What is Trichotillomania?

Trichotillomania, also known as hair-pulling disorder, is a mental health condition that involves recurrent, irresistible urges to pull hair from the scalp, eyebrows, eyelids, and other areas of the body. Trichotillomania is classified in the obsessive-compulsive disorder (OCD) and relates disorders in the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5).

Trichotillomania often results in complete or partial removal of hair on the body, most commonly from the scalp and face. Depending on the individual, symptoms and effects can be severe or manageable.

Symptoms and Complications

Symptoms

People with hair-pulling disorder often feel an intense urge to pull their hair out and experience growing tension until they do. After pulling their hair out, they feel relieved. They may also pull their hair out because of stress, or they may do it without giving it much thought.

Behaviors associated with hair-pulling disorder include:

• Repeatedly pulling hair out
• Irresistible urge to pull hair out
• Noticeable hair loss
• Bald patches, which tend to have an unusual shape or affect one side more than the other
• Biting, chewing, or eating pulled-out hair
• Daily life is negatively impacted as a result of pulling out hair

Studies show that those who live with trichotillomania are likely to engage in episodic or frequent trichophagia as well, which is the action of eating hair. About 5-20% of individuals with trichotillomania engage in this behavior.

Regardless of how and what they do, hair pulling is often followed by guilt and shame and will often be done in private if possible.

The hair-pulling behavior of people who have trichotillomania can be classified as focused, automatic, or mixed. These subtypes specify more clearly how aware the individual is of their hair-pulling:

• Focused: Focused hair-pulling is characterized by a compulsive quality and awareness of their actions. It is often done in response to a negative emotion or intense urge
• Automatic: When someone engages in automatic hair-pulling, they pull their hair without consciously deciding to do so. This type often occurs when the individual is doing sedentary activities like watching TV or waiting for the bus
• Mixed: Mixed hair-pulling is a mix of focused and automatic hair-pulling. The individual will sometimes be aware and sometimes unaware of their hair-pulling

Complications

Trichotillomania comes with many physical and emotional complications. They are usually a result of excessive hair-pulling.

Physical complications of hair-pulling disorder include:

• Hair loss and bald spots
• Itching
• Localized skin infection
• Chronic pain
• Blepharitis from pulling out eyelashes
• Repetitive motion injuries to muscles and joints like carpal tunnel syndrome
• Tissue damage
• Gastrointestinal distress and/or hairballs from eating pulled hair

Emotional complications include:

• Anxiety
• Depression
• Loneliness
• Substance abuse
• Guilt and shame
• Low self-esteem

Additional complications include social isolation from hiding to pull out hair and financial impact from being unable to continue with normal daily activities like work.

Causes

It's not clear what causes trichotillomania, but experts recognize a few main theories behind why some people may have hair-pulling disorder, including:

• Familial Component: Studies have shown that hair-pulling disorder runs in families
• Genetic Component: Variants of the SAPAP3 gene is linked to the development of early-onset OCD
• Brain Changes: Results of brain imaging showed people with trichotillomania have certain brain changes that correlate with the disorder.
• Emotional Regulation: Studies show increased hair-pulling behaviors associated with larger decreases in feelings of sadness, boredom, and anger

The average onset of this disorder is between 10 and 13 years old, and hair-pulling disorder has the potential to be lifelong. People who are prone to stress or who have high levels of stress in their life are at a higher risk of developing trichotillomania.

Diagnosis

Diagnosis is made by a mental health professional based on a thorough clinical evaluation, patient history, and testing to rule out other causes of hair loss.

The DSM-5 criteria for hair-pulling disorder include:

• 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 symptoms of another mental disorder or medical condition
• Hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Trichotillomania is often misdiagnosed as OCD. While the repetitive and compulsory actions of hair-pulling disorder may be similar to those in OCD, they are different.

When differentiating trichotillomania from OCD, clinicians will screen for repetitive hair pulling and any other repetitive habits, as well as a screening for OCD.

Common questions asked when screening for OCD include:

• Do you wash or clean a lot?
• Do you check things a lot?
• Is there any thought that keeps bothering you and that you would like to get rid of but you can't?
• Do your daily activities take a long time to finish?
• Are you concerned about orderliness or symmetry in general?

Additionally, clinicians will have to differentiate hair-pulling disorder from alopecia areata, a medical condition that causes hair to fall out in small patches. A few ways to distinguish one from the other is with trichoscopy, medical history, and scalp biopsy.

With an honest and open dialogue, diagnosing hair-pulling disorder is straightforward.

Treatment

While hair-pulling disorder cannot be cured, it can be managed with therapy. There are various options for treating hair-pulling disorder.

Habit Reversal Therapy

Habit Reversal Therapy, or HRT, is a form of treatment that aims at recognizing and changing the patterns that lead to hair pulling. The goal is to replace hair pulling with a healthy behavior.

A few strategies used in HRT include:

• Education
• Self-monitoring
• Relaxation and breathing techniques

Cognitive Behavioral Therapy

Another useful form of therapy to treat trich is Cognitive Behavioral Therapy (CBT). CBT goes hand in hand with HRT, but is a deeper dive into the thoughts behind an individual's hair pulling.

Some common CBT techniques include:

• Discussing factors leading to hair pulling and repercussions
• Using HRT to promote mindfulness around hair-pulling
• Identifying limiting beliefs and combating them

Group Therapy

Trichotillomania can feel isolating, and it's nice for the individual with the condition to know they're not alone. Group therapy is a great option for those struggling to overcome hair-pulling disorder.

Group therapy sessions include:

• Having an open and honest discussion
• Sharing tips and tricks
• Finding a support system

Medications

No drug has been found to treat or cure trichotillomania. Some medications, while not specifically approved for treating hair-pulling disorder, may be prescribed to help affected individuals cope with the condition.

There are different interacting neurotransmitter systems involved in the pathophysiology of disorders like trichotillomania. Drugs that are able to act on these transmitters are therefore often used to treat this condition. 

Some of the common medications used to treat trich include:

• Selective serotonin reuptake inhibitors
• Clomipramine
• Lamotrigine
• Olanzapine
• N-acetylcysteine
• Inositol
• Naltrexone

A Word From Verywell

Trichotillomania can feel embarrassing and beyond control. Move past the guilt and shame about hair pulling and having an open and honest conversation with your healthcare provider or a mental health professional. That's the first step towards getting this condition under control. Hair-pulling disorder isn't an individual's fault, and while it may take some effort, there are many different ways to treat it.