Trichotillomania(Hair Pulling Disorder)

Introduction of Trichotillomania

Trichotillomania is a psychological disorder. The term trichotillomania is commonly

not known to everybody but its symptoms are somewhat familiar to many of us. In
trichotillomania, patients feel strong compulsion to pull out hair from their head
and other parts of the body. Generally people mistake such symptoms with bad
habits failing to realize that they have got a type ofpsychological disorder.
Anybody of any age or background can get affected with trichotillomania. Even
children have also been seen affected with this disorder.

Causesof Trichotillomania
It maybe because ofabnormalities of brain functions. Brain areas related to
emotion, habit formation, movement and impulse control might be affected and
causing this.
There might be an involvement ofserotoninanddopamine.
Depression or anxiety could be one more cause.
Genes might be playing a role.
In extreme cases of trichotillomania wherehair pulling, for example from scalp,
becomes severe and leads to many patchy bald spots which cause
embarrassment, and disturbs personal and social life. Trichotillomania is a long
term (chronic) psychological disorder which if goes untreated, can cause other
serious psychological problemsand get worse with time.

Symptomsof Trichotillomania
After observing the causes, it is important to check all thesymptoms of
trichotillomaniabefore starting treatment.
Trichotillomania patientsare seen picking their skin, chewing their lips and
sometime biting their nails or eating pulled out hair.
Trichotillomania patients often get a feeling of tension before pulling hair or when
trying to resist the urge to pull hair, and feel relieved after pulling their hair.
In most of the cases, patients are not even aware of their behavior. It becomes so
automatic that they just do it during the moments oftension or stress, while
watching TV or movie or reading.
Mostly, circumstances and emotions trigger hair pulling. And certain positions or
behavior pattern may also trigger hair pulling, such as resting head on hand or
brushing hair.
Patients play with pulled out hair or rubbing it across lips or face.
Sometimes patients pull hairs from pets or dolls or from materials, such as clothes
or blankets, might be anindication of trichotillomania.
A number of patients who are suffering from trichotillomania pull hair in private
and generally try to hide the disorder from others.

Treatmentof Trichotillomania
Trichotillomania may not always be severe and is generally manageable but for
some patients, the compulsive urge to pull hair might become overpowering.
Usually, symptoms of trichotillomania keep coming and going, and if proper
treatment is taken, chance of relapse significantly reduces. In many instances,
certain treatment options have helped many people reduce their hair pulling and in
some cases it never came back.
Habit reversal training (HRT) is used to treatbehavior disordersby
psychotherapists and is widely used and immensely helpful in trichotillomania cases.
As the name suggests, it is used to change the behavior patterns which have been
formed by the patients causing the disorder with some other habits. During the habit
reversal therapy, patients become more aware of their thinking and behaviors, and
gain control over the impulse to pull their hair by changing it to something else.
Cognitive therapy, which is about finding out triggers which compel the patients to
pull their hair and helping them to learn from new behaviors. By forming new habits
with repetition, the actual shape of brain changes and new brain pathways are built.

Acceptance and commitment therapy (ACT) which is based on accepting and

committing to the solutions. It helps trichotillomania patients by making them
accept and become mindful of their hair- pulling urges then work on the ways to
improve their behaviors and stay committed to them.
NLPorhypnotherapyis also very useful in helping patients recognize the
stressful situations which causes them to pull their hair and learn to relax and
work on the solutions to deal with the problems.
There might be a requirement for medications to control trichotillomania
symptoms which is something a therapist or doctor decides. They may prescribe
antidepressants, such as selective serotonin reuptake inhibitor (SSRI) or
clomipramine(Anafranil) and other medication to improve neurotransmitters
e.g. N-acetylcysteine, andolanzapine(Zyprexa) oraripiprazole, etc.

SNRB-SELECTIVE NERVE ROOT BLOCK.

Fluoroscopically performed it is a good diagnostic & therapeutic procedure for radiculopat

pain if
*There Is minimal or no radiological finding.
*Multilevel imaging abnormalities
*Equivocal neurological examination finding or discrepancy between clinical &
radiological signs
*Post Op patient with unexplainable or recurrent pain
*Combined canal & lateral recess stenosis.
*To find out the pathological dermatome for more invasive procedures , if need

EPIDURAL NEUROLYSISOR PERCUTANEOUSDECOMPRESSIVE NEUROPLASTY for

EPIDURAL FIBROSIS OR ADHESIONS

IN FAILED BACK SURGERY SYNDROME(FBSS)
A catheter is inserted in epidural space via caudal/ intralaminar/ transforaminal approac
After epidurography testing volumetric irrigation with normal saline/ L.A./ hyalase/
steroids/hypertonic
saline in different combinations is then performed along with mechanical adenolysis with
loaded
or stellated catheters or under direct vision with EPIDUROSCOPY.

