Trichotillomania (TTM), also called hair pulling disorder, is a mental disorder that involves a person removing hair from their body in a persistent and problematic way. Hair pulling disorder affects children and adults with the power to trigger high levels of distress and anxiety. Professional treatment, including therapy and medication, can address hair pulling and increase a person’s well-being.
What Is Trichotillomania?
Trichotillomania is a mental health diagnosis and type of body-focused repetitive behavior (BFRB) resulting in thoughts and behaviors centered around the individual pulling out their hair. Cognitively, the person will experience a mental urge to pull out their hair, and behaviorally, they will follow through on the craving by physically pulling out their hair, often in a specific or ritualized way.1
The American Psychiatric Association (APA) classifies trichotillomania, or TTM, as an obsessive-compulsive-related disorder. These conditions share commonalities of intense and intrusive thoughts paired with compulsive or unhealthy behaviors that are performed in an effort to make the unwanted thoughts fade.
In this way, TTM shares similarities with disorders including:1
- Obsessive-compulsive disorder (OCD)
- Body dysmorphic disorder (BDD)
- Hoarding disorder
- Excoriation (skin-picking disorder)
TTM affects people of all ages. Women are more likely than men to have this disorder, with the typical age of onset being between 10 and 13 years old.2 Symptoms may start slowly and build in frequency and intensity with time. A person who begins pulling at age 10 may not seek treatment until their late teens or early 20s as symptoms worsen.
TTM is a chronic disorder with an average duration of about 22 years. Sadly, less than half of those with the condition (about 40%) seek treatment from a therapist and even fewer (27%) seek psychiatric care.2
People with TTM may have very different experiences before, during, and after their hair pulling. TTM can differ in regards to:1,2
- Pulling awareness: “Automatic” pulling involves a person engaging in the TTM without any conscious awareness that the behavior is occurring, while “focused” pulling involves the person being very aware of the process.
- Pulling reactions: Some people will pull to provide a strong sense of relief, relaxation, or gratification, while others will note feelings of shame, guilt, or embarrassment during and after the process.
- Pulling locations: Pulling may be widespread for some as they remove hair from their scalp, eyebrows, pubic area, and underarms, and others may only pull from a specific area.
- Pulling time: Some people will pull for extended sessions that last for hours and remove many hairs. Others may only participate in very short sessions resulting in minimal loss.
- Pulling technique: Tweezers, scissors, and other tools are frequently used to remove hairs for some people with TTM, others will only use their hands, and another group will pull hair with their teeth.
- Pulling ritual: Collecting, rolling hair with hands, or pulling the strands aparts are all common rituals. Some people elect to discard or conceal their pulled hairs without any ritualistic behaviors. About 20% of people with TTM will eat their hair, which is called trichophagia.
Signs of Trichotillomania
Noting the signs of TTM in a person may be very complicated or quite obvious depending on the individual and their style of pulling. A person could have very evident patterns of TTM behaviors, or they could engage in the behavior in a way that makes detection challenging.
In the situations where the missing hair is observable, the hair will likely be missing from a person’s:2
- Scalp—almost 73% of people with TTM pull here
- Eyebrows—about 56% target this area
- Arms and legs
- Neck and throat area
People with TTM usually do not pull in front of people. Even in the presence of close friends and family, these behaviors are avoided due to feelings of discomfort and concerns of judgment.1 These people may opt for extended periods of isolation and look for reasons to avoid others, so they can continue their pulling behavior. These trends often make the signs of trichotillomania unclear.
