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Hair pulling disorder (trichotillomania)

What Is It, How Is It Managed, and More

Author:Ali Syed, PharmD

Editors:Alyssa Haag,Józia McGowan, DO

Illustrator:Jillian Dunbar

Copyeditor:David G. Walker


What is trichotillomania?

Trichotillomania (TTM), or hair pulling disorder, is a repetitive behavior that involves an irresistible urge to repeatedly pull out one’s own hair. Trichotillomania belongs to a group of disorders known as body-focused repetitive disorders, in which individuals compulsively damage their physical appearance. Individuals with trichotillomania may pull out hair from the scalp, eyebrows, eyelashes and other areas of the body, and over time, this can lead to bald patches and thinning hair. 

Trichotillomania is included in the diagnostic and statistical manual of mental disorders, fifth edition, or DSM-5, in the group of obsessive compulsive disorders and related to skin picking disorders, in which individuals pull, pick, scrape, or bite their hair, skin, or nails, resulting in damage to the body

Trichotillomania most commonly presents in individuals between the ages of 10 and 13. Although trichotillomania affects those assigned male at birth and those assigned female at birth equally in childhood, it typically affects individuals assigned female at birth more frequently during adulthood.

What causes trichotillomania?

The cause of trichotillomania is currently unknown and may be a result of a combination of genetic and environmental factors. Risk factors for trichotillomania may include a family history of trichotillomania and stress. Trichotillomania may also be related to other conditions, such as obsessive compulsive disorder (OCD), anxiety, and depression

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What are the signs and symptoms of trichotillomania?

Signs and symptoms of trichotillomania primarily involve having irresistible urges to pull out one’s own hair; feeling a sense of pleasure after hair is pulled; biting, chewing or eating one’s hair; and playing with pulled hair. Many individuals with trichotillomania may also pick their skin, chew their lips, or engage in nail biting. Individuals with trichotillomania often experience signs and symptoms in private in an attempt to hide the disorder from others to avoid embarrassment or judgement.

Trichotillomania hair pulling may be focused, in which individuals intentionally pull their hair to relieve tension or distress, or automatic, in which individuals may pull their hair subconsciously. Individuals may present with focused, automatic, or a mixture of both types of hair pulling, depending on their unique situation or mood.

Symptoms of trichotillomania may last for different lengths of time, ranging from a few months to several years and can occur in cycles or continuously. Long-term consequences of trichotillomania may include noticeable hair loss, thinning of one’s hair, bald patches, missing eyelashes or eyebrows, irritation at the site where hair was pulled, repeatedly trying to stop hair pulling without success, avoidance of social situations, and presence of significant distress in social situations.

Although the severity of hair pulling varies widely among individuals, many people with trichotillomania attempt to cover their hair loss with wigs and scarves. Similarly, individuals with missing eyelashes, eyebrows, or body hair may use false eyelashes, makeup, clothing, or other means.

How is trichotillomania diagnosed?

Since the exact cause of trichotillomania may be due to a combination of factors, diagnosis by a mental health professional can include a variety of techniques. Trichotillomania is often underdiagnosed, and individuals with symptoms may feel embarrassed or afraid to talk to a health professional about what they are experiencing. 

Diagnosis is generally based on an individual’s medical, social, and family history. In addition, assessment of symptoms and individual interviews are often used to classify the diagnosis according to the guidelines set forth by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).  

In some cases, physical examination, laboratory tests (e.g. blood tests and urine samples), and a skin biopsy may be conducted in order to rule out other illnesses that could result in similar symptoms to trichotillomania, such as a dermatological condition. Other psychiatric conditions exhibiting similar symptoms to trichotillomania, such as obsessive compulsive disorder and body dysmorphic disorder, must also be ruled out. In order to manage the associated conditions appropriately, seeking medical advice from a mental health professional is very important.

How is trichotillomania treated?

Treating trichotillomania usually depends on the severity of the condition and the medical history of the individual. Typically, trichotillomania treatments involve habit reversal training (HRT), cognitive behavioral therapy (CBT), acceptance and commitment therapy, and the use of medications under the supervision of a certified mental health professional. Therapies that are targeted towards improving other mental health disorders often associated with trichotillomania (e.g., depression, anxiety, or obsessive compulsive disorder) can be an important part of treatment.

HRT is a behavioral therapy and primary treatment for trichotillomania, which teaches an individual to recognize their triggers of trichotillomania, substitute their hair pulling behaviors with other behaviors, find new ways to stay motivated, and practice newly learned avoidance techniques in different situations. CBT may help individuals identify and understand any beliefs they may have in relation to hair pulling, while acceptance and commitment therapy can assist individuals in learning to accept their hair pulling urges without acting on them.

Depending on an individual’s situation and past treatments, certain medications may also be used to control symptoms of trichotillomania. Some medications that may be used in cases of trichotillomania include N-acetylcysteine, which is an amino acid that influences neurotransmitters related to mood; atypical antipsychotics, such as olanzapine; or antidepressants, such as clomipramine, to help mitigate symptoms related to trichotillomania.

What are the most important facts to know about trichotillomania?

Trichotillomania is characterized by the irresistible urge for an individual to repeatedly pull out their own hair. Trichotillomania most commonly presents in individuals between the ages of 10 and 13 and may be related to other conditions, such as obsessive compulsive disorder (OCD), anxiety, and depression. Symptoms of trichotillomania may last for different lengths of time and range in level of severity among individuals. Diagnosis of trichotillomania is typically made by a health professional following guidelines outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Treatment of trichotillomania is highly dependent on the severity of symptoms, and may involve habit reversal training, cognitive behavioral therapy (CBT), acceptance and commitment therapy, and the use of medications under the supervision of a certified mental health professional.

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Related links

Body Focused Repetitive Disorders
Obsessive-compulsive disorder
Generalized anxiety disorder
Body dysmorphic disorder

Resources for research and reference

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, D.C.: American Psychiatric Publishing. 

Franklin, M. E., Zagrabbe, K., & Benavides, K. L. (2011). Trichotillomania and its treatment: A review and recommendations. Expert Review of Neurotherapeutics, 11(8), 1165-1174.

National Organization for Rare Disorders (NORD) (2021). Trichotillomania. Rare Disease Database. Retrieved Aug 13, 2021, from: https://rarediseases.org/rare-diseases/trichotillomania/

NHS. (2021). Trichotillomania (hair pulling disorder). Retrieved Aug 14, 2021, from:  https://www.nhs.uk/mental-health/conditions/trichotillomania/

The TLC Foundation for Body-Focused Repetitive Behaviours. What is Trichotillomania (Hair Pulling Disorder)?. Retrieved Aug 14, 2021, from:  https://www.bfrb.org/learn-about-bfrbs/trichotillomania