Role of opioid system in self-directed behaviours?

No one knows explicitly why people pull out their hair (stereotypy) or perform acts that cause self injury, such as self-cutting (Self injurious behaviour/SIB) .  But from reports by patients, these self-directed behaviours make them feel better than if they didn't engage in these actions.  In other words, these actions are possibly a form of coping behaviour - though the mechanisms involved and causes too may vary.

   Research into the risk factors for developing self-directed behaviours found that Rhesus monkeys who were reared in isolation had a much higher chance of self-biting.  It led researchers towards a developmental neuro-chemical hypothesis in which self injuring arises from adverse life events (such as environmental deprivations) and is maintained by dysregulations of several neurochemical and physiological systems - and serves to reduce anxiety. (Tiefenbacher et al. 2005)

    Evidence in support that self-directed behaviours help in reducing stress and anxiety comes from studies using monkeys.  Monkeys with a history of self-inflicted wounding had a higher stress (or cortisol) response to the mild stress of blood sampling.  Self-biting was also preferentially directed to body sites associated with acupuncuture analgesia (sites of the body that acupuncture is applied to to reduce pain).  These correlations point to the possibility that self-injuring or self-infliction of pain may help mediate or reduce anxiety.  Whether this is a cause of the action or a consequence of SIB is unclear.

    In both hair pulling and self injuring subjects report relief directly after the self-directed action, e.g self-cutting.  In monkeys, a rise in heart-rate has been found to precede the SIB, followed by an immediate return to baseline after the episode. (Novak, 2003) It is this cycle of heightened internal tension, self-directed behaviour and immediate relief that hair pullers report sustains the process of hair extraction.  Many researchers believe the opioid system is implicated in this process.

    Self-stimulation of opioids (the body's own natural painkillers) could be key to why self injuring occurs.  In fact, after treatment with naltrexone (an opioid receptor antagonist) which reduces opioid levels, the chances of self-injuring behaviour can increase because individuals need to stimulate opioid release which may decrease any rise in tension or anxiety.

    One outcome from all this is that to investigate self-directed behaviours further researchers need to focus on the benefits of these actions.  Could it be the case that people who pull hair or who self harm have lower baseline opioid levels than others?  If so, maybe their harming behaviour is a way of coping by stimulating opioid release to address a heightened level of stress and anxiety caused by a non-optimal environment?

    The opioid system is not the only one that has been implicated with self-directed behaviour.  The serotonergic system may play a role too.  But it would seem the opioid correlation is a strong lead for future research.

References:

Stereotypic Animal Behaviour: Fundamentals and Applications To Welfare 2nd Edition (1996) edited by G. Mason and J. Rushen (CABI)  [see pp.176-180]

Hair pulling and D.W. Winnicott's theory of transitional behaviour

photo by Annie Chartrand

British psychoanalyst D.W. Winnicott was an amazingly close observer of child behaviour.  His is the only voice in psychology I know that has ever made mention of the way babies self-comfort using hair like fibres.  In Playing and Reality (1971) Winnicott describes how babies may pluck wool strands from a blanket and use them to caress the mouth area and sometimes even swallow the strands too.

Winnicott called this transitional behaviour - when an object is needed to soothe anxiety at a time when a transition from one state to another (such as from waking to sleeping) is occurring.  At such a time the baby may feel lonely or depressed and a specific object or behaviour helps offset this.  On this basis thumb sucking may also included too as a way of helping a child cope with the transition of having the mother present to her disappearance from view.

It is odd to me that Winnicott's observation has not really been fully followed up and related to hair pulling in later childhood.  The idea that this behaviour may link to how babies self-comfort could imply hair pulling is an innate behavioural pattern of the human species, or at very least a throwback to a behaviour learned in the early months of life.

For Winnicott, a baby's adoption of a bit of wool from a blanket or other material is a pattern (think of Linus in Charlie Brown) which can persist into late childhood or even adult life and is part of normal development.  This is speculation on my part, but could hair pulling disorder be another part of the same spectrum?  In this sense, the child is using a part of his own body (a part that resembles a woollen fibre, which is detachable and can be owned or possessed in its own right) to provide material comfort.  

Winncott's theory of transitional behaviour is interesting.  He believed that self soothing took place when an object was needed to bridge the gap between external reality and the inner physiological need of the child.  Or in other words, to assist adaptation to the world a child might need an object in order to facilitate adjustment to an otherwise challenging situation, such as to sleeping in a room by itself.  Applied to hair pulling, it is easy to imagine that a child unable to cope with his environment may turn to the body as a source of comfort where lack of social support was available.

But does this help explain all facets of hair pulling?  What about hair root eating?  Well, hair root eating does meet the oral need of sucking which babies do.  But why pull hair when one could use a blanket instead?  Maybe the child has not been able to form a successful attachment to physical objects or possessions in its environment and in this way hair pulling possibly signals a mode material deprivation or a disturbance to the capacity for 'ownership' (self-identification with the world around it).

Personally, I think Winnicott's observations are extremely important and helpful in gaining insight into hair pulling behaviour and into other forms of self-directed actions too.  Maybe a sense of comfort from hair or hair-like fibres goes all the way back to our primate origins when mothers were hairy too.

References:
Winnicott, D.W., The Family and Individual Development (Routledge, 2006)
Winnicott D.W.,  Playing and Reality (Tavistock, 1971)

Hair pulling in ancient literature - Part Two (continued) : Homer's Odyssey

At the end of Book X, following great suffering and hardship, Odysseus' men finally believe they will set sail for home. But the way back to Ithaca not to be a simple one.  Odysseus learns (from Circe, the witch) he must consult with the spirit of the blind prophet Tiresias to learn the route home.  For his men, knowing that they are finally going home but realising that they must do so by such a painful circuitous route precipitates hair pulling behaviour.


"The men were broken-hearted as they heard me, and threw themselves on the ground groaning and tearing their hair, but they did not mend
matters by crying. When we reached the sea shore, weeping and lamenting
our fate, Circe brought the ram and the ewe, and we made them fast
hard by the ship. She passed through the midst of us without our knowing
it, for who can see the comings and goings of a god, if the god does
not wish to be seen?

