Trichotillomania (Hair-Pulling Disorder): Symptoms, Causes, & Treatments

What Is Trichotillomania?

Trichotillomania is a type of body-focused repetitive behavior (BFRB) resulting in thoughts and behaviors centered around pulling out hair. Individuals will experience a mental urge to pull out their hair, often in a specific or ritualized way.¹

Behaviors associated with trichotillomania include:

• Pulling awareness: “Automatic” pulling involves engaging in trichotillomania without conscious awareness, while “focused” means being aware throughout the process.
• Pulling reactions: Some people pull their hair for a strong sense of relief, relaxation, or gratification, while others note shame, guilt, or embarrassment during and after the process.
• Pulling locations: Pulling may be widespread, and individuals may remove hair from their scalp, eyebrows, pubic area, and underarms. Others may only pull from a specific bodily region.
• Pulling time: Some people pull for extended sessions that last hours, while others engage in brief episodes.
• Pulling technique: Those with trichotillomania may use tweezers, scissors, their hands, their teeth, or other tools to remove hairs.
• Pulling ritual: Collecting, rolling hair with hands, or pulling strands apart are common trichotillomania rituals. Some people discard or conceal their pulled hair without any ritualistic behaviors. About 20% of people will eat their hair (trichophagia).

Is Trichotillomania OCD?

Trichotillomania has similar characteristics to OCD, and compulsive hair-pulling may resemble OCD hair-pulling. However, trichotillomania and OCD are quite different. People with OCD have obsessions (uncontrollable, intrusive thoughts) that may not inherently be present in trichotillomania. Instead, the strong desire to pull hair represents more of an irresistible urge to achieve immediate gratification.²

How Common Is Trichotillomania?

Trichotillomania affects people of all ages and genders, but women are more likely than men to have the disorder.³ Symptoms may start slowly before increasing in frequency and intensity. Unfortunately, many individuals may not seek early intervention, leading to worsening symptoms and complications.³

Some studies show almost 73% of people with trichotillomania pull hair from their scalp, 56% from their eyebrows, and 51% from the pubic area. About 20% will eat their hair. Only 14% of people see their hair-pulling disorder improve without treatment.^1,3

Signs of Trichotillomania

Recognizing signs of trichotillomania can be complicated or obvious, depending on the individual and type of hair-pulling. A person could exhibit evident patterns of TTM behaviors or engage in discrete, unnoticeable behavior. Missing hair from the scalp, eyebrows, arms, legs, and neck can indicate trichotillomania.

Generally, people with the disorder do not pull in front of others. They often avoid these behaviors due to discomfort and concerns of judgment, even in the presence of close friends and family.¹

Common signs of trichotillomania include:¹

• Increase isolation to engage in hair-pulling
• Pulling hair from a specific area
• Bald spots, missing eyebrows, or patches of missing hair on their arms and legs
• Wearing hats, long sleeves, or long pants, even in the summertime
• Hiding hair loss with wigs, makeup, and scarves

Trichotillomania Symptoms

The DSM-5 notes specific trichotillomania symptoms that differentiate the disorder from other mental health conditions. Medical conditions like alopecia can lead to hair loss, and substance use disorders can involve hair pulling and skin picking. Thus, ruling out these issues is essential before professionals can diagnose trichotillomania.

Symptoms of trichotillomania include:¹

• Recurrent hair pulling that results in hair loss
• Repeated, unsuccessful attempts to stop pulling out hair
• Significant stress from hair pulling affects functioning at home, work, or school
• Experiencing pleasure or relief after pulling out hair
• Feeling tension before or when resisting pulling out hair
• Biting, chewing, or swallowing hair
• Rituals may accompany hair-pulling

Trichotillomania Causes & Risk Factors

Unfortunately, clinicians and researchers do not know what causes trichotillomania. Genetic and environmental factors most likely affect development, including poor coping skills, family history of mental illness, and stress.

People with trichotillomania may start hair-pulling to experience positive emotions but must continue to avoid feeling anxious or stressed. This pattern is also associated with substance use and addiction.

