Sunday, July 13, 2014
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What's a trich disorder?

Trichotillomania is voluntary, repetitive hair-pulling usually from the head, that results in noticeable hair-loss. Learn more about what you can do if you child has this disorder.

What's a trich disorder?

A significant part of my work as a cognitive-behavioral therapist specializing in anxiety and related disorders is providing families with recommendations for good resources. “Good resources,” in these cases, are usually books and websites that offer general, up-to-date information on the disorder for which I am treating the child, as well as sound suggestions for at-home interventions (i.e., parent manuals).  Of course I provide such psychoeducation in session, but I like parents to be able to hear the information more than once, from more than one source, and for it to be accessible to them outside of the therapy hour.

What I do not want is for families to garner information or recommendations for treatments from “unsafe” sources – that is, sources that provide information that is not scientifically supported or has been directly contradicted by science.  In fact, I explicitly warn families about this, because there is so much misinformation on the web. During initial sessions, when giving my families handouts printed with what I think are the best and safest sources of information on their child’s disorder and treatment for that disorder, I typically say: “Please DO NOT put the name of your child’s diagnosis into Google search and hit ‘return.’ You will receive millions of hits, many of them from untrustworthy sources having something to sell, and you will feel even more overwhelmed than you already do.  Instead, start with these I am recommending – you can always read more later.”

I've given my recommendations for resources on obsessive-compulsive disorder, for children who have difficulty with pill swallowing, tic disorders and school refusal. What follows are my current recommendations for good resources on trichotillomania and other habit disorders.

Trichotillomania and Other Habit Disorders:

Trichotillomania (TTM) is voluntary, repetitive hair-pulling (usually from the head, but sometimes from other areas like eyebrows or eyelashes) that results in noticeable hair-loss. Similarly to chronic skin picking (now, officially! Excoriation Disorder), nail biting, and thumb-sucking, TTM is conceptualized as a body focused repetitive behavior.  People tend to engage in these activities  because they are 1) attempting to self-soothe from painful emotions (anger, sadness, anxiety), 2) bored or relaxed, in which case they do the behavior without thinking and are later genuinely surprised by the pile of hair on the floor or the bloody half-moons where their fingernails formerly were.

Babies and toddlers are sometimes prone to pulling their own hair, but this tends to resolve on its own when the developmental stage is over with no harm done.  By contrast, the most frequent age of onset of TTM is around 9-12 years old, is associated with lots of additional problems (anxiety, depression), and tends not to resolve unless there is thoughtful intervention.

The results of this disorder are heartbreaking: I’ve seen children and teens (and adults) who are confused, nonplussed and miserable about why they cannot stop an activity that results in bald-patches. They wear wigs, hats, and bandanas, and live in fear of the swimming pool, gym class, and high gusts of wind lest they be “found out” for pulling out their own hair.  They feel ashamed and alone. Parents are typically frustrated and at a loss as to what they can do to help their child.

Currently, no medications have been established through good scientific trials to be helpful for the disorder.  There have been just a few randomized controlled trials (the Queen Bee of scientific studies) testing the success of a behavioral treatment known as Habit Reversal Therapy (HRT).  In HRT, those with TTM (and their parents) are helped to determine the triggers for the pulling (or picking) and then practice substituting some other behavior that is incompatible with the pulling.

Online:

The truly wonderful website maintained by the Trichotillomania Learning Center at www.trich.org is the go-to source for information on TTM and all other body focused repetitive behaviors.  There is general information on the disorders, a special section for youth, a special section for parents, and good tips on finding a therapist. They also run an annual conference for researchers, treatment providers, and sufferers that I hear is excellent every year.

Books:

Lots of books are recommended on the trich.org website. One that I often recommend to parents and kids for tips on treating the problem at home is Dawn Heubner’s What To Do When Bad Habits Take Hold, because it covers the gamut of habit disorders (picking, pulling, biting, sucking, and the like).

Support Group:

A free support group organized by the Center for Emotional Health of Greater Philadelphia meets at their Cherry Hill location the first Saturday of the month. The Center was gracious enough to once let me sit in on a support group meeting and it was fantastic – I recommend to all of my patients with TTM.

Nerd Corner:

Because of the few number of scientific treatment studies for the disorder, no “official” treatment guidelines or practice parameters have yet been released by the American Academy of Child and Adolescent Psychiatry.  However, those at the Trichotillomania Learning Center convened a board of experts in the field and published their own treatment guidelines. It’s good.


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Katherine K. Dahlsgaard, Ph.D. Lead Psychologist - The Anxiety Behaviors Clinic, CHOP
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Stephen Aronoff, M.D., M.B.A. Temple University Hospital
Christopher C. Chang, M.D., Ph.D Nemours/Alfred I. duPont Hospital for Children, Jefferson Medical Colg
Mario Cruz, M.D. St. Christopher’s Hospital for Children, Drexel University College of Medicine
Katherine K. Dahlsgaard, Ph.D. Lead Psychologist - The Anxiety Behaviors Clinic, CHOP
Gary A. Emmett, M.D. Director of Hospital Pediatrics at TJU Hospital & Pediatrics Professor at Thomas Jefferson Univ.
Lauren Falini Bariatric exercise physiologist, Nemours/Alfred I. duPont Hospital for Children
Hazel Guinto-Ocampo, M.D. Nemours duPont Pediatrics/Bryn Mawr Hospital
Rima Himelstein, M.D. Crozer-Keystone Health System
Anita Kulick President & CEO, Educating Communities for Parenting
Janet Rosenzweig, MS, PhD, MPA VP for Programs & Research for Prevent Child Abuse America
Beth Wallace Smith, R.D. Children's Hospital of Philadelphia
W. Douglas Tynan, Ph.D. Nemours/Alfred I. duPont Hospital for Children, Jefferson Medical Colg
Flaura Koplin Winston, M.D., Ph.D Scientific Director of the Children’s Hospital of Philadelphia’s Center for Injury Research and Prevention
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