Trichotillomania

1. Trichotillomania(Hair Pulling Disorder)

2. 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.

3. Causes of Trichotillomania
•It maybe because of abnormalities 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 of serotonin and dopamine.
•Depression or anxiety could be one more cause.
•Genes might be playing a role.
In extreme cases of trichotillomania where hair 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
otherserious psychological problems and get worse with time.

4. Symptoms of Trichotillomania
After observing the causes, it is important to check all the symptoms of trichotillomania before starting
treatment.
•Trichotillomania patients are 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 of tension 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 an indication of trichotillomania.
•A number of patients who are suffering from trichotillomania pull hair in private and generally try to
hide the disorder from others.

5. Treatment of 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 treat behavior disorders by 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.

6. 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.
NLP or hypnotherapy is 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) orclomipramine (Anafranil) and other medication to improve
neurotransmitters e.g. N-acetylcysteine, and olanzapine (Zyprexa) or aripiprazole, etc.

7. SNRB-SELECTIVE NERVE ROOT BLOCK.
Fluoroscopically performed it is a good diagnostic & therapeutic procedure for radiculopathy 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 needed
EPIDURAL NEUROLYSIS OR PERCUTANEOUS DECOMPRESSIVE NEUROPLASTY for
•EPIDURAL FIBROSIS OR ADHESIONS
•IN FAILED BACK SURGERY SYNDROME(FBSS)
•A catheter is inserted in epidural space via caudal/ intralaminar/ transforaminal approach
•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 spring loaded
or stellated catheters or under direct vision with EPIDUROSCOPY.

8. 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 with L.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:

9. 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.

10. NEUROMODULATION TECHNIQUES:
SPINALCORD STIMULATION (SCS) IMPLANTS :
Done for FBSS(failed back surgery syndrome) & CRPS(comlex regional pain syndromes)
inUSA.In Europe it 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.