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Trichotillomania

Trichotillomania is a compulsion to repetitively pull or pluck one's hair, resulting in noticeable hair loss. Many people with trichotillomania feel ashamed and embarrassed by their hair pulling, attempt to hide it from friends, co-workers and family members, and do not seek help. Many who consult their personal physician or a dermatologist because of hair loss never reveal the true cause and doctors often fail to consider this diagnosis. Some experts feel that trichotillomania is a variant of obsessive compulsive disorder. Both conditions are characterized by compulsive behavior that is usually recognized as senseless, is difficult to resist, and is associated with anxiety. Also, treatment with medications that have similar effects on serotonin, a brain neurotransmitter, may benefit both trichotillomania and OCD. In addition, OCD is more common in people with trichotillomania than in the general population. The observation that a higher-than-expected number of relatives of trichotillomania sufferers have obsessive compulsive disorder suggests a genetic link between the two disorders.In contrast to OCD, people with trichotillomania tend not to have obsessive thoughts, do not engage in rituals other than hair pulling, and have a different pattern of abnormal brain metabolism. Trichotillomania patients are more likely to be women while OCD has a more even gender distribution; the relationship of trichotillomania to OCD is not fully understood and currently they are thought to be related but distinct disorders .

Incidence; Causes and Development


Researchers estimate that some 1-2% of the U.S. population has trichotillomania. Although trichotillomania can begin in very young children or middle-aged adults, the most common age of onset is during early adolescence. Women seem to be affected more than men with some estimates suggesting a ratio of 3 women to every man. Trichotillomania is currently categorized as an impulse control disorder in which the urge to pull hair is associated with an increasing sense of tension. The act of pulling itself is presumed to relieve that tension. Trichotillomania has been considered a habit, like nail biting, that can have both a soothing function and potential consequences .

While the actual cause of trichotillomania is not known for certain, several factors appear to play contributing roles: Yeast infection. Some consider trichotillomania to be an allergic reaction to the Mallesezia-yeast and that certain foods encourage growth of this yeast in the body. This causes an urge with some people to pull out their own hair. Professor John Kender from Columbia University tried a diet which changed his life dramatically, as well as the lives of hundreds of others with trichotillomania. Metabolic abnormalities. Alterations in brain metabolism seem to be involved. Investigators have found differences in neuropsychological testing and in special brain scans between people with trichotillomania and people who do not pull out hair. There is some suggestion that abnormalities in the functioning of serotonin, a chemical neurotransmitter in the brain, might be involved. Interestingly, several medications that have shown promise in trichotillomania increase the amount of serotonin available to brain cells.

Stress. The onset of trichotillomania is sometimes associated with a stressful event and, indeed, stressful life experiences may be important in its development or its continuation. Stressors may include school conflict, abuse, family conflict, threatened loss of a significant other, severe medical illness, or previous scalp trauma or surgery. More often than not, a significant life event cannot be identified that is related to the onset of trichotillomania. Family history. There may be some genetic predisposal ion to developing trichotillomania. Relatives of people with the condition have a slightly increased likelihood of developing trichotillomania compared to the general population. In addition, relatives of people with trichotillomania may have a higher prevalence of other psychiatric disorders, particularly depression and obsessive compulsive disorder, than the population at large. Unresolved psychological conflicts. Psychoanalysts have suggested that pulling out hair is related to erotic wishes or unresolved life conflicts, or that hair pulling releases unsatisfied sexual tension or substitutes for masturbation. Other theories have suggested that hair pulling is an aggressive reaction against feelings of grief or rage or even against feelings of being deserted or unloved. While all of these ideas are interesting, they are unproven, speculative and have no treatment utility.

Signs and Symptoms


Most people with the condition experience anxiety, embarrassment and diminished self-confidence and self-esteem. Attempts to keep the condition a secret can lead to avoidance of everyday activities such as visits to the hairdresser, sports, exercise, dancing, public showers, swimming, and being in brightly-lit rooms. Some avoid treatment for medical or dental problems because of concern that their hair pulling will be discovered. Many go to great lengths to conceal their hair pulling and try to camouflage hair loss with different hair styles, make-up, clothing, or wigs or other hair pieces. Scalp inflammation, irritation, itchiness and tenderness are common.Some researchers have found that nearly 20% of hair pullers eat their hair or chew off and swallow the root ends. Called trichophagy, it can lead to hair being lodged between the teeth and more seriously to large accumulations of retained hairs in the stomach and digestive tract called trichobezoars (hair balls). Symptoms of trichobezoars include abdominal pain, nausea, vomiting, and sometimes blood and/or visible hairs in the stool. Trichobezoars can also cause foul breath, poor appetite, constipation, diarrhea, excessive gas, bowel obstruction, and even bowel perforation. Liver and pancreas functions can be adversely altered. Sometimes a physician can feel a trichobezoar by gently pushing in the mid or left upper area of a patient's abdomen. Trichobezoars can be diagnosed by using special upper gastrointestinal X-rays, looking into the stomach with an endoscope, or using ultrasound. Surgical removal is the most common treatment.

