least six months of deteriorating function where the illness is present. Additionally, two or more positive symptoms, such as hallucinations, delusions, and/or disorganized speech, as well as negative symptoms, must be significant and last for at least one month to make a diagnosis. In some cases, only one symptom is required for diagnosis if the delusions are bizarre enough or if dangerous auditory command hallucinations are present, or if there are two or more voices “conversing.” Social or occupational problems can also be taken into account in diagnosis. What causes schizophrenia is still unknown. Scientists are working to understand the genetic and environmental mechanisms that combine to cause schizophrenia. It is not purely genetic, because one of a pair of identical twins may have it while the other does not. In terms of environmental issues, when a baby is in utero, it can be exposed to bacteria, viruses, environmental toxins, poisons, and contaminants, which may also play a role. Trauma at birth and decreased oxygenation may play a role. Some psychological and social issues may also contribute. Sexual abuse, physical abuse, a neglectful family, a stressful life, parents that have died, people raised or living in rough urban areas, and people who move from their home country- are more prone to schizophrenia. As more is discovered about chemical circuitry and structure of the brains of people with the disease, better diagnostic tools and early intervention techniques can be developed. This is crucial for schizophrenia, as it is believed that with every psychotic episode, increased damage is done to the brain. It doesn’t go back to it’s previous place. Speaking of the brain, their can be some differences in the schizophrenic brain. In general, but not always, people with schizophrenia may have less intracranial volume, which basically means their brains are small. They have less white matter and their grey matter decreases over time. There is an increase in ventricular volume, meaning that the ventricles that house the brain get larger, but the actual brain itself gets smaller. As mentioned before, schizophrenia can be cyclical, with periods of remission and relapse, but no cure exists for schizophrenia. However, it is treatable and manageable with medication and behavioral therapy, especially if diagnosed early and treated continuously. Those with acute symptoms, severe delusions or hallucinations, suicidal thoughts, or the inability to care for themselves may require hospitalization. Schizophrenia treatments typically include antipsychotic drugs as the primary medication to reduce the symptoms of schizophrenia. They relieve the positive schizophrenia symptoms by impacting the brain’s neurotransmitters. Other treatments for schizophrenia include cognitive and behavioral therapy that can then help “retrain” the brain. These approaches improve communication and motivation, and can teach coping mechanisms so that individuals with schizophrenia may attend school, hold down a job, and socialize properly. Obviously, patients who are compliant with medications and therapy do better than those who are not. Social networks and family member support have also been shown to be helpful. Unfortunately, there are sad cases, people that for whatever reason(s) don’t do well. Life is difficult for them. You may have seen them, wandering the streets aimlessly, making bizarre movements, having an argument with someone who is not there. It is very hard to treat these people who are socially withdrawn. They’re going nowhere in life. They usually live in an assisted living facility, if they’re lucky. Many live on the street. They are sedentary. They usually neglect their hygiene. They don’t eat a healthy diet. They chain smoke cigarettes. Believe it or not, nicotine may be helpful for the treatment of schizophrenia. It sort of calms them down. They drink soda and eat sugary foods. They eat too much and very poorly. They’re prone to developing diabetes because the treatments, the medications, on top of the smoking and the sedentary lifestyle can cause coronary artery disease, diabetes, and fatty liver. They do not live healthy lives due to their illness. In general, schizophrenics live an abbreviated life, about 20 years less than the norm. The most common issues are delusional beliefs and command hallucinations to kill themselves. Disorganized behavior in public may result in them being victims of crime. They usually have violent ends because they are victims of crime. Substance abuse is often rampant in schizophrenics seeking an escape from the chaos inside their heads. Non-compliance with treatment is another factor. Also, the much higher incidence of smoking cigarettes, poor diet, poor exercise habits, and poor self-care contribute. All of these separately or together in some form or fashion is what usually causes their longevity to be dramatically decreased. But with full compliance, patients can have a good life. There are famous people with schizophrenia. John Nash, the Nobel Prize winning mathematician. The great author Jack Kerouac. Peter Green, guitarist for Fleetwood Mac. Syd Barrett founder and member of Pink Floyd, and Beach Boy Brian Wilson. For case studies of schizophrenia as well as other psychiatric diagnoses, check out my book, Tales from the Couch, available on Amazon.com.
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