FACET SYNDROME:- FACET JOINT INJECTION OR

RF MEDIAL BRANCH NEUROTOMY
It is due to mechanical stress on the Zygapophysial joints or traumatic/anatomical
derangement & degenerative facet arthropathy. It is commoner in male of younger
age group during active careers . CT/ MRI/ Bone Scan show structural pathology, but
diagnosis is confirmed by relief of pain with joint injection (1 ml of LA+ 20 mg
triamcinolone) which has therapeutic therapeutic value.After effective facet joint
block, fluoroscopic percutaneous radiofrequency(RF) thermal rhizotomy of two level
medial branches of dorsal ramus is a safe, effective & long term treatment.
SACROILIAC JOINT INJECTION & DENERVATION:
The only way to make a definitive diagnosis is pain relief with image guided joint
injection of depo-steroid withL.A..This Can be followed by joint denervation of L4-5
S1-3 branches to this joint providing long term pain relief.
INTRADISCAL PROCEDURES::
PROVOCATIVE DISCOGRAPHY: coupled with CT
A diagnostic procedure or prognostic indicator for surgical outcome is necessary in
the evaluation of patients with suspected discogenic pain, its ability to reproduce
pain(even with normal radiological finding), to determine type of disc herniation
/tear,finding surgical options & in assessing previously operated spines
PERCUTANEOUS DISC DECOMPRESSION (PLDD)
After diagnosing the level of painful offending disc various percutaneous intradiscal
procedures can be employed:

OZONE-DISCOLYSIS: Ozone Discectomy a revolutionary least invasive safe &

effective alternative to spine surgery is the treatment of choice for prolapsed
disc (PIVD) done under local anaesthesia in a daycare setting. This procedure is
ideally suited for cervical & lumbar disc herniation with radiculopathy. Total cost
of the procedure is much less than that of surgical discectomy. All these facts
have made this procedure very popular at European countries. It is also gaining
popularity in our country due to high success rate, less invasiveness, fewer
chances of recurrences,remarkably fewer side effects meaning high safety
profile, short hospital stay,no post operative discomfort or morbidity and low
cost.
DEKOMPRESSOR: A mechanical percutaneous nucleotomy cuts & drills out the
disc material somewhat like macerator debulking the disc reducing nerve
compression.
INTRATHECAL(SPINAL) PUMP IMPLANTS:
Opted when oral narcotics provide insufficient pain relief or side effects are
troublesome in intractable cancer & chronic pain patients. It delivers drug via
an implanted catheter directly into CSF needing a very small dose (1/300 of oral
dose). The programmable pump is implanted in ant. lower abdomen. It delivers
the drug as per the patients needs. More powerful analgesia & spasticity control
is achieved using lower doses, constant relief & fewer side effects as with oral
doses eg. Somnolence, mental clouding, constipation, euphoria with decreased
chances of drug addiction or misuse.

NEUROMODULATION TECHNIQUES:
SPINALCORD STIMULATION (SCS) IMPLANTS :
Done for FBSS(failed back surgery syndrome) & CRPS(comlex regional pain
syndromes) inUSA.InEuropeit is done for chronic intractableangina & pain of
peripheral vasculardiseases (PVD). The indications are expanding further in
chronic pain states. A Set of electrodes is placed in epidural space & connected
to a pulse generator ( like a cardiac pacing device) that is implanted in upper
buttock.Low level of electric impulses replace pain signals to the brain with mild
tingling sensation. A trial stimulation is done before permanent SCS lead
implant.
PERCUTANEOUS VERTEBROPLASTY / KYPHOPLASTY:
A NEWER APPROACH TO MANAGEMENT OF VERTEBRAL BODY FRACTURES
As life expectancy is increasing so is the incidence of vertebral body (VB) # now
being the commonest # of the body. PVP is an established interventional
techniques in which PMMA bone cement is injected underL.A.via a needle into a
# VB with imaging guidance providing increased bone strength, stability, pain
relief, decreased analgesics, increased mobility with improved QOL and early
return to work.