The first inference of this quote is that hair pulling is being practised to produce a cathartic effect, so that the extra pain of yanking hairs will magnify their distress to a high point, after which it will be alleviated.  In other words, by raising their pain levels over and beyond that which has been caused by their disappointment some kind of benefit is expected.  Alternatively, hair pulling occurs unconsciously but the body aims at the same effect.  If unconscious, which seems most likely, the pulling seem sto stem from the postponement of the fulfillment of their desire.   The goal of returning home remains but gratification has been postponed and it is the sense of being thwarted when the end seemed so close that appears significant here.   Maybe the sailors’ sufferings would be less great if the possibility of returning home had never been dangled so agonisingly in front of them.  For this would have led to acceptance and resignation of the kind that will allow for some kind of adaptive response.  But here, the men are caught in two minds - unable to cease dreaming of home and yet unable to realise this dream.  It is this contradiction in their minds that appears to facilitate hair pulling.

The other mention of hair pulling in The Odyssey features in Book XXIV, when Agamemnon's ghost and that of Achilles argue over who had the better death.  Agamemnon recalls how:

We fought the whole of the livelong day, nor should
we ever have left off if Jove had not sent a hurricane to stay us.
Then, when we had borne you to the ships out of the fray, we laid
you on your bed and cleansed your fair skin with warm water and with
ointments. The Danaans tore their hair and wept bitterly round about
you.

 Therefore, in both The Odyssey and The Iliad, hair pulling emerges as a means by which (a) energy is either discharged cathartically or (b) a means by which neurochemical change occurs that ultimately produces a state of calm and from this more constructive and considered actions may ensue. Since The Odyssey is not a work of psychology, Homer probably uses hair pulling as something of a dramatic cliche - for his audience would have instantly identified with the passion and tension that any reference to hair pulling implied.

More examples of hair pulling and self directed behaviour in ancient literature will follow in later posts.

Hair pulling in ancient literature - Part Two: Homer's Iliad

Hair pulling behaviour is frequently manifested by characters in Homer's Iliad and Odyssey, particularly at times of great emotional stress.  In this blog page we look at hair pulling in The Iliad.

The Iliad (800 B.C.)
In Book X  line 15, Agamemnon pulls out his hair in desperation at the plight he faces.  Unable to sleep, his mind is in torment.  He is caught between dishonourable retreat to Greece, where he will face shame and ignimony, and staying to fight to almost certain death against the Trojans:

"When he looked upon the plain of Troy he marvelled at the many watchfires burning in front of Ilius, and at the sound of pipes and flutes and of the hum of men, but when presently he turned towards the ships and hosts of the Achaeans, he tore his hair by handfuls before Jove on high, and groaned aloud for the very disquietness of his soul."

Preceding the hair pulling, Agamemnon realises that Jove has favoured his foes' sacrifices to the gods over his own. Sleep alludes him as he experiences restlessness and anxiety. In other words, the transition to a sleep state has been disrupted by an internal conflict from which Agamemnon can find neither escape (into unconsciousness) nor a resolution (cognitive dissonance).  Hair pulling appears to constitute some mode of an outlet where no other seems possible.

  
In Book XVIII Achilles responds to news of Patroclus's death, his great comrade in arms, with an extreme display of grief :        

"A dark cloud of grief fell upon Achilles as he listened. He filled both hands with dust from off the ground,  and poured it over his head, disfiguring his comely face, and letting the refuse settle over his shirt so fair  and new. He flung himself down all huge and hugely at full length, and tore his hair with his hands. "

Unlike with Ezra of the Old Testament, hair pulling here is preceded by a ritual of pouring of dirt and dust over his head, face and clothing.  It appears that Achilles is acting in obeyance with a funereal tradition whereby hair is shorn in respect for the dead.  Hair tearing was a formal component of mourning in classical Greece and was often accompanied by head beating.  (Encyclopedia of Hair: A Cultural History By Victoria Sherrow, p.277 2006)  Since a loud display of grief was deemed respectful to the departed, it is likely that hair pulling was painful enough to facilitate the required audible wailing and groaning effects.  It also the case that a dishevelled appearance of ruffled or unkempt hair was an outward sign of loss and grief so that pulling hair or lowering one's hair were both practised in ancient Rome also.  Later in Book XXIII, Patroclus' comrades cover him with locks of their hair after which Achilles cuts a lock of his own hair and places it in the hand of the dead Patroclus as he lays on his funeral pyre.
    In Book XXII Hector's parents tear their hair.  Priam does so when beseeching his son to withdraw from a confrontion with Achilles, whose mother is a water nymph, and who is divinely protected as a consequence.  The pulling is a sincerity signal intended to publically communicate the severity of distress.  

"The old man tore his grey hair as he spoke, but he moved not the heart of Hector."

As expected Achilles defeats Hector and in revenge for the loss of his dear comrade Patroclus, proceeds to disrespect the body by dragging it behind his chariot:

"Thus was the head of Hector being dishonoured in the dust. His mother tore her hair, and flung her veil from her with a loud cry as shelooked upon her son. His father made piteous moan, and throughout the city the people fell to weeping and wailing."

It is notable that this behaviour is not copied by Priam, her husband, following Hector's death, suggesting that public displays of hair pulling was predominantly a mode of female grief expression.  Finally in Book XXIV the body of Hector is restored to Troy after Achilles relents in his anger and accepts ransom for the body.  As it enters the city gate the womenfolk again demonstrate hair tearing, signalling themselves as chief mouners through this and, no doubt, the intensity of their wailing above all other mourners present:

"Clasping Hector’s head, they wailed and tore their hair, while the great host of people wept."

     So, we can infer a number of things from these passages. Firstly, hair pulling was a ritual that marked great public displays of grief and served as a sincerity signal to all those watching on - for who would pull out their hair unless their emotion and feeling were genuine?.  But hair pulling also occurs when people are caught in two minds - or between two states of being and can find no easy resolution to their internal state of struggle.  I find these references incredible because they reveal a side of human psychology and behaviour that modern life has forgotten.  Perhaps people who pull out their hair are expressing behaviours that would once have been more naturally perceived and have been more publically acceptable in years gone by.