Some people with TTM will pull out every hair from an area, resulting in persistent hair loss. These people may present with bald spots, missing eyebrows, or patches of missing hair on their arms and legs. They may also take extraordinary measures to conceal their hair loss by wearing hats, long sleeves, or long pants, even in the summertime. They could also use wigs, makeup, and scarves to hide their hair loss.1
When the direct signs of TTM are concealed, a person may see the side effects of trichotillomania present in other ways. A person with TTM could:1
- Endure injuries to their fingers and hands from excessive pulling
- Damage their teeth due to hair biting
- Have inflamed or damaged skin at the picking site
- Experience trichobezoars (hairballs) when the hair is eaten
Trichobezoars, or hairballs caused by trichotillomania, create a number of unwanted and uncomfortable effects. Someone with hairballs linked to TTM could:1
- Become anemic
- Feel stomach pain
- Experience nausea and vomiting
- Endure various intestinal issues
Anytime a person is showing hair loss, secretive behaviors, isolation, or complaining of these gastrointestinal symptoms, trichotillomania could be to blame.
Symptoms of Trichotillomania
As an officially recognized mental health disorder, trichotillomania has several symptoms that must be present. Reviewing these symptoms helps experts and others differentiate between TTM and typical behaviors, as well as between TTM and another mental health condition.
Unlike other psychological disorders that have many symptoms, there are three main symptoms of trichotillomania, including:1
- Recurrent hair pulling that results in hair loss
- Repeated, unsuccessful attempts to stop pulling out hair
- Feeling high levels of stress from the hair pulling that begins to affect the person’s functioning at home, work, or school
To have the condition, the symptoms of trichotillomania cannot stem from another mental disorder or from a medical issue. Medical conditions like alopecia can lead to hair loss, and substance use disorders can involve hair pulling and skin picking, so ruling out these issues is essential.
One issue clouding the symptom presentation is comorbidity. Since TTM frequently occurs simultaneously with depression, skin-picking, or anxiety disorders, the symptoms of these conditions could overshadow or disguise the hair pulling.1 Professionals must fully assess symptoms to arrive at the most accurate diagnosis in order to guide treatment.
Causes & Triggers of Trichotillomania
Unfortunately, clinicians and researchers do not know the precise causes of trichotillomania yet. Like other mental health disorders, a combined effect of genetic and environmental factors most likely create the condition.
Common causes, triggers, and risk factors of trichotillomania include:3,4
- Poor coping skills: TTM could emerge as a coping skill, albeit negative, for periods of increased stress and anxiety
- A lack of serotonin: Experts think that having too little of this neurotransmitter could trigger TTM
- Atypical brain structure or functioning: Brain scans show differences of certain brain regions and the way they metabolize glucose
- Hypersensitivity of touch: People who are especially sensitive to touch and textures may pull hair that feels odd
- The presence of other comorbid OCD-related mental health conditions: These could be in the individual or their close family members
- Other behavioral habits: For example, thumbsucking as a younger child
Rather than thinking about TTM as the result of just one cause, consider the notion that the condition likely emerges due to the combined effect of many triggers and risk factors.
Emotional States Related to Trichotillomania
Trichotillomania is linked to feelings at two ends of the spectrum for people with the condition.
People may associate TTM with both negative and positive emotions:3
- Negative emotions: When some people experience unwanted feelings like stress, anxiety, tension, boredom, anger, loneliness, or uncertainty, they may pull hair to diminish the emotional impact. In this way, TTM is a way to lessen these undesirable feelings and feel “normal.”
- Positive emotions: For other people, hair pulling is a behavior that feels good and rewarding. They feel calmer, relaxed, happy, and even more confident when pulling. In this way, TTM is a way to move from feeling “normal” to feeling good.
It’s valuable to note that TTM can begin in one way before shifting to another. People could start the behavior as a way to feel well (positive emotions), but over time, they must continue the pulling to avoid feeling bad (negative emotions). This pattern is common with substance use and addiction.
Treatment of Trichotillomania
When a person acknowledges their hair pulling as more than just a “bad habit” and decides to seek out treatment, they greatly improve their odds of symptom relief. With a combined treatment plan of therapy, medication, and lifestyle changes, a person can confront and manage the signs and symptoms of trichotillomania.
