Objective: Nurses, skilled in the art of sensing that which is not obvious, may not see that the woman standing before her/him is suffering from trichotillomania (TTM). Shame and embarrassment cause people with TTM to hid the telltale signs of the disease. TTM is an enigmatic disease characterized by an overwhelming compulsion to pull out one's hair, most notably scalp hair, but also eyebrows, eyelashes and hair from the extremities, axillary, and public areas. Current estimates are that clinically significant hair pulling is manifested by 3.4% of all females during their lifetimes. The objective is to inform nurses about the relationship between types of violence, (e.g., self-injury, emotional, sexual, physical) experienced by the subjects and the subsequent development of TTM. The overall goal is to enable nurses to better detect both TTM and histories of violence in their patients based on the interrelationship of these often hidden syndromes.
Design: This project employed a qualitative approach using grounded theory methodology. Semi-structured interview schedules lasting 1-2 hours were conducted. The participants were invited to describe in their own words how they live and cope with TTM within the context of their life histories.
Population, Sample, Setting, Years: Upon the approval of a proposal submitted to the scientific advisory board of the national trichotillomania organization, the P.I. was given the opportunity to call for volunteers in their official publication. The subjects (age=33.7 ±8.9 S.D.) represent a convenience sample consisting of 44 women with trichotillomania from 21 states and Canada. These women were well educated with an average of 3.7 ±2.3 S.D. years of college; the subjects were employed in a wide range of occupations. Based on education and employment, this population of women appeared to be largely middle to upper middle class.
Concepts Studied: General areas of questioning included but were not limited to include: demographics; first memory of activity, i.e., age of onset; events or feelings preceding the activity, occurring during the activity and following the activity. Concepts and themes revolving around the construct of violence in childhood and/adulthood revealed a strong presence.
Methods: The women with TTM agreed to be interviewed by phone and taped for analysis purposes. The interviews took place over two summers. This data were analyzed using content analysis and quantified for presentation in this study. Checks were instituted to establish reliability of the content analysis using the criteria of reproducibility and stability.
Findings: Forty of the 44 women (91%) reported some form of trauma or violence occurring during their lives while 39 (89%) reported episodes of violence associated with the onset on TTM. Events ranged from repetitive and moderate abuse in the family (i.e., chaos, on-going yelling, screaming, shaming) to severe familial abuse (i.e., raging, threatening, sexual, physical) to acquaintance/stranger abuse (i.e., sexual assault, rape, gang rape).
Conclusions: Women with trichotillomania have experienced a disproportional number of traumatic or violent episodes in their childhood. In most cases, the onset of TTM appears to be causally related to specific episodes of violence occurring during childhood. Of special interest is the significant impact that family chaos experienced during childhood appears to have on the development of TTM. This link of TTM with episodes of violence should be addressed by nurses and other health care providers.
Back to Violence: Symptoms and Consequences
Back to The Advancing Nursing Practice Excellence: State of the Science