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Compulsive Hair Pulling (Trichotillomania)
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What is trichotillomania and how is it treated? 1:41
Trichotillomania, or TTM, is a mental health condition classified as a body-focused repetitive behavior (BFRB). It involves compulsively pulling out or breaking hair from the scalp, eyebrows, eyelashes, or other areas. Unlike OCD, TTM does not involve obsessions, and individuals often feel relief or positive emotions after hair pulling.
Symptoms include repeated hair pulling that causes noticeable hair loss, biting, chewing, or eating pulled hair, and repeated attempts to stop or reduce the behavior. The behavior often negatively affects daily life and must be distinguished from other medical conditions. TTM often appears in early adolescence, around 10 to 13 years old.
The causes of TTM are not fully understood but include genetic predisposition, differences in brain structure or chemistry affecting dopamine and serotonin regulation, and using hair pulling as a coping mechanism for stress or strong emotions.
Diagnosis is clinical. A healthcare provider reviews health history, current behaviors, and any underlying medical conditions. In some cases, a small skin sample may be analyzed, and additional tests like a CT scan or blood work are used if there are concerns about ingested hair causing blockages.
Genetic and hereditary factors can increase risk. Research shows that individuals with close relatives who have OCD or other BFRBs are more likely to develop TTM.
No. TTM is a chronic condition. Symptoms may fluctuate and go through periods of remission, but treatment is usually needed for consistent management. Hormonal changes, particularly in women, can temporarily worsen symptoms.
Effective treatments include habit reversal training (HRT) with treatment such as cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) to manage urges. Certain medications may be beneficial for some individuals, especially in combination with therapy.
Symptoms can increase during stress, anxiety, or boredom. Low levels of physical activity may also contribute. Co-occurring conditions such as anxiety, depression, OCD, or ADHD can intensify hair pulling behaviors.
TTM can cause emotional distress, shame, low self-esteem, and social withdrawal. It may create tension in family or peer relationships and interfere with school, work, or social activities. Ingesting hair can lead to digestive complications such as hairballs that may block the intestines.
Support includes listening without judgment, helping identify triggers and develop replacement behaviors, and encouraging professional treatment. Understanding and empathy are key to fostering recovery.
Understanding Trichotillomania
Trichotillomania is considered an impulse control disorder.
It involves the irresistible urge to pull out one’s hair from any area of the body including the scalp, eyebrows, eyelashes, and pubic area resulting in noticeable hair loss. If untreated, it is a chronic, though often intermittent condition. Pulling hair can result in visible bald patches, which can lead to significant distress and feelings of shame about the inability to stop this behavior. Urges increase at times of stress with individuals unaware that they are engaging in the hair pulling behavior.
Symptoms often start around puberty and occur more often in females. The disorder affects 4 in 100 people with an estimated 3-5 % lifetime prevalence. Some studies suggest that genetics play a role in the development of the disorder. Alternative theories propose that a stressful event such as abuse, family conflict, school difficulties, or death may trigger symptoms. People with trichotillomania may also have other disorders such as depression, OCD, or other anxiety disorders.
Trichotillomania Experience
People with trichotillomania describe experiencing an increase in tension prior to pulling hair or when trying to resist the urge to pull.
For many people with the disorder, hair pulling is a way of dealing with negative or uncomfortable feelings, such as stress, anxiety, or tension, loneliness, or frustration. It can also occur in relatively emotionally uneventful times such as when one is bored or relaxed (e.g. reading a book or watching a movie).
Some may intentionally make time to pull hair with a certain goal in mind, such as pulling out all gray hairs or hairs of a certain texture. Some people may develop rituals for pulling hair, such as playing with it in some way, biting pulled hair, rolling it between their fingers or lips, or swallowing the hair. Hair pulling may also be done without intent to pull the hair out but only for the satisfaction of feeling the texture of the hair. When the hair is pulled, people describe experiencing immediate feelings of gratification and relief. As a result, sufferers continue to pull their hair to maintain these positive feelings.
People with trichotillomania experience significant distress and shame. Distress may include feeling a loss of control, embarrassment, or shame and impairment may occur due to avoidance of work, school, or other public situations. Some people with trichotillomania also pick their skin, bite their nails, or chew their lips.
Impact of Trichotillomania
Adolescence is an especially important time for development of identity, body image, self-esteem, relationships with others, and comfort with sexuality.
Due to noticeable hair loss, sufferers may endure negative comments from others resulting in feelings of negative self-worth and shame about their lack of impulse control.
People with trichotillomania fear their disorder will be discovered and may go to great lengths to hide the disorder from others. They may pull their hair in private, wear wigs and style their hair to disguise bald patches or wear false eyelashes.
The avoidance can be socially debilitating. Trichotillomania sufferers may avoid intimacy, social activities, or even job opportunities due to embarrassment and fear of discovery and judgement. Some may experience depression, low self-esteem, or abuse substances due to hair pulling distress.
Prevalence of trichotillomania
Trichotillomania typically impacts 1-4% of the population. Onset typically occurs in early adolescence. Prevalence of trichotillomania is equal between genders. When tension release is excluded, females are two times more likely to be impacted than males.
Effective Trichotillomania Treatment
The two methods of treatment that have been found to be most effective are cognitive behavioral therapy (CBT) and medication, which are generally used in combination, but therapy is essential as the symptoms return when medication is stopped.
Cognitive behavioral therapy (CBT) is focused on understanding the function and patterns of the pulling behavior, awareness and tracking of hair pulling, learning new ways to regulate emotion, developing new physical habits, practicing physical relaxation techniques, and using environmental interventions such as removing tweezers, or utilizing habit reversal training (HRT) technology (e.g. awareness bracelets) that alert the user to pulling movements, and other techniques aimed at reversing the “habit” of pulling.
Resources
Behavior therapy for pediatric trichotillomania: Exploring the effects of age on treatment outcome
Child and Adolescent Psychiatry and Mental Health
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Duke, C. D., Keeley, L. M., Geffken, R. G., Storch, A. E. (2010) Trichotillomania: A current review. Clinical Psychology Review, 30(2), 181-193.
Mental Health America;
http://www.mentalhealthamerica.net/conditions/trichotillomania-hair-pulling
Recent Advances in the Understanding and Treatment of Trichotillomania
J Cogn Psychother
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Stay Out of My Hair
Suzanne Mouton-Odum, Goldum Publishing. (2009).
Find it on Amazon
StopPulling.com;
http://ww2.stoppulling.com
The TLC Foundation for Body-Focused Repetitive Behaviors;
www.bfrb.org
Trichotillomania and Co-occurring anxiety
Comprehensive Psychiatry
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Trichotillomania & Hair Pulling: It’s More than Just Stress!
Ali M. Mattu, Ph.D.
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