Trichotillomania, or chronic hair pulling, is known to be heritable, suggesting a
possible family link. Research involving families and twins has also shown a
higher occurrence of hair pulling when one or more family members also have trichotillomania.
One specific study explored heritability across three
generations of male relatives, pointing to a potential familial connection.
Scientists have even discovered a rare variant of the SLITRK1 gene that could
contribute to the development of the medical condition.
The SLITRK1 gene is responsible for producing a protein that belongs to the SLITRK family. This family of proteins is present in the brain and contributes to the maturation and expansion of nerve cells.
The SLITRK1 protein is potentially involved in directing the development of specialized projections (axons and dendrites) that enable each nerve cell to connect with adjacent cells.
Researchers showed interest in the SLITRK1 gene because previous studies have linked it to similar emotional health conditions that also involve repetitive and uncontrollable behaviors, like Tourette’s syndrome.
A 2006 Duke University study investigated 44 families where at least one member had trichotillomania to look for common genetic traits. The study found that the SLITK1 gene was mutated (abnormal) in the family members with the condition, but not in the family members without trichotillomania.
This evidence shows a definite connection between genetic differences and the onset of trichotillomania in people studied.
The study’s lead researcher Dr. Stephan Züchner says, "Society still holds negative perceptions about psychiatric conditions such as trichotillomania.
Dr. Allison Ashley-Koch, who also worked on the study, said numerous other genes likely to contribute to the condition.
She explains, "The SLITRK1 gene could be among many other genes that are likely interact with each other and environmental factors to trigger trichotillomania and other psychiatric conditions. Such discoveries could open the door for genetic testing, which is completely unheard of in the field of psychiatry."
To be clear, this means that while you may be born with a modified SLITRK1 gene, it doesn't necessarily mean you will develop trichotillomania. Rather, it means you may be predisposed for the condition, and something in your environment amplifies it to cause hair pulling urges to flare up.
Learn more about genetic testing for the SLITK1 gene here. 
Trichotillomania (TTM) manifests differently in different people, with various presentations:
Simple TTM: Hair pulling without any comorbid disorders
Depressive TTM: Hair pulling accompanied by depression
Complex TTM: Hair pulling with multiple comorbid disorders
Research indicates that the more comorbidities, the more severe the symptoms. Additionally, there are distinct subtypes within these forms:
Automatic pulling: low awareness of the urge to pull or the pulling action
Focused pulling: greater awareness of the urge to pull and tension relief from pulling
These subtypes seem to respond differently to treatment.
Focused pullers often appear to benefit more from Habit Reversal Training (HRT), the primary treatment for trichotillomania, whereas
automatic pullers don't experience the same success rate. The reason for this difference remains unknown.
To uncover possible clues about forms of hair pulling and how it may guide treatment plans, researchers are increasingly examining family history.
Researchers compared individuals with TTM to those without the condition, analyzing the prevalence of psychiatric illness in their first-degree relatives. First-degree relatives are often considered in genetic and medical research to study the heritability of certain traits, diseases, or conditions.
A first-degree relative refers to a person's closest blood relatives, which include their parents, siblings, and children.
These family members share approximately 50% of their genes with the individual in question, making them genetically the closest relatives.
The results revealed a family connection between hair pulling and family history, particularly regarding subtypes. The study proved that:
• Major depression, OCD, and other BFRBs like skin picking were more prevalent in the family history of individuals who have trichotillomania.
• People who have trich and a family history of OCD were much more likely to exhibit higher levels of impulsivity and reduced distress tolerance.
The researchers also investigated symptom severity, impairment levels, and neuropsychological constructs like memory, attention, executive function, language, and visuospatial processing.
Neuropsychological constructs are often used in research to understand the underlying mechanisms of various cognitive, emotional, and behavioral phenomena.
They can also be used to assess and diagnose various disorders, as well as to design treatments aimed at improving cognitive and emotional functioning.
According to the researchers, the family history of having OCD in people who struggle with hair pulling might indicate they have a more impulsive, less distress-tolerant personality.
This correlation resembles the impulsive/perfectionistic puller who pulls to cope with distressing emotions and has difficulty resisting urges. People who have these traits often experience more impairment from the condition as well as mood disturbances.
The study's authors propose that this type of puller might benefit more from therapy focused on addressing emotional dysregulation, rather than traditional Habit Reversal Training.
There are several types of therapy that focus on healing emotional dysregulation, some of which include:
Dialectical Behavior Therapy (DBT): DBT is a form of cognitive-behavioral therapy (CBT) specifically designed to help individuals with emotional dysregulation.
DBT was originally developed as treatment for borderline personality disorder (BPD), but it has grown in application to other conditions as it has offered significant improvements for people who are suicidal or have emotional control issues.
DBT emphasizes mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness skills to help clients manage intense emotions and develop healthier coping strategies.
Emotion-Focused Therapy (EFT): EFT is a humanistic, process-experiential approach that aims to help individuals understand, express, regulate, and transform their emotions.
EFT is particularly useful for individuals struggling with attachment and relationship issues, as well as those experiencing emotional dysregulation.
Acceptance and Commitment Therapy (ACT): ACT is a form of CBT that focuses on developing psychological flexibility through mindfulness, acceptance, cognitive diffusion, and values-based action.
ACT aims to help individuals accept their emotions and thoughts without judgment, allowing them to better cope with emotional dysregulation.
Cognitive Behavioral Therapy (CBT): While traditional CBT mainly focuses on identifying and changing maladaptive thoughts and behaviors, it can also be helpful in addressing emotional dysregulation.
CBT therapists may work with clients to develop emotion regulation skills, such as identifying emotions, understanding the links between thoughts and emotions, and implementing adaptive coping strategies.
Each individual's needs and preferences will determine the most suitable therapy for addressing emotional dysregulation and/or trichotillomania.
It is essential to work with a qualified, trich-informed mental health professional who can tailor a therapeutic approach to the unique needs of the person seeking help.
Although not an absolute predictor, family history does seem to play a role in TTM like it commonly does in other medical conditions.
More research is required to fully comprehend the extent of family history's influence on hair pulling, but current findings emphasize the importance of considering family history during assessment and treatment planning.
Tailoring care to the individual’s history and life experiences, rather than merely addressing hair pulling, can lead to more successful treatment outcomes.
Grant, J. E., Peris, T. S., Ricketts, E. J., Lochner, C., Steins, D. J., Chamberlain, S. R., … Keuthin, N. J. (2020). Identifying subtypes of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder using mixture modeling in a multicenter sample. Journal of Psychiatric Research, in press. Retrieved from
https://www.sciencedirect.com/science/article/abs/pii/S0022395620310578?via%3Dihub
Lamothe, H., Baleyte, J. M., Mallet, L., & Pelissolo, A. (2020). Trichotillomania is more related to Tourette disorder than to obsessive-compulsive disorder. Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999), 42(1), 87–104.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6986481/
McGuire, J. F., Myers, N. S., Lewin, A. B., Storch, E. A., & Rahman, O. (2020). The influence of hair pulling styles in the treatment of trichotillomania. Behavior Therapy, 51(6), 895-904.
https://www.sciencedirect.com/science/article/abs/pii/S0005789419301455?via%3Dihub
