討 論
拔毛症屬於衝動控制疾患之一，衝動(impulse)
是一種由心理動機所產生的行為現象，若在此方面失去了協調，則成為衝動控制疾患；基本特質是無法抗拒執行對自己或他人有害活動的衝動、驅力或意圖。人類的衝動，一般來說可透過學習的過程和社會化而加以適度掌控；若是已達衝動控制疾患的臨床表現，則多已造成人際關係上的困擾或個人極大的身心痛苦。
早期兒童心理學界一直將拔毛症視為與吸吮拇指、咬指甲等不良習慣類似。拔毛症多開始於孩童與青少年階段，以女性明顯居多；典型拔毛症發生於兒童，隨患者年齡增長而症狀改善。病因可能具多重性：舉凡學業壓力、不健全之親子關係、害怕孤獨、客體失落(object
loss)及不滿足等皆是可以造成潛在焦慮與憂鬱的心理動力[4]，另外不可忽略體質生物因素或與制式行為疾患(stereotypic
movement disorder)之共病性(comorbidity)。鑑別診斷尚包括其他病理性禿髮，如黴菌感染、簇狀禿髮(alopecia
areata)、雄性禿(male-pattern baldness)、慢性盤狀紅斑性狼瘡(chronic discoid lupus
erythematosus)、扁平毛髮苔蘚(lichen planopilaris)、禿性毛囊炎(folliculitis decalvans)
以及其他精神疾患，諸如精神分裂症、強迫症、以身體病徵及症狀為主之人為疾患(factitious disorder with
predominantly physical signs and
symptoms)引發的扯髮症狀[3]。明顯的拔髮會造成外觀和皮膚生理上的傷害，最初極易被認為是皮膚科病灶而忽視心理問題；皮膚科領域中，針對此類患者亦有所謂精神皮膚醫學(psychodermatology)的非藥物治療[5]；此類患者除原發性心理困擾外，倘若處理不當，極易衍生出學習及人際關係上的困擾，成為續發性適應及心理問題。國內Chang等人則發現，此類患者通常在精神科評估介入後，一至三個月內通常可長出新髮，若病程超過六個月仍有扯髮行為者，需更進一步的精神科處理，且預後較差[6]。Keuthen等人針對拔毛症病程追蹤之結果，發現拔髮症狀如長期持續，則易明顯伴隨自尊心受損及憂鬱之情形[7]。本文個案則是因拔髮症狀持續，在遭父親強迫剃髮後，產生了受同學嘲笑以及拒絕上學(school
refusal)的情形，此為另外一種自我形象受損而造成的自尊受挫及環境適應問題。
目前咸信明顯衝動性之病生理與血清張力素路徑之失調關係密切，藥物治療之選擇類似強迫症之治療，以選擇性血清張力素抑制劑(Selective
Serotonin Reuptake Inhibitor,
SSRI)或clomipramine為首選治療藥物[8]，buspirone、單胺氧化 抑制劑(monoamine oxidase
inhibitors)，clonazepam為二線用藥，近年來亦有使用venlafaxine來治療拔毛症之文獻報告，然療效仍需進一步評估[9]。雖然藥物選擇類似治療強迫症，拔毛症在心理社會層面之治療模式比強迫症更見多元及困難，根本治療應將壓力源去除；將頭髮剃去並無法解決根本問題，可由所遇到之壓力來決定治療模式，心理評估及諮商對一般個案有其重要效果；過去研究顯示拔毛症之治療以行為治療較分析性治療為佳[10]，若以分析性療法中，深度心理治療(insight-oriented
psychotherapy)在臨床上效果顯著，因而最常被使用，例如阿德勒學派心理治療 (Adlerian
Therapy)、存在主義學派心理治療(existential therapy)，精神分析之理情療法 (psychoanalytic
rational-emotive therapy)、完型治療(gestalt therapy)、現實療法 (reality
therapy)等，但對年幼個案並非合適。Elliot 和
Fuqua的研究指出，最為拔毛症患者所樂意接受的四種治療模式中，以催眠和習慣改變(habit
reversal)的接受度最好，超過了藥物治療和處罰，此差異不受患者年齡與症狀嚴重程度而有所差別[11]。許多文獻皆強調兒童拔毛症之治療，主要在訓練父母親成為醫療者，並且這一直是兒童精神醫學界所努力之目標[12]。文中針對兒童個案，請學校配合施以簡易之認知行為治療，並由院方按週實施以包含父母訓練的家族晤談及家族治療，短期內幫助個案緩解了內在焦慮，進而改善其症狀。
參考文獻
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2. Hallopeau M: Alopecia pa Grottage: Trichomania au trichotillomania. Ann Derm Syphil 1889; 10:440.
