Trichotillomania in African American females is a topic that is not widely covered in the literature . In an older study by Angela Neal-Barnett et al., they interviewed African American hair care professionals and chronic hair pulling customers . They found chronic hair pulling was the primary cause of 29/80 customer’s own hair loss, and all customers that hair care professionals identified to be hair pullers were all women . Of the 29 individuals, 21 customers, all of which were women all met criteria for trichotillomania, one customer admitted to trichophagia, and 3 customers noted these behaviors had been ongoing since childhood . This suggests that there are many women that suffer from trichotillomania and go untreated. A unique finding about our patient is that the hair extraction was not from a part of the patient’s own body, but from a weave made of human hair. She did not report feeling any sensations, either emotional or physical, when pulling the hair from the weave. The consumption of the hair is what brought relief from her feelings of anxiety, which had been exacerbated by her recent pregnancy and relationship issues. A previous episode of this behavior at the age of 13 had likewise relieved stress, at that time described by the patient as related to expectations of high academic performance from her mother.
To fully appreciate the cultural presence of the weave in African American society, an understanding of why many African American people wear weaves is important. Black hair's role in shaping black identity in America can be traced at least as far back as the early 1900s, in which straight, long hair and lighter skin was more favored, both within white and African American communities . Advertisements for hair products began to proliferate, all promoting an idealized version of straight Black hair that eventually became associated with higher chances at employment and success . In addition, part of what drove this shift toward straight hair was the economic appeal of a growing market of Black consumers as thousands migrated into northern cities throughout the first half of the 20th century. White-owned companies such as Plough and Ozonized Ox Marrow marketed their products by "promising a cure for the curse of kinky hair” . By the early 1990s and throughout the later years, the weave industry, which produced a stylized form of synthetic or real human hair, became so popular that 1.3 million pounds of human hair valued at $28.6 million was imported from countries like India, China, and Indonesia .
To continue the discussion of Black hair and its importance, a study performed by Brittani Young, in which 15 African American women from South Carolina were interviewed can be discussed. Many of the participants discussed difficulty with managing their hair due to thickness, and eventually opted to perm their hair, which refers to a chemical procedure that loosens the kinks of the hair. Another interviewee expressed that she believed her mother encouraged a perm in order to “align herself with the imposed Eurocentric beauty standards that deemed straight and sleek hair as beautiful and acceptable” . Other interviewees recalled moments in which they felt anxiety about fitting in at school or were mistreated by other professionals in the workplace due to the nature of their hair.
Young further highlights how many of her interviewees have discussed the concept of being in a “black space” where young women do not feel confined to a certain standard and feel more freedom and expression. On the opposite spectrum, Young compares black hair to the concept of a “veil” and states that “as a form of covering, hair wigs and weaves take on the same meaning of the veil,” as in non-safe spaces such as the workplace, where such hairstyles are considered being more “appropriate”. Many interviewees described being more comfortable with their natural hair as they aged due to positive shifts in platforms like social media. More and more women continue to celebrate and embrace their natural hair, with many partaking in the “big chop”, where all chemically treated hair is cut to allow for new growth, natural curl patterns and textures . However, there is still much controversy surrounding Black hair today, even in the 21st century. This analysis regarding black culture and the involvement of hair in shaping one’s identity cannot fully explain the patient’s presentation of trichotillomania, but it can perhaps partially explain the patient’s presentation of anxiety and stress, which was relieved by consumption of her weave.
To reiterate one of the earlier points made, a consideration to keep in mind when treating black patients is that most of the current literature about trichotillomania is regarding its presentation in the White population. Thus, it is important to keep in mind that some Black patients have grown up in a societal environment where non-natural methods of attending to Black hair have been promoted, which, as aforementioned, can lead to a presentation of generalized anxiety and trichotillomania at least in part due to self-perception related to the differences in the physical properties of black hair . Bringing more awareness to trichotillomania in the Black population can help patients better understand their diagnosis.
In terms of possible treatments for trichotillomania, there is a wide range of therapy available, which include cognitive behavioral therapy, habit reversal training, acceptance and commitment therapy. Other treatment options that may be effective include supportive counseling, support groups, hypnosis, medications and combined approaches . In regard to pharmacological treatments, data on SSRIs remain controversial, noting behavioral therapy sustained more long-term benefits compared to fluoxetine . There is some data on TCAs such as clomipramine however side effect profile may confer more risks than benefits. Other pharmacological treatments that have been investigated include a-acetylcysteine, olanzapine, naltrexone, topiramate, modafinil as well as cannabinoid agonists like dronabinol, however more research is needed to confirm their efficacy .
Unfortunately, there is not a strong amount of literature supporting approaches, with fewer than 20 randomized controlled trials available to guide treatment choice and implementation. Additionally, many of the randomized treatment outcome studies have looked at behavioral therapies or medications, with mixed results, especially with respect to the efficacy of medication. Conclusions that can be drawn from analysis of this data include several points. First, cognitive behavioral therapy has shown to be helpful for treatment following acute treatment, although relapse appears to be a problem. Selective serotonin-reuptake inhibitors generally do not appear to be efficacious in reducing trichotillomania .