Hair pulling in the writings of Shakespeare

In the works of William Shakespeare hair pulling appears quite a bit.  It is performed to:

(a) reveal grief
(b) demonstrate madness (mental illness)
(c) show despair

It appears in the following works by Shakespeare:

The Rape of Lucrece (poem)

    "Let him have time to tear his curled hair,  [line 1120]
    Let him have time against himself to rave,
    Let him have time of time's help to despair,
    Let him have time to live a loathed slave,
    Let him have time a beggar's orts to crave,
    And time to see one that by alms doth live
    Disdain to him disdained scraps to give."

Much Ado About Nothing (2.3)

 Claudio:
    Then down upon her knees she falls, weeps, sobs, beats her heart, tears her hair, prays, curses--'O sweet Benedick! God give me patience!'


Romeo and Juliet (3.3)

Romeo:
    Thou canst not speak of that thou dost not feel.
    Wert thou as young as I, Juliet thy love,
    An hour but married, Tybalt murdered,
    Doting like me, and like me banished,
    Then mightst thou speak, then mightst thou tear thy hair,
    And fall upon the ground, as I do now,
    Taking the measure of an unmade grave.

Troilus and Cressida (4.2)

Cressida:
 Tear my bright hair and scratch my praised cheeks,
 Crack my clear voice with sobs and break my heart
 With sounding Troilus. I will not go from Troy.



King Lear (3.1)

Kent:
I know you. Where's the king?

Gentleman:
    Contending with the fretful element:
    Bids the winds blow the earth into the sea,
    Or swell the curled water 'bove the main,
    That things might change or cease; tears his white hair,
    Which the impetuous blasts, with eyeless rage,
    Catch in their fury, and make nothing of;
    Strives in his little world of man to out-scorn
    The to-and-fro-conflicting wind and rain.

King John (3.4)

Constance:
I am not mad: this hair I tear is mine;
My name is Constance; I was Geffrey's wife;
Young Arthur is my son, and he is lost:
I am not mad: I would to heaven I were!
For then, 'tis like I should forget myself:
O, if I could, what grief should I forget!
[snip]

King Philip:
Bind up those tresses. O, what love I note
In the fair multitude of those her hairs!
Where but by chance a silver drop hath fallen,
Even to that drop ten thousand wiry friends
Do glue themselves in sociable grief,
Like true, inseparable, faithful loves,
Sticking together in calamity.

Constance:
To England, if you will.

King Philip:
Bind up your hairs.


Constance:
Yes, that I will; and wherefore will I do it?
I tore them from their bonds and cried aloud
'O that these hands could so redeem my son,
As they have given these hairs their liberty!'
But now I envy at their liberty,
And will again commit them to their bonds,
Because my poor child is a prisoner.
[...]

King Philip:
You are as fond of grief as of your child.

In the final example given above in King John (3.4), Constance defends her hair pulling as an expression of her grief for her son, rather than a sign of her madness.  But whatever meaning the audience is supposed to place upon hair pulling in Shakespeare's plays (and in the poem) the underlying purpose of the action is to reveal the sincerity of the feelings, emotions, heart ache and frustration that underlies it.  This reveals hair pulling to be an action that is not something that people feign or pretend to perform.  It is a behaviour that is painful under regular circumstances. No one does it for fun!  But in the face of genuine grief and anxiety it becomes a reaction that reveals itself to have benefits.  It helps take some of the pain away by, paradoxically, increasing the intensity of a person's pain through the yanking of hairs.  Maybe hair pulling is akin to self injuring in some way? However, whether self injuring behaviour is as automatically performed as hair pulling is hard to say.  I find it fascinating that references to hair pulling in English literature are so plentiful. I just wish there were more references to it in psychology too!

My research interests

If you haven't already figured, my interest is in what happens when people are in some way caught in two minds.  It can be a strange sensation that we all experience at various moments and it leads to behaviour being directed towards ourselves.  So, chin rubbing or head scratching are the most common manifestations.  Now some people might ask, so what?  Such behaviours are so natural and simple they might wonder, what is there to research?  The reason I think these behaviours are interesting is because they are so close to what we are as human beings that we barely notice them.  They are automatic and occur without conscious intention.  This fact alone reveals something startling: self-grooming reflects our ancient ancestral behaviour patterns.  Scratching or rubbing or stroking ourselves is behaviour so linked to our primate past that these are the actions that we are! It is the fact we overlook these actions because they are so normal that makes them so fascinating when they are highlighted. 

     In terms of research my aim is to better understand the benefits or advantages these kinds of behaviours have for us and in turn this will help explain why we developed them in the first place.  Soothing oneself by touching, rubbing, smoothing, stroking, scratching or pulling actions means that we feel better in some way for doing it than if we didn't do it.  So, rubbing your chin when weighing up the pros and cons of a decision somehow assists in the decision making process by allowing you to tolerate the discomfort of being in two minds about something until you can resolve the dilemna one way or another.  But what would happen if you had to make an important decision that placed you in a dilemna and you couldn't self-soothe (let's say your hands were bound in some way)? Would you make more hurried and less prudent choices as a result?  

     Another behaviour that interests me a lot is when footballers or fans clasp their hands above their heads when a goal has been missed.  Usually it happens when they expect the ball to go into the net but it diverges or swerves away or gets saved at the last moment.  I regularly do it when I watch my team  (West Bromwich Albion) narrowly send a ball over the bar or past the post.  But I don't do it when I can see from the first moment that the ball is not on course for the back of the net.  It requires the expectation of a goal and then the sudden thwarting of this hope to produce the response.  But why?  Why can't I just sigh or groan and let that be enough?  Why do I have to raise my hands to my head and pass my fingers through my hair?  What is that about?  Again, there must be benefits to the behaviour that help reduce the sudden discomfort and stress when two opposing impulses are activated simultaneously or when a cued behaviour (celebration) is suddenly deselected.

     My other interest, hair pulling, is a behaviour that I feel may be a stereotypical action that occurs when tension or stress is prolonged by being in an unnatural situation.  Imagine being caught in two minds about something not just for a few seconds but for hours, days or even years!

