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Taming Trichotillomania While Weeding the Garden

Taming Trichotillomania While Weeding the Garden


Amy’s 5 years in New York City had been a success. She completed college and earned an internship in a prestigious publishing house before the economy collapsed. Her bachelor of arts degree with honors brought no job prospects, however, because no one was hiring. Fortunately, her recent mental health “report card” was as good as her college transcript.

She had bipolar disorder that was largely quiescent, so much so that it was barely on the radar as graduation rolled by. She kept appointments, always remembered her medications, and never needed hospitalizations, unlike family members whose severe symptoms reportedly worsened with alcohol overuse. Only 2 challenges remained: she needed a job and an income, and she wanted to tame her trichotillomania (TTM). Her TTM worsened under stress and never fully responded to behavioral techniques, such as habit reversal therapy recommended by experts.1

Medications had little effect on her hair-pulling. Amy’s struggles were not surprising, considering the difficulty of treating TTM. A favorite symptom-substitution behavioral technique—plucking orthodontic rubber bands fitted to the fingertips—was no help. Nor was the hand-held rubber band ball sold by office supply stores. High doses of serotonin reuptake inhibitors or any dose of clomipramine or fluvoxamine brought more adverse effects than positive effects. Anticonvulsants that treated her bipolar disorder had no effect on her TTM, even though they kept her mood swings in check. Naltrexone helped a little but hurt her stomach a lot.

Drawing Venn diagrams to show how TTM symptoms overlap with OCD, impulse control disorder, anxiety, and even addiction explained her symptoms without offering relief. And Amy needed relief, especially if she returned to the family business while waiting out the financial storm. It was immaterial that there might be more than a chance association between bipolar disorder and TTM.2

From experience, she knew that her TTM surged in response to her emotionally explosive family. Family dinners literally made her “pull her hair out,” as the saying goes. She had avoided visits home, until economic necessity left her little choice.

Superficially, Amy’s home sounded picture perfect. Flower gardens flourished, as often occurs in the South. Yet Amy insisted that the occupants of the picture-perfect house were far from perfect. She said that she came from a hybrid of Tennessee Williams and William Faulkner.


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