Prognosis; Complications
Hair pulling very rarely causes irreversible baldness. However, when the behavior stops, hair occasionally grows back gray or white and it may be finer, coarser or curlier. These changes may normalize over time. Some researchers have described early onset (childhood) and later onset (adolescent) types of trichotillomania. There is no clear evidence that children with this form of the disorder are at increased risk for developing future psychiatric problems. However, children who are four, five or six and are still pulling their hair may begin to overlap with the later onset type trichotillomania which has a less favorable prognosis. The trauma of hair pulling also increases the risk for scalp infection. Sometimes repetitive hair pulling can cause problems such as carpal tunnel syndrome, tendonitis, and neck/back strain. Perhaps the most common serious medical complication of trichotillomania is avoiding medical care for other illnesses because of the shame associated with hair pulling and the fear of its discovery.

Kleptomania is an impulse control disorder characterized by a recurrent failure to resist


stealing. Description: Kleptomania is a complex disorder characterized by repeated, failed attempts to stop stealing. It is often seen in patients who are chemically dependent or who have a coexisting mood, anxiety, or eating disorder. Other coexisting mental disorders may include major depression, panic attacks, social phobia , anorexia nervosa , bulimia nervosa , substance abuse, and obsessive-compulsive disorder . People with this disorder have an overwhelming urge to steal and get a thrill from doing so. The recurrent act of stealing may be restricted to specific objects and settings, but the affected person may or may not describe these special preferences. People with this disorder usually exhibit guilt after the theft. Detection of kleptomania, even by significant others, is difficult and the disorder often proceeds undetected. There may be preferred objects and environments where theft occurs. One theory proposes that the thrill of stealing helps to alleviate symptoms in persons who are clinically depressed.

Causes and symptoms Causes: The cause of kleptomania is unknown, although it may have a genetic component and may be transmitted among first-degree relatives. There also seems to be a strong propensity for kleptomania to coexist with obsessive-compulsive disorder, bulimia nervosa, and clinical depression. Symptoms: The handbook used by mental health professionals to diagnose mental disorders is the Diagnostic and Statistical Manual of Mental Disorders . Published by the American Psychiatric Association, the DSM contains diagnostic criteria and research findings for mental disorders. It is the primary reference for mental health professionals in the United States. The 2000 edition of this manual (fourth edition, text revision), known as the DSM-IV-TR, lists five diagnostic criteria for kleptomania:

Repeated theft of objects that are unnecessary for either personal use or monetary value. Increasing tension immediately before the theft. Pleasure or relief upon committing the theft. The theft is not motivated by anger or vengeance, and is not caused by a delusion or hallucination. The behavior is not better accounted for by a conduct disorder , manic episode , or antisocial personality disorder. Demographics Studies suggest that 0.6% of the general population may have this disorder and that it is more common in females. In patients who have histories of obsessive-compulsive disorder, some studies suggest a 7% correlation with kleptomania. Other studies have reported a particularly high (65%) correlation of kleptomania in patients with bulimia. Diagnosis Diagnosing kleptomania is usually difficult since patients do not seek medical help for this complaint, and initial psychological assessments may not detect it. The disorder is often diagnosed when patients seek help for another reason, such as depression, bulimia, or for feeling emotionally unstable (labile) or unhappy in general (dysphoric). Initial psychological evaluations may detect a history of poor parenting, relationship conflicts, or acute stressorsabrupt occurrences that cause stress, such as moving from one home to another. The recurrent act of stealing may be restricted to specific objects and settings, but the patient may or may not describe these special preferences.

Treatments Once the disorder is suspected and verified by an extensive psychological interview, therapy is normally directed towards impulse control, as well as any accompanying mental disorder(s). Relapse prevention strategies, with a clear understanding of specific triggers, should be stressed. Treatment may include psychotherapies such as cognitive-behavioral therapy and rational emotive therapy . Recent studies have indicated that fluoxetine (Prozac) and naltrexone (Revia) may also be helpful. Prognosis Not much solid information is known about this disorder. Since it is not usually the presenting problem or chief complaint, it is frequently not even diagnosed. There are some case reports that document treatment success with antidepressant medications, although as with almost all psychological disorders, the outcomes vary. Prevention There is little evidence concerning prevention. A healthy upbringing, positive intimate relationships, and management of acutely stressful situations may lower the incidence of kleptomania and coexisting disorders.

Anxiety Disorders
There are many types of anxiety disorders that include panic disorder, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder, specific phobias, and generalized anxiety disorder. Anxiety is a normal human emotion that everyone experiences at times. Many people feel anxious, or nervous, when faced with a problem at work, before taking a test, or making an important decision. Anxiety disorders, however, are different. They can cause such distress that it interferes with a person's ability to lead a normal life. An anxiety disorder is a serious mental illness. For people with anxiety disorders, worry and fear are constant and overwhelming, and can be crippling. What Are the Types of Anxiety Disorders? There are several recognized types of anxiety disorders, including: Panic disorder : People with this condition have feelings of terror that strike suddenly and repeatedly with no warning. Other symptoms of a panic attack include sweating, chest pain, palpitations (irregular heartbeats), and a feeling of choking, which may make the person feel like he or she is having a heart attack or "going crazy."