     I would like to undertake research into what the benefits of these behavours are to, as I said, find out how they benefit us.  Do they reduce stress or the heart rate?  Do they affect metabolic rate?  What happens if these behaviours are prevented in some way so the discomfort of being in two minds is not relieved?  These are the kinds of questions I would like to answer.  This week I added a paypal button to my site to receive donations to this site.  With any money these are the questions I would aim to research into further.

Lack of research into trichotillomania

It is not easy to research displacement behaviour - for a few reasons.  The main one is that not many psychology departments or schools focus on it.  This is surprising when one considers that hairpulling, for example, may affect up to 13 per cent of the population (by some estimates). In regards to trichotillomania (aka hair pulling), another problem that I discovered all to well, is that it is hard to find hair pullers willing to come and be subjects of studies.  In most cases hair pullers will not even go and see their regular doctor, let alone volunteer to take part in an experiment. People with trichotillomania may feel very ashamed of what they do and cover up bald patches with hats, wigs etc.  But because hair pulling does not detrimentally affect their overall state of physical health and because the behaviour is pleasurable and may even lower ongoing stress, they don't report it.  After all, why try to cure yourself of something that has clear benefits?  One area of research I would have liked to engage in (and maybe will in the future) is to try and assess what those benefits to a hair puller actually are.  For example, does pulling out hair lower stress (cortisol) levels?  Does it lead to endorphin release into the bloodstream (painkiller)?  My intention was to create a pain test to establish a person's pain threshold.  This might be done simply, such as seeing how long a person can stand having an ice pack placed against their skin.  Then the test would be done again to see if pain tolerance is higher after a bout of hair pulling.  A mouth swab could aslo be used to check cortisol levels.  A very simple experiment but unfortunately it was not performed.  Other things I would have liked to examine include:

Do hair pullers prefer certain types of hairs over others? e.g. wiry, kinked or curly hairs over and above straight, smooth, fine ones.

Can hair pulling be affected by ensuring the head and neck remain in an erect position and so the head bowing that makes hair pulling possible can not take place?

I believe that simple experiment that focus on direct observations can me most useful and helpful.  Of course, using an fMRI scanner to observe brain areas related to hair pulling is valuable too.  But, and I might be wrong, the technology is not yet in place to do both together - undertake a scan of someone in the process of hair pulling!  I think when that day comes some serious new data will emerge.  Hopefully.

Hair Pulling in Art

It is fascinating to think that the association of madness and hair pulling goes back to medieval times.  The fool or the madman in earliest artistic representations of madness was marked by a dishevelled appearance, and chiefly by wild unkempt hair.  This image is most likely derived from the fact that people with mental illness would have led socially isolated lives outside of the local community.  They may well have become forest dwellers, where they would have been left alone to forage for berries and other freely growing morsels.  If and when they emerged in society they would have been instantly recognisable by their tattered, dirty attire and, of course, ungroomed appearance.  Another fascinating fact is that the classical image of the court jester, a professional fool appointed at court, is of a man wearing gaudy unmatching colours and wearing a three-pronged hat with bells.  What we have here is the image of the forest madman but in an ornate , costume - the colours signify a madman's lack of taste and dress co-ordination and the three-pronged hat invokes association with twisted clumps of upstanding unbrushed hair.

    Images of madness appear aplenty in art, but hair pulling per se is more rarely depicted.  But one example can be found in Artus Quillinus De Oude's sculpture called The Women From The Madhouse from the 17th century (Gilman, 19, 1996).  A seated woman, naked for only a cloth around her waist area, yanks with her left hand at at a thick and entwined handful of hair.  She is pulling at far too many hairs at once for them to become extracted, so self-inflicting pain seems to be her object.  And with her right hand she is twisting tightly another thick bundle of hairs and pulling them downwards.  On her face is a mixture of both agony and pleasure (or relief), as if the mind and body are somehow split; her emotional and physical needs so neglected that automatic grooming behaviours have become more exagerated and self-directed than normal.  It is as if her soul seeks relief from the otherwise lack of control she has over her immediate environment, and obtains it via hair manipulation.

     A second interesting presentation of hair pulling can be found in Thomas Rowlandson's and Augustus Pugin's drawing of the interior of St. Luke's Hospital in 1809 (Gilman, 146, 1996).   Four women in the forefront clearly have very dishevelled hair. One seated in the left corner appears to be holding up in each hand a clump of extracted hairs.  A second seated woman in the middle of the picture is clutching at her hair, possibly seeking to extract some fibres.  Two other women walk together and although their hands are not engaged in pulling activity their hair is clearly of uneven lengths indicating sporadic and unco-ordinated growth - resulting perhaps from hairs having been plucked out at diverse times.  In this scene the forementioned patients reflect, 'standard images of Bedlam, raving mania and melancholy' (Gilman 1996).  The artist divides the image into two halves - the left side where the hair pullers dwell represents the old style Bedlam or unreformed asylum where inmates are abandoned and left alone.  The hair pulling may then be symptomatic of the hospital environment itself.  On the right side, hospital life is organised and ordely with inmates performing useful chores and where no self-directed behaviours are being indulged in. The implication is that healthy minds require healthy socially functional lifestyles - an affirmation of the christian sentiment that the devil makes work for idle hands.  

   Again we can see that references to hair and hair pulling are core to the commonly held images that we all carry with us but which are so close to us that we often overlook them. 

 References:

Gilman, S. (1996), Seeing the Insane (University of Nebraska Press)

Hair Pulling in Medical Literature

The first ever reference made to hair pulling in a medical context was by the father of modern medicine, Hippocrates around 400 B.C.  In Epidemics, Book III he lists hair plucking as one of the many signs and symptoms a doctor must consider when assessing a patient in order to identify the disease.  I very much doubt if such an item would be on many doctors’ checklist today!  Most interestingly he gives an account of a patient in Thasos, referred to as the wife of Delearces.   She is suffering with a high fever that involves shivering.  Her illness is thought by Hippocrates to be brought on by grief.  Her hair pulling is accompanied by her falling silent and scratching too.  She also cannot sleep and is constipated.  