Common causes, triggers, and risk factors of trichotillomania include:^4,5,6,7,8

• Poor coping skills: When some people experience unwanted feelings like stress, anxiety, tension, boredom, anger, loneliness, or uncertainty, they may pull hair to diminish the emotional impact.
• Positive feelings associated with behavior: Hair-pulling can feel good and rewarding. Individuals feel calmer, relaxed, happy, and even more confident afterward.
• A lack of serotonin: Some research shows a relationship between compulsive behaviors like hair-pulling and the serotonin 2A receptor.
• Atypical brain structure or functioning: Emerging studies have also found an association between trichotillomania and increased right middle frontal and decreased right occipital cortex activation. Neuroimaging studies also show evidence of gray matter abnormalities.
• Hypersensitivity of touch: Compulsive pulling can be a sensory reward, and people may use this activity to stim or self-soothe when regulating emotion.
• Co-occurring mental health conditions: Trichotillomania can coexist with other mental health conditions, including anxiety and mood disorders, eating disorders, ADHD, and substance use disorders.
• Other behavioral habits: Trichotillomania may also be comorbid with unhealthy behaviors, including compulsive shopping, gambling, overeating, or self-harm.
• Chronic or toxic stress: Some people find relief or a sense of control from pulling their hair when stressed.
• Genetic factors: People with trichotillomania may be more likely to have a first-degree relative with the condition.

Complications of Trichotillomania

Consistently pulling hair can cause permanent scarring and other damages, including bacterial infections and stunted hair growth. Eating hair can result in matted hairballs within the digestive tract, which can be highly dangerous. In addition, trichotillomania can cause immense psychological impairment, which can result in relational and self-esteem problems.

Possible complications associated with trichotillomania include:

• Emotional distress: Trichotillomania can cause immense shame and anxiety, and people may struggle more with heightened emotions due to having this condition.
• Gastrointestinal issues: If someone with trichotillomania eats their hair, they may experience problems with digestion, which can coincide with serious issues like intestinal obstruction, persistent vomiting, and even death.
• Skin and hair damage: Trichotillomania may cause skin and hair scarring, and it can also affect hair growth.
• Difficulties functioning: Trichotillomania can impair daily functioning, and people with this condition may have issues with school or work.
• Relationship problems: Trichotillomania may lead to social withdrawal or relationship issues, which can make the issue worse.
• Low self-esteem: People with trichotillomania often feel embarrassed about their condition or about their hair loss.
• Social anxiety: Trichotillomania can lead to or exacerbate social anxiety issues, as people may feel panicked about others discovering their condition or negatively judging their behavior.

Trichotillomania & Co-Occurring Conditions

Trichotillomania rarely exists on its own, and it’s common for people to have this condition along with other mental health diagnoses. Compulsive behaviors often stem from other sources of emotional distress or difficulties with emotional regulation. Stress may aggravate symptoms from both conditions, and a relapse in one illness may cause a relapse in another set of symptoms.

Common comorbidities associated with trichotillomania include:

• Anxiety disorders
• Substance use disorders
• Depression
• Obsessive-compulsive disorder (OCD)
• Attention-deficit/hyperactivity disorder (ADHD)
• Autism

How Is Trichotillomania Diagnosed?

Trichotillomania is a relatively straightforward diagnosis, and a healthcare provider can diagnose it based on a simple physical exam (that observes hair loss or other apparent signs of the condition) and a biopsychosocial assessment that overviews your past and current symptoms. Many people self-diagnose this condition on their own before seeking help.

Trichotillomania Treatment Options

Seeking help with trichotillomania significantly improves the odds of symptom relief. Individuals can confront and manage trichotillomania with a combined treatment plan of therapy, medication, and lifestyle changes.

Therapy

Therapy for trichotillomania focuses on eliminating excessive hair-pulling and related behaviors. Another crucial factor is addressing and reducing symptoms of co-existing conditions. In this way, the person’s overall health and well-being will improve.

Determining how to treat trichotillomania depends on the individual and their unique circumstances. However, specific behavioral approaches can increase mindfulness, self-awareness, and insight into symptoms to help clients achieve long-lasting relief.

Therapy options for trichotillomania include:

• Habit reversal training (HRT): HRT focuses on the link between thoughts, feelings, and behaviors.³ Clients track their behaviors to gain awareness and shift away from automatic or unconscious hair-pulling. Identifying emotional and environmental triggers can help them avoid trichotillomania urges in the future.
• Acceptance and commitment therapy (ACT): ACT encourages clients to accept the strong desire to pull while actively refusing to engage in the behavior.
• Dialectical behavior therapy (DBT): DBT teaches mindfulness, interpersonal communication skills, distress tolerance, and emotional regulation to help individuals cope with trichotillomania symptoms.