Obsessive-compulsive disorder (OCD) : People with OCD are plagued by constant thoughts or fears that cause them to perform certain rituals or routines. The disturbing thoughts are called obsessions, and the rituals are called compulsions. An example is a person with an unreasonable fear of germs who constantly washes his or her hands. Post-traumatic stress disorder (PTSD) : PTSD is a condition that can develop following a traumatic and/or terrifying event, such as a sexual or physical assault, the unexpected death of a loved one, or a natural disaster. People with PTSD often have lasting and frightening thoughts and memories of the event and tend to be emotionally numb. Social anxiety disorder : Also called social phobia, social anxiety disorder involves overwhelming worry and self-consciousness about everyday social situations. The worry often centers on a fear of being judged by others, or behaving in a way that might cause embarrassment or lead to ridicule. Specific phobias : A specific phobia is an intense fear of a specific object or situation, such as snakes, heights, or flying. The level of fear is usually inappropriate to the situation and may cause the person to avoid common, everyday situations. Generalized anxiety disorder : This disorder involves excessive, unrealistic worry and tension, even if there is little or nothing to provoke the anxiety. What Are the Symptoms of an Anxiety Disorder? Symptoms vary depending on the type of anxiety disorder, but general symptoms include: Feelings of panic, fear, and uneasiness Uncontrollable, obsessive thoughts Repeated thoughts or flashbacks of traumatic experiences Nightmares Ritualistic behaviors, such as repeated hand washing Problems sleeping Cold or sweaty hands and/or feet Shortness of breath Palpitations An inability to be still and calm Dry mouth Numbness or tingling in the hands or feet Nausea Muscle tension Dizziness

What Causes Anxiety Disorders? The exact cause of anxiety disorders is unknown; but anxiety disorders -- like other forms of mental illness -- are not the result of personal weakness, a character flaw, or poor upbringing. As scientists continue their research on mental illness, it is becoming clear that many of these disorders are caused by a combination of factors, including changes in the brain and environmental stress. Like certain illnesses, such as diabetes, anxiety disorders may be caused by chemical imbalances in the body. Studies have shown that severe or long-lasting stress can change the balance of chemicals in the brain that control mood. Other studies have shown that people with certain anxiety disorders have changes in certain brain structures that control memory or mood. In addition, studies have shown that anxiety disorders run in families, which means that they can be inherited from one or both parents, like hair or eye color. Moreover, certain environmental factors -- such as a trauma or significant event -- may trigger an anxiety disorder in people who have an inherited susceptibility to developing the disorder. How Common Are Anxiety Disorders? Anxiety disorders affect about 19 million adult Americans. Most anxiety disorders begin in childhood, adolescence, and early adulthood. They occur slightly more often in women than in men, and occur with equal frequency in whites, African-Americans, and Hispanics. How Are Anxiety Disorders Diagnosed? If symptoms of an anxiety disorder are present, the doctor will begin an evaluation by asking you questions about your medical history and performing a physical exam. Although there are no lab tests to specifically diagnose anxiety disorders, the doctor may use various tests to look for physical illness as the cause of the symptoms. If no physical illness is found, you may be referred to a psychiatrist or psychologist, mental health professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for an anxiety disorder. The doctor bases his or her diagnosis on the patient's report of the intensity and duration of symptoms - including any problems with daily functioning caused by the symptoms -- and the doctor's observation of the patient's attitude and behavior. The doctor then determines if the patient's symptoms and degree of dysfunction indicate a specific anxiety disorder. How Are Anxiety Disorders Treated? Fortunately, much progress has been made in the last two decades in the treatment of people with mental illnesses, including anxiety disorders. Although the exact treatment approach depends on the type of disorder, one or a combination of the following therapies may be used for most anxiety disorders:

Medication : Drugs used to reduce the symptoms of anxiety disorders include anti-depressants and anxiety-reducing drugs. Psychotherapy : Psychotherapy (a type of counseling) addresses the emotional response to mental illness. It is a process in which trained mental health professionals help people by talking through strategies for understanding and dealing with their disorder. Cognitive-behavioral therapy: People suffering from anxiety disorders often participate in this type of psychotherapy in which the person learns to recognize and change thought patterns and behaviors that lead to troublesome feelings. Dietary and lifestyle changes RelaxCan Anxiety Disorders Be Prevented? Anxiety disorders cannot be prevented; however, there are some things you can do to control or lessen symptoms: Stop or reduce consumption of products that contain caffeine, such as coffee, tea, cola, energy drinks, and chocolate. Ask your doctor or pharmacist before taking any over-the-counter medicines or herbal remedies. Many contain chemicals that can increase anxiety symptoms. Seek counseling and support after a traumatic or disturbing experience