      Amazingly, it will be almost 2000 years later before another mention is made of hair pulling in the medical literature.  In 1777-8 a French surgeon named Baudamant finds masses of hair in the stomach of a teenage boy indicating hair pulling and hair ingestion.  But it is not until 1889 in a medical report by the French physician Francois Henri Hallopeau that hair pulling receives its first formal diagnostic label.  Hallopeau gave it the name trichotillomania, from the Greek words thrix (hiar), tillein (to pluck or pull) and mania (an abnormal love for).  This name remains today, though mostly it is referred to simply as hair pulling disorder.  Hallopeau’s first report in 1889 described a young man who pulled out all of his body hair.  Another more detailed report by Hallopeau in 1894 identified the key features of hair pulling as:

1) itching sensation extending to all the hairy parts of the body
2) a “type of insanity” that drives the patient to seek relief from pruritus via hair pulling
3) normal appearance of skin and hair
4) long duration
5) lack of cure

Hallopeau had sought to cure hair pulling by applying mentholated camphor and wrapping the patient in rubber.  But when the method proved ineffective he declared the disorder incurable.
     Since this time, doctors have found establishing a diagnostic criteria for hair pulling very problematic.  It remains a poorly understood disorder and it varies in its particular manifestations which include:

(a) hair can be pulled from different sites of the body
(b) hair may or may not be chewed and the root eaten and/or the hair ingested
(c) there may or may not be a tingling itchy sensation prior to pulling etc
(d) pulling may occur consciously or unconsciously.  

To date trichotillomania evades a fully inclusive medical definition.  But according to DSM IV (American Psychiatric Association, 1994) the criteria for hair pulling includes:

A. Recurrent pulling out of one's hair resulting in noticeable hair loss.
B. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior.
C. Pleasure, gratification, or relief when pulling out the hair. [- but not always the case]

D. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition).
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

It is currently classified in the category Impulse Control Disorders Not Otherwise Specified though this may change in time (for the very latest current definition see DSM V).

     Considering that records of hair pulling go back as far as the writings of Hippocrates, not to mention featuring in the Bible, Homer’s Iliad and in Shakespeare (more on these references in future posts) it is extraordinary to reflect that in the 21st Century psychologists and psychiatrists continue to struggle to find a meaningful diagnostic category that might help to shed light on an age old enigma of psychology.

References:
American Pschiatric Associaton, DSM IV, (1994)

Christenson, G.A. and Mansueto, C.S. (1999), "Trichotillomania: Descriptive characteristics and phenomenology". Chapter in the book "Trichotillomania", edited by D.J. Stein et al. 1999.

Hair pulling in ancient literature - Part One: The Bible

Hair pulling in various forms features heavily in the works of ancient literature and also in later English literature too.  In the next series of blog posts I will cover some of these references to pulling hair and attempt to comment on how hair pulling is depicted, the situations in which it occurs and what this possibly reveals to us about human nature.

    Since the Bible is a text at the very heart of Western culture it is fascinating to extract instances of hair pulling from it, considering that hair pulling is a behavior that is largely unrecognised in modern society.  

    In fact, biblical references to hair are not hard to find.  In the King James Bible there exist eighty references to hair - both in relation to animals and humans. (There are also 11 separate references to locks of hair.) However, there is only a single primary reference to actual body directed hair pulling itself, and this appears in the Book of Ezra, 9:3-7:

When I heard this news, I rent my robe and mantle, and tore my hair and my beard, and I sat dumbfounded; and all who went in fear of the words of God of Israel rallied to me because of the offence of these exiles.  I sat there dumbfounded till the evening sacrifice.
   Then at the evening sacrifice, I rose from my humiliation and, in my rent robe and mantle, I knelt down and spread out my hands to the Lord my God and said, ‘O my God, I am humiliated, I am ashamed to lift my face to thee, my God; for we are sunk in our iniquities, and our guilt is so great that it reaches high heaven.

The background to this odd behaviour, which entails tearing his clothes and his hair, is when Ezra (a very devout man) learns that people returning to Israel have not kept themselves sexually apart from non-jews during their time in exile.  Fearing the wrath of God for breaking His covenant Ezra has some kind of fit that involves yanking out his hair and this is then followed by some kind of trance state or unconsciousness.  The episode seems to be brought on by an extreme internal conflict whereby the God fearing man suddenly feels contaminated by the sins of his people. The sudden manic tearing of his clothes, and the self-directed pulling out of his head hair and facial hair would on one level appear to be an attempt to rid himself of contamination, to pick off or groom away unwanted particles adhering to his body.  And yet we know that what ails him is not physical contamination but a sense of a tainted spirit.   From this, Ezra's sense of true helplessness is conveyed by  (a) using a contaminated part (his hand) to attempt to clean the whole (body) and (b) using a misapplied physical grooming strategy to achieve spiritual cleanliness.  In other words, not only is Ezra’s hair pulling an inappropriate method to achieve a spiritual effect but it is also symptomatic of a state of mind in which no adaptive solution can be found the problem he faces.  

   The emergence of grooming behaviour during this internal conflict is perhaps revealing.  The Bible is not a work that exemplifies psychological realism but in Ezra's case the hair pulling seems to produce a beneficial effect or neuro-chemical change.  It precedes a state of calmness, which is inkeeping with the notion that endorphins have been released into the blood stream as a direct result of inflicting pain on himself.  Interestingly too, the people around him express no surprise or alarm towards his hair pulling and impute no case of demonic possession to him; hair pulling would seem to be within the normal realm of their common experience of human social behaviour.  Following the incident no further reference is made to Ezra’s hair pulling episode.  Perhaps it marks the continuation of a habitual behaviour that has persisted for years. 

        Rather than viewing his manic episode as a moment of divine interaction between a holy prophet and his God, viewed psychologically it may instead reveal an organism caught in two minds, or two states.  On one hand he yearns to feel righteous and holy but on the other he knows that he shares the sins of his people in the eyes of his God.  The co-existence of these two incompatibles in the same moment therefore negate each other and produce a third alternative state - hair and beard pulling.   In this respect Ezra's case possibly supports the theory that trichotillomania is a stereotypical displacement behaviour.

Interview questions raised on hair pulling...

A student this week asked me some questions about hair pulling for a project she was working on.  In trying to answer her questions it hit me just how little we really know and investigate this condition.  She asked firstly:

What do you think triggers the beginning of trichotillomania in someone? 