TTM is a complex condition and treatment may not result in the kind of immediate results people desire. People who take action to quickly identify and resolve their TTM see treatment success rates of only 50%.2
This number may appear disappointing, but response rates are much lower for people who avoid treatment. People who do not choose professional treatments experience recovery rates of only 14%, which means treatment improves outcomes by three and a half times.2
Because TTM is a specific disorder that shares few similarities with other mental health conditions, it needs specialized care from a trained and experienced therapist. Therapists, including psychologists, social workers, and counselors, can provide services in the home, school, community, or office setting to address and eliminate TTM symptoms.
Shifting the behaviors linked to TTM will be a demanding process in many situations. Clients must practice diligence and consistency to find the relief they seek.
Three forms of psychotherapy are used most commonly with trichotillomania—habit reversal therapy (HRT), acceptance and commitment therapy (ACT), and dialectical behavioral therapy (DBT). Although these treatments all offer benefit, HRT is the most studied and most successful therapy for TTM.
Habit Reversal Therapy
HRT uses a basis of behavioral and cognitive behavioral therapy (CBT) to decrease trichotillomania symptoms, which focuses on the link between a person’s thoughts, feelings, and behaviors.
The four components of successful HRT include:2
- Self-monitoring: Asking the person to track their pulling behaviors to find a baseline of time and intensity
- Awareness training: Gaining awareness of their pulling habits to shift away from automatic or unconscious pulling
- Competing response training: Finding activities or behaviors that make pulling impossible, like wearing mittens or otherwise occupying their hands
- Stimulus control procedures: Identifying emotional and environmental triggers that tend to result in pulling to adjust or avoid in the future
Acceptance & Commitment Therapy
ACT works by balancing a level of acceptance and mindfulness to acknowledge how things are, while bringing attention to ways to create change. By accepting the strong desire to pull and committing to behavioral change, symptoms could dissipate.5
Dialectical Behavioral Therapy
DBT combines fundamental CBT values with aspects of Eastern meditation. DBT strives to teach:5
- Mindfulness and relaxation
- Interpersonal communication skills
- Distress tolerance
- Emotional regulation
Therapy for trichotillomania will be less available than treatments for more common conditions, like depression, so people should always work to find a competent professional.
Intended Treatment Outcome & Timeline
The intended outcome of therapy for trichotillomania will be to eliminate the excessive hair pulling and related behaviors. Another important outcome, though, will be to address and reduce symptoms of any depressive, anxious, or OCD disorders that exist alongside the TTM. In this way, the person’s overall health and well-being will improve.
The prospective timeline ranges widely, with some people finding desired results after only four hour-long HRT sessions and others needing 22.2 Since gains can last an average of three to six months following treatment, people may need some level of ongoing therapy to maintain results.
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Currently, there are no medication options specifically approved for the treatment of TTM, but since there seems to be some connection between the condition and serotonin levels, prescribers may offer antidepressants. Psychiatrists, nurse practitioners, and primary care physicians (PCPs) may also recommend other medications to help in the recovery process.
One medication that prescribers frequently recommend for trichotillomania is called acetylcysteine (Mucomyst), an antioxidant that interacts with the brain chemical glutamate. This medication helps to alter the rewarding impact of TTM.4
Two types of antidepressants, selective serotonin reuptake inhibitors (SSRIs) and tricyclics (TCAs), are recommended for TTM. Examples of SSRIs for TTM include:4
- Fluoxetine (Prozac)
- Sertraline (Zoloft)
- Fluvoxamine (Luvox CR)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
Tricyclic antidepressants are older medications with a higher chance of side effects, which makes them less desirable for younger people with TTM. Some examples of TCAs include:4
- Clomipramine (Anafranil)
- Imipramine (Tofranil)
- Nortriptyline (Pamelor)
- Desipramine (Norpramin)
When prescribing medication, professionals must exercise some level of trial and error to discover the medication that offers the most benefit with the fewest side effects, so people should practice patience and communication with their doctor or nurse.
