Hair Pulling Disorder (Trichotillomania) · What Is It, How Is It Managed, and More

Trichotillomania (TTM), or hair pulling disorder, is a repetitive behavior involving the 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 perform repetitive self-grooming behaviors that may inadvertently 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, under obsessive-compulsive and related disorders.  

Trichotillomania most commonly presents in adolescents, generally between the ages of 10 and 13. Although trichotillomania affects individuals of all genders equally during childhood, it tends to be more prevalent among those assigned female at birth in adulthood. 

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 attempt to hide their behaviors from others to avoid embarrassment or judgement. 

Trichotillomania hair pulling can be categorized as focused (individuals intentionally pull their hair to relieve tension or distress), or automatic (individuals may pull their hair subconsciously. Those with trichotillomania can experience focused, automatic, or a mixture of both types of hair pulling, depending on their unique situation or mood. 

Individuals with trichotillomania may experience symptoms lasting anywhere from a few months to several years, and symptoms can occur in cycles or continuously. Long-term consequences of trichotillomania 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 all of which can result in significant distress.  

Trichotillomania can be diagnosed by a healthcare professional after thorough history and physical examination. According to the DSM-5, the diagnosis of trichotillomania can be made if the individual exhibits the following symptoms: recurrent pulling out of one’s hair resulting in hair loss; repeated attempts to decrease or stop hair pulling; hair pulling cannot be better explained by the symptoms of another mental disorder; and hair pulling or hair loss cannot be attributed to another medical condition (e.g., a dermatological condition). Lastly, the disturbance should be severe enough to cause significant distress or impair one’s social or work life.  

Trichotillomania is often underdiagnosed as individuals with symptoms may feel embarrassed or afraid to talk to a health professional about what they are experiencing.  

In some cases, laboratory tests (e.g. blood and urine tests), and skin biopsies may be needed to rule out other dermatologic conditions, such as alopecia areata or tinea capitis.  

Other psychiatric conditions that can co-exist with trichotillomania include obsessive-compulsive disorder, body dysmorphic disorder, anxiety disorder, and depression. Seeking medical advice from a mental health professional can be beneficial for those suffering from trichotillomania.

Treatment of trichotillomania depends on the severity of the condition. Treating trichotillomania often includes 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. Treatment of comorbid  mental health conditions  (e.g., depression, anxiety, or obsessive-compulsive disorder) may be necessary.  

HRT, a form of behavioral therapy, is the primary treatment for trichotillomania.  It teaches individuals to recognize their triggers and substitute their hair pulling behaviors with other behaviors. Part of treatment includes learning to become aware that the habit is about to occur, replacing that habit with a less harmful action, and practicing relaxation techniques to break the cycle. CBT can help individuals change the negative beliefs they may have in relation to hair pulling, while establishing goals for change. Lastly, acceptance and commitment therapy can assist individuals in learning to accept their hair pulling urges without acting on them. 

Medications may also be used to control symptoms of trichotillomania, for example N-acetylcysteine, an amino acid that influences neurotransmitters related to mood; atypical antipsychotics, such as olanzapine; or antidepressants, such as clomipramine. 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 and wear makeup or cover their bodies with clothing.