 

My answer to this question was that different fields of psychology have different perspectives on it.  The neurobiologist might point to dysfunction in the basal ganglia and cerebellum which implicate the role of serotonin.  The behaviourist might see it as a random behaviour that results when an environment inadequately enforces normal behaviours so that unintended behaviours develop.  Evolutionary psychology (in which camp I place myself) might view it as a 'mental program' or an innate behaviour derived from man's ancestral past which is triggered under certain conditons.  Those triggering conditions are most threatening during a sensitive period when the young developing organism's brain is becoming wired to its environment.  If the environment is unnatural or inadequate and thwarts, prevents or does not reciprocate and support species specific behviours then a self-directed behaviour might emerge.  But I could not say why hair pulling develops over, say, nail biting or thumb sucking etc.  One of the reasons I could not say is because so little research has gone into this question, if any!  So, I want to put forward some suggestions of my own here for what they are worth.

1. no research has gone into why the lipid fat root is so valued by hair pullers.  This eating behaviour that forms part of hair pulling is often completely omitted from considerations of the condition because the focus is placed instead on coping with the social embarrassment of hair loss.

2. no research has gone into the effect of hair pulling and lipid fat hair root eating on a person's metabolic rate.

3. no research has gone into why certain kinds of hairs and certain areas of the scalp are preferred over others.

I believe that the eating component of hair pulling is an attempt to control or homeostatically regulate in some way the metabolic rate, i.e. that rate at which the body conserves or spends energy.  The implication here is that hair pulling is triggered by environmental conditions which are stressful and which the brain may interpret as conditions in which resources and social support are scarce.  Hair pulling and root eating may be an activity that aims at preserving resources and reducing exposure time to a disadvantegeous situation because it is an activity that: (a) is a form of self-feeding as well as self-grooming (b) is mode of foraging applied to the body (c) is a form of tolerating exposure to an environment in which the indivudual feels powerless by triggering behaviours that utilise grooming and feeding brain circuitry implicated in survival (d) is a way of focusing attention towards the body and away from the world because the act of pulling involves bowing the head and obtaining an object that fills the foreground.  Of course, without research pointing in this direction this is but conjecture on my part. 

The student's second question was:

How would someone with the condition overcome it?  

I suggested that unless hair pulling is engaged with early on and during the developmental period when the brain is becoming wired to its environment then it could well become a lifelong condition.  In other words, the environment needs to be altered as soon as the problem surfaces to address the triggering circumstances.  Maybe family system therapy would be the best place to start.  In short, some sort of environmental enrichment is required - a method successfully employed with captive animals that fur pull.

Maybe the moral here, is that unless we see ourselves as organisms that have developed to be sensitive to environmental signals - as animals are - we cannot hope to understand hair pulling fully.

Common hair pulling expressions and sayings

Though hair pulling as a self-directed behavior is little known among the general population, references to hair pulling are in fact an everyday part of English colloquial expression.  The phrase, “to tear one’s hair out’ is one commonly used by English speakers and its meaning generally assumed to imply the frustration of an impulse, even by people who may have never pulled hair nor heard of trichotillomania. Indeed, colloquial references to hair are plentiful and the following is very much a truncated list:

To keep one's hair on (to stay calm)
To let one’s hair down (relax)
To make one’s hair stand on end (terrify)
To get in someone’s hair (to annoy)
To split hairs (to argue pettily)
To have a bad hair day (to feel unattractive because one's hair is restive)
To not have a hair out of place (to be tidy)

and, of course, the above mentioned,
To tear one's hair out! (to be at one's wits end)

      It is fascinating that hair references should abound, particularly the way that hair and mental states are so entwined in folk consciousness.  And yet, the idea that hair may play a role in homeostatic regulation and that hair pulling is such a little known disorder is in this context quite surprising.  Hair and hair related actions or grooming behaviours are so much part of what makes us human it is that it is perhaps more difficult to get clear perspective on the function it serves for us - why we do it and the benefits that accompany these actions. 

Captive States

It is amazing that only animals in captivity display repeated or stereotypical behaviour - and not animals in the wild.  Repeating the same actions again and again is something that is thought to characterise a very high percentage of behaviour found in animals living in laboratory conditions (more than 50% by some stats).   Types of behaviour consists of:

• wool chewing in sheep, where sheep in close proximity chew the wool of the sheep in front
• steel bar chewing in pigs and cows where enclosures are very small and diet is restricted
• cage jumping in mice
• cage pacing where physical space is very limited e.g mink, zoo animals etc.

     Many factors have been given in trying to understand these events.  But the concept of thwarting is key.  Animals fed on artifical diets (e.g. liquid diets) may never get to experience a 'gut full' feeling, so they remain in feeding mode constantly.  This may spill over onto objects that are not food related e.g. steel bars.  In fact diet is very important in how an animal regulates its behaviour because food seeking or oral behaviours are linked to internal assessments by the organism of its energy and nutrient requirements.  Pacing is another common behaviour, especially in animals that have evolved to roam long distances.  Big cats or dogs in pent up conditions will often display this.  Again being prevented from fulfilling natural behaviour patterns means these patterns emerge in ways that betray a stereotypical quality.  Cage jumping in mice is also very common, though some view it less as a displacement behaviour (a behaviour that is expressed because another regular behaviour has been thwarted by the environment) as a direct response to wanting to escape from confinement. 

     Understanding human behaviour in terms of captivity is more difficult.  Humans are rarely kept in cages, except in prisons, and even then it can be argued that man is an adaptive animal with the intellectual ability to understand and regulate his situation.   On the other hand, some people might suggest that all of human life is a form of captivity in as as far as we all have to accept limitations on our natural desires for much of the time.  The point at which everyday repression tips towards producing stereotypical behaviour is what interests me a lot.