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American Psychiatric Association: Diagnostic And Statistical Manual of
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psychiatric disorders: Patterns of familial aggregation. Psychological
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5. Fried RG: Nonpharmacologic treatments in psychoder-matology. Dermatol Clin 2002; 20:177-185.
6. Chang CH, Lee MB, Chiang YC, Lu YC: Trichotillomania: A clinical study of 36 patients. J Formos Med Assoc 1991; 90:176-180.
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Keuthen NJ, Fraim C, Deckerbach T, Dougherty DD, Baer L, Jenike MA:
Longitudinal follow-up of naturalistic treatment outcome in patients
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Hollander E: Obsessive-compulsive disorder-related disorders: The role
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：壹例報告。中華精神醫學 1991; 5:167-172。
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Elliot AJ, Fuqua WR: Acceptability of treatment for tri-chotillomania.
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A Successful Experience Treating Trichotillomania --- A Case Report
Guang-Chyi Liu, Hsin-I Li1,Cheng-Jung Yao2, Pan-Ming Chen
Department
of Psychiatry, Military Hualien General Hospital, Hualien, Taiwan;
Department of Educational Psychology and Counseling1, National Taiwan
Normal University, Taipei, Taiwan; Department of Adult Psychiatry2,
Taoyuan Psychiatric Center, Department of Health, Taoyuan, Taiwan
ABSTRACT
Trichotillomania,
also named hair pulling, trichologia or trichomania, is an impulse
control disorder that occurs mostly in children and adolescents. More
than a quarter of young patients with this disorder have been found to
suffer from significant psychological stress such as an instable
parent-child relationship, a fear of emptiness or a recent loss. In this
article we try to analyze the relationship between the hair-pulling
impulse and inner anxiety. The client, a 9-year-old native girl, is in
the 3rd grade of primary school and was brought to our hospital by a
school nurse and a counselor because she had been pulling her hair for 2
months. An examination by a dermatologist found no skin lesion, so
together with a complete psychological assessment, we performed
cognitive-behavioral therapy, family counseling, family therapy and
supportive psychotherapy with the aim of alleviating the hair pulling.
No drugs were prescribed during the course of treatment.
Trichotillomania is an impulse control disorder, with its main
behavioral symptoms being hair pulling. Many victims have been under
psychological stress before the behavior occurs and the approach to
treatment should be one of understanding rather than getting rid of the
behavior. Thus, the treatment modality should depend on the nature of
the stress. This article describes how a psychosocial approach can play a
role by integrating versatile psychological assessment, counseling,
family therapy and supportive psychotherapy in the treatment of such a
patient successfully without using any medication. We suggest that it is
important to emphasize psychosocial intervention in the treatment of
this kind of patient rather than medication. (Tzu Chi Med J 2003;
15:135-139)
Key words: trichotillomania, impulse control disorder, school refusal, psychotherapy
Received: January 3, 2002, Revised: January 16, 2002, Accepted: October 11, 2002
Address
reprint requests and correspondence to: Dr. Guang-Chyi Liu, Department
of Psychiatry, Military Hualien General Hospital, 163, Chyali Road,
Chyali Village, Hsin Chern, Hualien, Taiwan