Trichotillomania

Key Takeaways

• