Trichotillomania (Hair Pulling)

Definition

Trichotillomania, commonly referred to simply as TTM, is a condition characterized by compulsive, mild-to-severe hair pulling from anywhere on the body. It is an impulse-control disorder and one of several body-focused repetitive behaviors (BFRB) currently classified in the DSM-5 as Obsessive Compulsive and Related Disorders. TTM affects up to 2 percent of the population and only about half of those affected receive some form of treatment. 

Symptoms

Symptoms of TTM typically first appear between the ages of 10 to 13. The primary symptom is an urge to pull hair from the scalp, eyebrows, eyelashes, pubic, or other area of the body. The behavior is compulsive and results in significant hair loss that can lead to alopecia, or bald spots on the scalp. Individuals with TTM usually suffer from feelings of distress, shame, anxiety, and embarrassment about their condition, and often avoid developing close relationships and attending group activities to avoid exposure. Scarves, wigs, alternative hairstyles and makeup are often used to cover up areas of the body with noticeable hair loss.

TTM can lead to infection and cause physical damage to skin tissue, joints and muscles, especially if scissors or other sharp objects are used to help facilitate hair pulling. In rare cases, people with TTM develop medical complications from eating their pulled hairs, which can result in the development of hairballs that obstruct the intestines. Co-existing psychological problems such as eating, mood, and personality disorders are common.

Causes

There may be a genetic link to TTM, since some people appear to have an inherited tendency to pull hair as well as higher-than-average rates of mood and anxiety disorders in first-degree relatives. TTM may also be associated with perfectionism and used as a means of avoiding stressful events or releasing tension that builds up as a result of emotions such as impatience, frustration, dissatisfaction, and even boredom. TTM is not diagnosed when hair loss is due to substance abuse, a dermatological condition, or another physical or psychological problem.

Treatments

Shame and other negative feelings may prevent some people from seeking treatment specifically for TTM, and those who do not pursue treatment may have less severe symptoms and fewer negative feelings about the condition than those who do seek treatment. Research results indicate, however, that severity and duration of hair pulling is similar for those who seek treatment and those who do not. People with TTM who also experience more severe depressive symptoms may also be more inclined to seek help for depression, which in turn may lead to help with hair pulling. Cognitive behavioral therapy (CBT) with habit reversal training and progressive muscle relaxation can be effective for treating TTM. Acceptance and commitment therapy (ACT) and a self-help technique known as movement decoupling may also prove beneficial. Researchers have also found that individuals who are reluctant to seek conventional treatment may benefit from Internet-based interventions. 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.

References

The TLC Foundation for Body-Focused Repetitive Behaviors website. What Is Trichotillomania?

Grant JE, Chamberlain SR. Trichotillomania. Treatment in Psychiatry. September 1, 2016;173(9):868-874.

Weidt S, Bruehl AB, Delsignore A, et al. Trichotillomania: the impact of treatment history on the outcome of an Internet-based intervention. Neuropsychiatric Disease and Treatment. 2017;13:1153-1162.  Published online April 21, 2017.

Last reviewed 04/17/2018