Given the opportunity, TTM can significantly impact a person’s lifestyle and well-being in negative ways. To avoid this influence, the individual should engage in healthy lifestyle changes to ward off symptoms, including:6
Focus on Physical Health
Eating healthier foods, getting enough rest, and setting aside time for exercise and physical activity may not completely resolve symptoms of hair pulling, but it will improve a person’s overall health. People tend to have lower symptoms of depression and anxiety when their physical health is functioning well, so this change could limit underlying conditions.
Share Your Story With People You Trust
Too many people work to hide away their hair pulling behaviors, which only adds guilt and shame while limiting the assistance of their support structures. A person does not need to shout their TTM from the rooftops, but letting a select few know can improve acceptance and treatment.
Seek Out Positive Feelings & Experiences
TTM can cover up unwanted feelings or produce wanted feelings, so a person will need to find plenty of substitutes if they want the pulling to diminish. Find activities you love, causes you’re passionate about, and people you want to take on these adventures.
Focus on Others
Mental health disorders like TTM tend to have the person focus on their symptoms, their experience, and their issues. Making the decision to shift the focus onto others in need can be a healthy choice, when done in moderation. Volunteering your services or donating your time to a good cause could improve symptoms.
How to Get Help for Trichotillomania
To actively seek out treatment, a person with TTM should consider doing some research online for providers who have experience and intimate knowledge of the condition. Even if it means a farther drive, having a treatment professional versed in trichotillomania treatment will result in better outcomes.
For a referral, consider:
- Speaking with your PCP
- Contacting local mental health agencies
- Asking about options at school
- Calling the mental health hotline for your insurance
Before they can get help for trichotillomania, a person must take the step to acknowledge the presence of their condition and make the choice to no longer hide their status. This way, when a trusted support or health professional asks about your hair loss, you will not let shame stop you from being honest.
How to Get Help for a Loved One
Helping a loved one centers around the idea of acknowledgement and acceptance of the condition. Let your loved one know what you have been seeing related to their hair pulling and your concerns. Offer to be involved as much or as little as they would like and suggest some available treatment options to get the process started.
4 Ways to Cope With Trichotillomania Symptoms
Professional treatment is invaluable to help resolve symptoms of trichotillomania, but negative or inconsistent coping skills can undo even the best services.
Some ways to cope with trichotillomania include:
1. Follow Treatment Recommendations, Even When They’re Difficult
Therapists and prescribers are going to make recommendations that may seem too difficult, too uncomfortable, or too distressing. Though the path is challenging, sticking to the treatment plan is essential for symptoms to improve. The professionals are not trying to create undue stress. They are only trying to help.
2. Be Honest & Open With Those You Trust
Whether it is with your clinicians, your friends, or your family, honesty and open communication will serve you well. Of course, the desire to be secretive and closed off is tempting, but pushing past the discomfort is necessary.
3. Limit Other Negative Coping Skills
Hair-pulling disorder represents a negative coping skill, so when you take steps to reduce it, other negative coping skills may rise to replace it. Substance use, compulsive shopping, unsafe sex, and other negative coping skills always seem appealing, but they rarely end well.
4. Find Relaxation Techniques that Work for You
TTM may be a response to high stress, so working to reduce daily stress and anxiety can help limit the effects of trichotillomania. Relaxation techniques are a terrific option to complete this. Options include deep breathing, progressive muscle relaxation, autogenic training, and guided imagery. Exercises like yoga offer relaxation and physical activity together.
Experts have been working for decades to better understand trichotillomania. Along the way, they have gathered useful statistics, like:1,2
- Women are more likely than men to have this disorder, with the typical age of onset being between 10 and 13 years old
- Almost 73% of people with TTM pull hair from their scalp, 56% from their eyebrows, and 51% from the pubic area
- About 20% of people with TTM will eat their hair
- 40% of people with TTM seek therapy and 27% seek medication
- Of people with trichotillomania, 83% report anxiety and 70% report depression due to pulling
- Only 14% of people see their hair-pulling disorder improve without treatment
For Further Reading
Despite the tremendous work done by pioneers of the past, much is left to be done by experts in the field of trichotillomania. Some of the leading groups on the topic include: