"Trichotillomania has correlation to sensory overstimulation disorder", ok and?

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I have wanted to write more about research on trichotillomania. No product out there is a going to "cure" anyone and I wonder if it's something that should be cured sometimes. I understand the shame aspect but I also now understand the freedom to say "This is me. If you think I am weird because I don't have perfect hair, that's a short coming on YOUR part". I don't feel like I owe anyone perfect hair or beauty. I don’t expect anyone to look perfect so why should anyone expect me to? So I understand acceptance but I also want to know why. Why do I do this? It’s ok that I do pull, but why? How come I don’t smoke cigs instead? Oh I know why, I can’t stand the smell. It makes me gag. But why can’t I stand the smell? This study could explain why.

What does it means on a deeper level to have this physiological urge that others don't have? What does it mean to experience the world this way? Those are questions I would like to explore more fully. The research out there isn't perfect and working in research enables me to suss out errors/weakness in studies more than a non-research person. For example, this study suggests, that people with Trichotillomania, have intense feelings and responses to sensory experiences. This could mean that smells or sounds and touch can bother/excite us more. That is to say, we experience the sensory part of the world differently.

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Sensory over-responsivity (SOR) has been described as a disproportionately intense, prolonged, or heightened reaction to ordinary sensory stimuli, such as tactile and auditory sensations (e.g., sound of people chewing, feeling of specific clothing textures) that leads to functional impairment Rogers and Luby, 2011). Recent research has begun to examine relationships between sensory triggers, perfectionism, and OC-related disorders, and in particular how these may be related to SOR.

There is wide variation among individuals with TTM in symptom presentation, and little is known about subtypes or endophenotypic variants, which could relate to treatment outcome, prognosis, and underlying genetic and neural vulnerabilities. Subtypes, or “styles,” of pulling have been proposed based on the degree to which an individual is aware of engaging in the pulling (e.g., Christenson and Mackenzie, 1994Flessner et al., 2008) and the extent to which pulling is related to emotion regulation processes (e.g., Alexander et al., 2016Diefenbach et al., 2008). 

So what does that mean? The authors jump to the conclusion that it means we have emotional regulation issues. Now I don't doubt I have those but I don't know if experiences sounds/smells more intensely = emotional regulation issues.

First the authors present that there appear to be two types of pulling

1) Automatic - characterized as a behavior that occurs outside of the puller's awareness.

2) Focused- occur within conscious awareness and to function more as an emotion regulation strategy.

I have always felt it would have been great to just be an automatic puller so I could buy an awareness device and be over it already. I know it’s not that simple though as there appears to be some overlap of both types for people so it’s probably more accurate to consider how much of your pulling style is automatic vs focused. An awareness device should be in your tool box if you have a lot of automatic pulling that you want to inhibit.

“Focused” pulling has garnered particular attention in the treatment development literature (e.g., Keuthen et al., 2012Woods et al., 2006) given that it may be less responsive to traditional habit reversal therapy (Azrin and Nunn, 1973). “Focused” pulling can often involve sensory triggers including tactile or visual sensations such as coarse hair, or the urge to pull hair to satisfy a need for symmetry, for example removing an eyebrow hair that seems out of place (e.g., Christenson and Mackenzie, 1994;), or with by-proxy urges to pull hair from other people that appear out of place (Falkenstein and Haaga, 2016). By-proxy urges have been associated with “focused” pulling and also perfectionism (Falkenstein and Haaga, 2016). Many hair pullers struggle with perfectionism as a trigger for pulling, and it has been found to be a useful treatment target for some (Mansueto et al., 1999Pélissier and O’Connor, 2004).

Whether “focused” pulling, SOR, and perfectionism are associated constructs in a sample with TTM remains unexamined.

Have you considered how much “perfectionism” plays into your trichotillomania? I hadn’t really until I read this carefully. I do exhibit the classic “that pokey hair is out of place and needs to be removed!” feeling intensely. Is it perfectionism? Is it an emotional regulation issue? Is it both?