    The tipping point seem to be when the environmental possibilities or opportunities for self expression and self-regulation become so restricted that a person is no longer is able to exercise control over his/her state of being.  For example, hair pulling has been found in children who exist in a symbiotic relationship to their parents.  This may mean the parent is so controlling that the child can only express its needs and desires through the agency of the parent figure and has no independent power.  Every need or want must be negotiated via the parent e.g. approval sought, permission granted, compromises made.  This power imbalance and over-dependence means that the child has little chance of regulating its own internal state.  Hair pulling has also been found in those children where incest has occurred.  Inability to avoid incest (or the sexual behaviour of parents), itself a very important aspect in ensuring genetic health of offspring, means that something very fundamental has been violated.  In short, the capacity to control homeostasis - the ongoing relationship between internal state and environment is compromised.  This lack of control or self-sovereignty, in the absence of bars, constitutes a mode of captivity.  For what is captivity if it is not the freedom to fulfill one's own needs and determine one's own inner sense of emotional well-being? This is a major starting point for people seeking to better understand self-directed behaviours in humans in my view.

hair pulling (trichotillomania) - a displacement action?

For anyone who may not have heard of hair pulling in humans, here is what it breaks down to:

1. the hand is raised to the head
2. a hair of a satisfying texture is sought out  - usually from the crown area
3. the hair is plucked out
4. the hair is examined, particularly the white root attached (not to get a root is a failure!)
5. the root is rubbed against the lips and sometimes licked
6. the hair root is combed off using the front teeth or simply bitten off
7. the root is eaten
8. the spent hair is discarded

This process can continue – depending on whether it’s interrupted or not – for hours at a time!

One of the predictable consequences of hair pulling is hair thinning and even baldness in those favoured areas of the scalp where pulling takes place.   It can be a source of great embarrassment and awkwardness and for this reason pullers and psychologists tend to overfocus on symptoms of hair pulling rather than examining its root causes (no pun intended).   This can mean people wearing hats, using hairnets, putting on gloves or keeping their mouths busy with gum, among other barrier techniques.  But to me, this response misses the mark and what’s more these methods are rarely effective.
  The point is that people are pulling their hair out because it is satisfying in some way – it makes them feel good!   There are a number of reasons this may be the case:

a. yanking out a hair can be painful, but like all painful activities after a while (think of jogging or extreme physical exertion) endorphins are released and these raise the pain threshold.

b. The act of rubbing, licking and removing the hair root involves a lot of oral manipulation which may increase saliva production.  If you can imagine anticipating your favourite food when saliva production occurs then you can get something of an idea as to why the 'tasty' lipid fat root is so prized.  It is also made of fat and fat is something that humans tend to enjoy.

My take on hair pulling is that is has homeostatic benefits -  which means that the activity helps the person regulate their internal physiological state in some way.   There has not been too much experimentation on this unfortunately.  (Partly because it can be hard to find subjects who hair pull to participate.)  But it would be interesting to find out:

i. are endorphins released which reduce the effects of pain?

ii. do cortisol levels (i.e. stress levels) decrease during hair pulling bouts?

iii. are there any other hormonal changes related to hair pulling, such as oxytocin release?

The other thing I would like to find out relates to the title of this blog page – is hair pulling a displacement behaviour.?  In other words, do people do it because a motivation or behaviour has otherwise been thwarted.  For example, thwarted attachment seeking (or grooming) due to a neglectful or rejecting parent may precipitate this form of self-grooming.   In this situation, a desire to approach or achieve comfort is constantly sought as an internal state but in an environment in which it cannot be satisfied.  This kind of mismatch, if occurring for a prolonged period and during a sensitive phase of development, may bring on hair pulling.  The final thing to mention is that the 8 stages above are so commonly observed in people who are hair pullers that it cannot be written off as an idiosyncratic behaviour that a few people coincidentally share.  Instead it can be viewed as a species specific behavioural program that emerges under conditions of prolonged frustration - and it also affects animals in captivity too.  So, the plot thickens….

displacement - defining terms

Anyone who has studied psychology to a reasonable extent can tell you that it is not a unified field.  As things currently stand, it is divided up into a number of different areas such as social, developmental, evolutionary and cognitive etc.  This is due to the fact it is very new science (or social science is more apt) and is still finding its way in terms of having a single theoretical foundation and being truly scientific, i.e. not merely a reflection of the researcher's personal value system.  Indeed, psychology did not exist till Freud effectively invented it as a form of treatment for patients suffering from 'hysteria'.  Freud set out to create a complete theory of man - a very ambitious project (to say the least) considering the state of technology at the time.  Even now, with fMRI scans the depths we can probe into the actual workings of the mind is very limited.  But this did not prevent Freud having a go and coming up with some key concepts such as transference, projection and displacement.   

     For Freud, displacement behaviour meant something slightly different to what I mean in my blog.  He was using the term to describe a behaviour that is expressed when the desired behaviour has been repressed and which the individual may not even be conscious of.  So, in the Victorian era when sex was taboo (at the public discourse level - privately, they were at it like no one's business!) Freud came across many cases where sexual desire could not be expressed directly. As a consequence he noted behaviour got channeled into alternative actions and from this he was able to recognise fetishes in his patients.

    In this blog my use of displacement behaviour is derived from ethology (study of animal behaviour) and links to the work of pioneers like Tinbergen.  He was one of the first people to notice that some behaviour does not always fit the context in which it emerges and is therefore hard to explain in terms of its relevance to the situation. An ethological definition does not assume, as does Freud, that all behaviour is merely a spill over from a single repressed drive, such as the sex drive or libido.  Several theories in the field of ethology exist in an attempt to explain behaviour that

seems to have no functional purpose.  This can include spill over theories but also includes:

disinhibition theory - in animals when incompatibility between behaviour patterns occurs, underlying patterns that otherwise are inhibited become expressed e.g. preening, pecking etc.  A variation on this hypothesis (McFarland) is that when frustrated (i.e. an action does not produce the reward or effect on the environment expected) animals switch their attention to stimuli other than that eliciting the ongoing activity.  Displacement behaviour marks this switch of attention and suggests that when an animal is only partially rewarded for an action it is more likely to attend to wider or incidental stimuli.  The displacement behaviour may also indicate the existence of a conflict between the established pattern of behaviour and an environment in which the established behaviour has failed to produce the reward expected or required.  

dearousal theory - my own position is that displacement behaviour is a means of homeostasis.  In other words, the behaviour helps to regulate the internal state of the animal when in a challenging environment.  For example, a hungry cat frustrated by an empty food dish will often start to groom itself.  (I see it as a cat's mode of waiting for its meal.)  The grooming is a displacement behaviour that does not help the cat obtain food but enables it to regulate itself in relation to its non-rewarding environment.  The self-directed behaviour serves to attain a mental state non-dependent on the wider environment but as a consequence of the lack of reward from the said environment.  It is a way of regulating arousal until environmental conditions (or the adaptive effect of behaviour) are more conducive.

