Introduction:
Trichotillomania (TTM) and excoriation are two psychiatric conditions with similar origins to OCD. TTM is specific to hair, and excoriation is specific to skin. Both diseases show symptoms in different locations though the cause of these two conditions is the same. Both conditions cause distress and result in various medical problems.
What Is Trichotillomania?
Trichotillomania is a hair-pulling disorder. The individual tries to pull hair from his body, generally from the scalp, eyebrows, and eyelids. They make many attempts to stop the behavior of pulling hair but result in embarrassment, loss of control, or shame. This behavior is accompanied by other behaviors involving searching for hair, a particular method of pulling hair, testing, or feeling of hair presence at the site where the hair is removed.
This condition is more common among females than males and in childhood. Both genders are equally affected. Individuals with this condition always show low self-esteem and try to avoid social interactions. Triggers for this condition include,
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The feeling of hair on the scalp.
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Being anxious, bored and angry.
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Thinking of hair strongly.
There are two types of the hair-pulling present.
1. Automatic Pulling: Not being fully aware of the action of pulling hair.
2. Focused Pulling: The individual sees and feels that hair should be pulled from that site.
Individuals use both types of hair-pulling techniques, and it keeps changing over time.
What Is Excoriation Disorder?
Excoriation disorder is characterized by the pulling of skin from their own body from different sites like the face, arms, and hands. Individuals may pick the skin from healthy skin or old lesions like pimples, calluses, at scabs from old picking. These individuals use fingernails, tweezers, pins, or any other objects.
Apart from pulling the skin, also perform actions like rubbing, squeezing, lancing, or biting. They spend most of their time on the behavior. Sometimes several hours of a day are spent on such actions. This condition results in dysfunction of work and social activities. Triggers for this condition include stress, anxiety, anger, boredom, tiredness, and time away from scheduled activities.
What Are the Symptoms of Trichotillomania and Excoriation?
Trichotillomania and excoriation both lead to many medical consequences. Symptoms of trichotillomania are,
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Hair loss due to repetitive actions of removing hair.
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Keep trying to stop the action of hair pulling and trying to do it less often.
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Negative feelings, thinking, and getting affected in work and social life.
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Hair loss is not due to any other reasons.
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They do not feel that hair loss is due to any mental health condition but believe their appearance is like that.
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Trichophagia (eating of pulled hair) can be observed among 20 percent of individuals affected by this condition. This may further lead to gastrointestinal tract obstruction because of hairball formation.
Symptoms of excoriation include
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Tissue damage occurs, and this may further lead to infections.
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Septicemia may also be possible due to skin picking.
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Repetitive behavior of excoriation may lead to skin grafting or blood transfusion.
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Creates cuts, bruising, and bleeding by doing the action.
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Picking moles and scars to smooth or perfect them.
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Not realizing that action is being done or doing the action in sleep also.
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Start the act of picking skin during stress or anxiety.
Individuals with these conditions consider that these acts are just bad habits than psychological disorders.
What Is the Neurobiology of Trichotillomania and Excoriation?
Many things related to neurobiology are not known much. Early research suggests that it is familial. Another study showed that 40 percent are affected due to genetic factors, and the remaining are due to other environmental factors.
It is observed that many brain structures and functions are involved in these two conditions. Excess gray matter density was observed in trichotillomania in structures like the striatum, amygdalohippocampal formation, and frontal and cingulate cortices. A recent study has shown the dampening of the nucleus accumbent response to reward anticipation.
Another study showed the disorganization of white matter tracts involved in the motor generation and suppression in both conditions. Neurophysiological studies have shown that cognitive ability deficits are linked to frontal lobe functions and frontal-subcortical structures like deficits in functioning, motor impulsivity, and cognitive behavioral flexibility.
What Is the Etiology of Trichotillomania and Excoriation Disorders?
Negative emotions like anxiety, sadness, and tension precede the actions of these two disorders. Picking and pulling behavior may function as a means to overcome specific negative experiences. Studies have shown that there is difficulty in the regulation of emotions among affected individuals with these disorders. In the same way, boredom also plays a role in triggering these conditions.
Some researchers have hypothesized that these picking and pulling actions help in adjusting negative emotions caused due to perfectionism. The feeling of perfectionism creates frustration, impatience, and dissatisfaction due to not meeting the standards or expectations. These actions help in releasing tension caused by these negative emotions.
How to Diagnose Trichotillomania and Excoriation?
Diagnosis is essential for treatments to be planned. Generally, these two conditions are usually misdiagnosed as OCD, anxiety disorder, and drug addiction. Treatments of these disorders differ from the treatment of trichotillomania and excoriation. Hence accurate diagnosis is to be done.
Trichography: Microscopic examination of plucked hair may help diagnose trichotillomania.
SPRS (Skin Picking Reward Scale): This scale evaluates skin picking and defines the wanting and liking of skin picking.
Blood Examination: Complete and differential blood counts help diagnose skin picking.
What Is the Treatment for Trichotillomania and Excoriation?
Treatments of these two conditions include
Psychotherapy: Behavioral therapy called HRT (habit reversal therapy) is used for trichotillomania; other components like acceptance, commitment, and dialectical treatment are also included. Regarding skin picking, HRT and cognitive behavioral therapy are used.
Pharmacotherapy: No pharmacotherapy has been accepted currently. Clomipramine has demonstrated some effect in trichotillomania. Other agents like SSRI (Selective Serotonin Reuptake Inhibitors), Glutamatergic agents, NAC (N-acetylcysteine) were used.
Sequencing treatment: Psychotherapy and pharmacotherapy together were used for effective therapies.
Conclusion:
Trichotillomania and excoriation are two different entities that are psychiatric conditions. If left untreated may show severe symptoms and become chronic. Hence it is essential to know about these conditions, causes, symptoms, diagnoses, and treatments. Knowing helps achieve early diagnosis and effective treatment. This, in turn, helps achieve a good quality of life.