So how did they study if people with trich had perfectionism and how did they define perfectionism? They recruited people online and with surveys they could classify someone as perfectionistic or not. The survey for perfectionism used a specific scale;

Frost Multidimensional Perfectionism Scale (FMPS; Frost et al., 1990)

This self-report measure assesses the following 6 dimensions of perfectionism across 35 items: concern about making mistakes, setting high personal standards, perceived parental expectations, parental criticism, doubts about actions, and the tendency to be organized (the organization subscale is not in the total score). Each item is rated on a 5-point Likert scale. This scale has been found to have adequate reliability and validity (Frost et al., 1990).

So they also used a similar scale to examine SOR and anxiety and depression. It remains to be known how accurate it is for someone taking a survey to be objective about themselves. It would be useful if patients had their therapists also complete the survey and that way the person could have a score that was averaged between to offset personal bias about yourself. But who has that kind of funding and resources? It’s just not feasible probably.

Results showed people with TTM were more sensitive/responsive to sounds and tactile sensations. I sleep with a sound machine every night and without it, I feel anxiety so I definitely can’t argue against that result. I hate sounds when I am trying to sleep. But who doesn’t? Apparently we hate it MORE than your non-puller type.

Participants also described experiences with auditory over-responsivity, including, “I cannot fall asleep if I hear a clock ticking, or a tap leaking. I have to shout louder than the sound the dishes make when I'm arranging them in the cupboard. I scream or cover my ears if a truck or a bus passes by me.” And another participant stated, “When there is fire alarm testing at work, I have to leave for the day or I get almost zero work done if I stay.”

“Symptoms of SOR were very common in a large sample of adults with self-reported hair pulling: 77% endorsed at least mild tactile symptoms and 73% at least mild auditory SOR (in contrast with the non-affected comparison group: 59% endorsed at least mild tactile symptoms, and 61% at least mild auditory).”

Conclusion: We feel sounds, smells, and tactile sensations more intensely.

“It is also possible that SOR symptoms contribute to high levels of emotional arousal, which in turn increases the likelihood of engaging in hair pulling as an emotion regulation strategy. SOR symptoms may also be more directly functionally related to pulling, as is illustrated by our participants’ qualitative descriptions of sensory stimuli that elicit the urge to pull. Finally, it may be the case that a shared underlying neuropathology underlies both TTM and SOR; abnormalities in cortico-subcortical circuitry involved in emotion regulationemotional processinginhibitory control, and memory processing have been implicated in both conditions (Odlaug et al., 2014Koziol et al., 2011).”

And here we are back to emotional regulation issues. lol

“There are currently no empirically supported treatments for SOR, and it is unclear which techniques may be most useful. Interventions reported in case studies have utilized exposure (e.g., McGuire et al., 2015Reid et al., 2016), but if SOR is indeed related to emotion regulation deficits, other viable candidate treatments could be interventions targeting distress tolerance/emotion regulation. Future research should focus on clarifying the role of SOR in TTM and more broadly, the role of SOR within OC-related disorders as a whole, with the ultimate goal of improving conceptualization and treatment options for these impairing phenomena.”

Well, so bad news first, there is no treatment for SOR. Good news maybe by treating SOR it would help with TTM? If you are considering how your emotional regulation (of lack thereof) is affecting your trich, I would suggest looking at DBT.

However, if we do assume their one idea that SOR increases pulling behavior, we could try to inhibit our sensitivity to sounds and tactile sensations somehow which would lessen urges to pull. Something to consider. How would we experience sounds and tactile sensations less? That’s a good point they don’t address very fully, they just cite “exposure therapy”.

Maybe keeping sound machines on all day everyday? Maybe wearing gloves so you feel less? What do you think? What would make you experience sounds and tactile sensations less? Greater exposure to them maybe? Or less exposure to them? Maybe emotionally regulating the experience of sounds and tactile sensations?

I guess this study was interesting but not sure what to do with this info (they don’t know either lol). I already knew I didn’t like loud sounds and tight clothes. When I asked my partner if he thought I responded more to sounds, smells, and tactile sensations, he was like “Oh yea”. So what do I do with this information? Maybe just keeping it in mind will help me understand myself more. Maybe I should be asking myself if I am tolerating something as a non-puller vs puller? Would a non-puller mind this as much? I think that’s an interesting thought. Something to consider.

Emily Kight