Medication

Research has not established specific evidence-based trichotillomania medications, but prescribers may recommend antidepressants to help reduce symptoms. Alternatively, acetylcysteine (Mucomyst) can alter the rewarding impact of trichotillomania, reducing the urge to engage in hair-pulling.⁵

Some trial and error may be necessary when exploring which medication offers the most benefit with the fewest side effects. Practice patience and communication with your doctor or nurse.

Can Trichotillomania Be Cured?

A trichotillomania cure does not exist. However, people can overcome their trichotillomania, and remission is possible. For some people, symptoms are chronic and can vary in severity over time. Regardless, individuals can learn to manage their condition while remaining aware of potential relapse.

How to Cope With Trichotillomania

Learning to stop trichotillomania and pulling out hair may not be entirely possible. Still, healthy lifestyle changes can significantly improve the likelihood of maintaining positive symptom management. Individuals struggling with trichotillomania may benefit from finding ways to decrease stress and practicing healthier coping mechanisms.

Below are 10 tips for coping with trichotillomania:

1. Focus on Physical Health

Getting enough healthy foods, rest, and physical activity may not resolve hair-pulling but can improve overall health. Maintaining physical well-being may lower symptoms of depression and anxiety, increasing your ability to stay positive and hopeful.

2. Share Your Story With People You Trust

Too many people hide away their hair-pulling behaviors. Unfortunately, this behavior increases guilt and shame while limiting access to support. You do not need to shout your struggles from the rooftops, but letting a select few know can improve acceptance and treatment.

3. Seek Out Positive Feelings & Experiences

Hair-pulling disorder can cover unwanted feelings, so find healthy alternatives to combat trichotillomania urges. Focus on activities you love, your passions, and your loved ones to maintain positivity and decrease stress leading to symptoms.

4. Focus on Others

Those with trichotillomania often focus on their symptoms, experiences, and issues. Shifting attention to others in need can offer a respite from this mental noise. Volunteering your services or donating your time to a good cause could improve symptoms.

5. Follow Treatment Recommendations

Therapists and prescribers may make recommendations that may seem too challenging, uncomfortable, or distressing. Though recovery can be rough, sticking to your treatment plan is essential. Your care team is not trying to create undue stress–they are only trying to help.

6. Be Honest & Open With Those You Trust

Honesty and open communication will serve you well, whether with clinicians, friends, or family. Of course, the desire to be secretive is tempting, but pushing past the discomfort is necessary.

7. Limit Other Negative Coping Skills

Hair-pulling disorder represents a maladaptive coping skill. Because of this, other negative coping mechanisms may replace trichotillomania when you attempt positive change. Avoid substance use, compulsive shopping, unsafe sex, and similar behaviors–these habits rarely end well.

8. Find Relaxation Techniques That Work for You

High stress can trigger trichotillomania, so reducing daily anxieties can help limit hair-pulling urges. Relaxation techniques, such as deep breathing, progressive muscle relaxation, autogenic training, and guided imagery, are helpful and healthy ways to combat stress. Exercises like yoga offer relaxation combined with the mental health benefits of exercise.

9. Use a Fidget Toy

Fidget toys may benefit people who need something to occupy their hands. These tools can provide a simple solution for releasing anxiety and also help temporarily improve concentration. Fidget toys are inexpensive and highly accessible, and they are a great way to distract yourself if an urge arises.

10. Find Ways to Reduce Urges

Eliminating all stress is wishful thinking. But, considering how to better manage stressors is helpful. Try to implement self-care as much as possible, like getting enough sleep, eating well, exercising regularly, practicing mindfulness, and staying connected to your support system. These lifestyle choices can improve your overall well-being, potentially reducing the urge to continue hair-pulling behavior.

Final Thoughts

Trichotillomania can be frustrating and discouraging. Remember, you are not alone and nothing is “wrong” or “bad” about you. Although seeking help can be scary, support may be the best step toward taking care of your well-being. With time and willingness, you can learn to overcome your urges and significantly reduce or even stop your compulsive behavior.