Overall, I take an evolutionary approach to displacement behaviour.  This means that I see the brain as an organ that pursues goal states e.g. safety, comfort, sex, food etc.  Each goal state is inextricably related to behaviour patterns which normally are successful in achieving the desired effect of meeting the organism's needs and supporting its well being.  Psychology then is the study of how an organism's evolved mindset or mentality links to its actual behaviour within the modern environment it finds itself.  Indeed, the brain is the organ that is constantly monitoring the state of the organism both internally (e.g. heart rate, oxygen levels) but also in terms of its relationship to the external world (danger, mating opportunities, food availability etc).  In short, its business is to monitor and regulate the ongoing relationship with the world.  From going to the fridge for a drink, to approaching someone at the disco, to putting an extra blanket on the bed - these are all brain state driven actions that man has been pursuing in one way or another since time immemorial.  Again, this marks a different focus from Freud whose theory derived from the immediate socio-historical context of his time and not from evolutionary history.

     The problem for any organism is when the environment does not support its psychological requirements.  In other words, no behaviour can be found that adequately achieves the goal states that constitute the organism's being or its nature. And this is what this blog is really concerned with - the displacement behaviours that emerge to regulate a situation characterised by disharmony or disruption between stimuli and mental states.

The Psychology of Everyday Life

Have you ever found yourself in one of the following everyday situations?

a. you are walking down the street and towards you is heading someone you know and like.  The sight of the person triggers a desire to say hello or wave, but social convention dictates that you refrain from doing so until the correct social distance is attained.  During this period there is a conflict and you find your gaze shifting around a lot and possibly avoiding direct contact with person approaching as a means of mediating the impulse to greet and the need to repress it.

b. you are in your car and are in a hurry.  You come to a junction but are not sure whether to turn right or left.  Behind you someone is bumper to bumper and a decision must be made quickly.  Automatically, your hand rises to your chin and rubs it.  Alternatively, you may touch and rub your forehead as you must put on hold the need to travel forward and re-evaluate your environmental bearings prior to recommencing your journey.

c. you are playing football and you are odds on to score.  The goal keeper has come out but you have rounded him and now the goal gapes.  If you score it will mean a lot.  The game is tied 0 - 0 and there is only 1 minute left to play.  You strike the ball but just before making contact it bobbles slightly on the uneven turf and the trajectory is skewed.  You watch on in the urgent hope of scoring and your body is set to celebrate wildy.  But the ball does not follow the course you want and just goes past the post.  This sudden thwarting of your intention produces a sudden automatic action: your hands rise to your head and your fingers comb back your hair and/or your hands in unison rest on the top of your head.

I would be very surprised if no one out there had ever experienced one of these situations.  In fact I would wager serious money against it.  Because automatic behaviours like these are key to our human experience and serve a very important function.  When a psychological or mental goal state (e.g. I'm hungry and I must eat;  I must find safety;  I want to bond or attach to someone etc.) is suddenly contradicated by social convention or incoming sensory data from the environment the human organism must recalibrate to bring the inner mental state and incoming external information into an adaptive relationship.  The brain of the football star who misses a goal must re-adjust his inner state of excitement that accompanies celebrating his goal in light of the changed situation of the wasted opportunity.  The driver must put on hold the project of moving towards his destination to reassess his current geographical location.  The person who sees his friend in the distance must contain his greeting performance through a displacement behaviour until the appropriate social proximity is attained and he can express his desire to renew a social bond.   So, at a point of social tension or stress a mismatch between an internal state (e.g. an intention, desire) and the environment leads to a displacment behaviour until the time when the moment of mismatch is passed and the desired (or undisturbed species specific) behaviour can recommence.  

   Problems for animals and people arise when this mismatch between inner state and external sensory data is prolonged.  An organism placed in an environment that limits behavioural possibilities so that certain goal states (a mental state that corresponds to a physical state of being e.g. happy - smile) cannot find expression is in a state of extended tension which can lead to stereotypical behaviours.  In humans the situation that prompted the behaviour may be forgotten in time but the action, such as hair pulling, may remain or be easily triggered when any frustration is felt.

   By relating abnormal behaviour to everyday behaviour it is possible to establish the existence of a mechanism that belies the whole spectrum.  What's more, it reveals that animals and humans are not poles apart in their biological and physiological make up.  This is important in improving our understanding of what we are and where we ultimately come from.

Introducing displacement behaviour

This blog is dedicated to the topic of displacement behaviour in humans.   So, what is displacement behaviour?  Well, put most simply it is a kind of fidgeting directed towards oneself. We have all experienced it when caught in two minds about something and we fidget or scratch the forehead or chin.  Technically speaking it is an automatic, self-directed behaviour that people engage in when they are anxious or stressed.   What makes it interesting from ethological and evolutionary points of view is that it is behaviour that very much links humans and animal behaviour together.  But more on that as this blog develops.  

My name is Will and this blog is my way of investigating further into displacement behaviour outside of a formal academic context.  It is a platform for expressing my interest and connecting with people out there who may have a similar fascination.  This started for me when I decided to study psychology in order to find out more about hair pulling behaviour (or trichotillomania) in people.  It led me to understand that animals too when in captivity have been shown to bite at their own hair or the hair of other animals around them.  Findings from the field of ethology (or the study of animal behaviour), have demonstrated that such self-directed behaviors occur when an animal is thwarted in the performance of an action by its environment or when two impluses (e.g. fight versus flight) are in opposition to each other. 

This blog aims to highlight different displacement behaviours, from common ones such as chin rubbing or lip chewing to hair pulling.  If you are interested, as I am, in what makes us human then I hope you will find it worth reading and posting comments on.

Will