Trichotillomania (Hair Pulling)
Trichotillomania is a condition characterized by a compulsive urge to pull out one’s hair. It is commonly referred to as “trich” or “hair-pulling disorder” and is sometimes shortened to “TTM.” Hair-pulling can occur anywhere on the body—though it most often affects the scalp, eyebrows, and eyelashes—and can range from mild to severe.
Trichotillomania is one of several body-focused repetitive behaviors (BFRBs) currently classified in the DSM-5 as Obsessive Compulsive and Related Disorders. The disorder is also thought to share characteristics with impulse-control disorders. Trichotillomania affects up to 2 percent of the population, though only about half of those are thought to receive some form of treatment.
The onset of trichotillomania often coincides with the onset of puberty, and symptoms typically first appear between the ages of 10 to 13. However, symptoms may also manifest in infants, younger children, older teens, or adults.
According to the DSM-5, the primary symptoms of trichotillomania include:
- an urge to pull hair from the scalp, eyebrows, eyelashes, pubic area, legs, or elsewhere on the body
- repeated attempts to stop or decrease pulling
- clinically significant distress or impairment due to the hair-pulling, which can interfere with social, academic, or occupational functioning
The behavior is compulsive and may even occur without conscious notice; it often results in significant hair loss that can lead to alopecia or bald spots. To warrant a TTM diagnosis, the hair loss must not be attributable to other medical conditions. The behavior must also not be better explained by another mental health disorder; individuals with body dysmorphic disorder, for example, may pull out their hair in order to correct a perceived “imperfection,” rather than as the result of a compulsive need to pull.
The distress associated with the disorder can be severe and debilitating and may lead someone with trich to:
- Feel acute shame, anxiety, depression, or embarrassment related to their condition
- Avoid developing close relationships
- Refrain from attending social events, getting one’s hair cut, or engaging in other activities that could result in exposure
- Practice secrecy to hide pulling behavior from others
- Use scarves, wigs, alternative hairstyles, or makeup to cover up areas of the body with noticeable hair loss
Trichotillomania can cause physical damage to skin tissue that may lead to infection, especially if tweezers, scissors, or other sharp objects are used to help facilitate hair pulling. The repetitive motions involved may also, in some cases, trigger joint injury or muscle pain.
In some cases, people engage in “rituals” after pulling, such as rolling the hair between their fingers, touching it to their lips or face, or inspecting the end to look at the root. Other people with trichotillomania eat their pulled hairs, a condition known as trichophagia. While the exact prevalence of trichophagia is not well understood, some studies estimate it occurs in 20 to 30 percent of those with trichotillomania. Trichophagia can be dangerous or even deadly, as it can result in the development of hairballs that obstruct the intestines.
In general, trichotillomania often co-occurs with other psychological problems, such as anxiety, OCD, or eating, mood, and personality disorders.
When seeking a diagnosis, most people with trichotillomania will acknowledge that they feel a compulsive need to pull out their own hair; beyond this query, clinicians may also ask about drug use and other mental health symptoms to eliminate other possible causes of hair-pulling (such as body dysmorphia or substance abuse). In some cases, clinicians will examine patterns of hair loss to determine the disorder’s severity or rule out other possible causes.
The disorder is usually chronic and lifelong, but its severity may ebb and flow with time. However, with treatment and/or effective self-help strategies, many individuals are able to successfully manage the urge to pull; many are able to go months or even years without pulling, although the urge may never fully dissipate.
The exact cause of trichotillomania is not fully understood, though experts suggest that, as with other mental health disorders, a mix of genes and environment are the likely culprits. Some people appear to have an inherited tendency to pull their hair; these individuals also have a higher-than-average number of first-degree relatives with mood and anxiety disorders. TTM may also be associated with perfectionism. It can be used as a means of avoiding stressful events or releasing the tension that builds up as a result of emotions such as impatience, frustration, dissatisfaction, and even boredom.
Individuals with trichotillomania are more likely than others to have first-degree relatives with the condition, suggesting that the disorder runs in families and has a genetic element. But experts believe that while a tendency to pull out one’s hair may be inherited to some extent, genes are not solely responsible for the development of trichotillomania.
Anxiety is a common trigger for pulling episodes; for many with trich, pulling can be soothing and may provide temporary relief from feelings of anxiety (though such relief is rarely long-lasting). Trichotillomania and diagnosable anxiety disorders also frequently co-occur. Trich is currently classified in the DSM as an obsessive-compulsive or related disorder, which is itself closely related to anxiety.
The connection between trauma and trichotillomania is not fully understood. Some small studies suggest that people with trichotillomania report a greater number of traumatic events and are more likely to be diagnosed with PTSD than the general population, but experts warn that more longitudinal research is needed to determine if the relationship is causal. Other studies suggest that experiencing trauma may increase the severity of hair-pulling, even if the former doesn’t necessarily cause the latter.
Brain imaging studies have found that people with trichotillomania show increased thickness in areas of the frontal cortex related to the development of habitual behaviors. Differences in this brain area have also been observed in individuals with OCD, suggesting a close relationship between the two conditions. Other studies have found evidence of decreased amygdala volume in people with trich, which may be related to difficulties in emotion regulation also observed in this population.
Shame and other negative feelings prevent many people from seeking treatment specifically for TTM. Because the disorder is not widely known or understood, many who struggle with it are not aware that it's a mental health condition for which they can seek treatment. While some have speculated that those who do not pursue treatment may have less severe symptoms and fewer negative feelings about the condition than those who do, research results indicate that the severity and duration of hair pulling is similar for those who seek treatment and those who do not.
Individuals with co-occurring mental health disorders may be more likely to seek treatment, evidence suggests. People with both TTM and depression, for example, may be inclined to seek help for their depressive symptoms; this may, in turn, lead to help with hair pulling.
While no treatment has been found to be universally effective, some show great promise and may deliver lasting relief. Cognitive behavioral therapy (CBT), coupled with habit reversal training (HRT), is currently thought to be the most effective approach for treating TTM. Researchers have found that individuals who are reluctant to seek conventional treatment may benefit from Internet-based interventions or support groups. While no medications are approved as a first-line treatment for TTM, some antidepressants, antipsychotic medications, and cannabinoid agonists have shown promise in limited studies.
Many people with trichotillomania mistakenly believe that the behavior is due to their own lack of willpower and that they could stop on their own if they just tried a little harder; others believe that the condition is not that serious, “all in their head,” or too embarrassing to seek help for. None of these beliefs are accurate. Anyone who feels distressed about their hair-pulling or feels that they are unable to control the behavior on their own could benefit from seeking treatment. Therapy, combined with self-help strategies and social support, can greatly reduce pulling behaviors, help manage shame, and improve quality of life.
Therapy is considered the front-line treatment for all BFRBs, including trich. Cognitive behavioral therapy—either on its own or combined with a specific type known as habit reversal training (HRT)—is often the approach of choice, as it targets the thoughts, emotions, and habit cycles that lead to pulling behaviors. Other kinds of therapy such as ACT and dialectical behavioral therapy (DBT) have also shown promise, especially when combined with HRT.
Currently, no medications are specifically approved for the treatment of trichotillomania. However, some patients have benefited from antidepressants—especially if comorbid anxiety or depression are present—or other psychiatric medications, including atypical antipsychotics. Supplementing with the amino acid N-acetylcysteine has proven effective at reducing hair-pulling behaviors in some small studies.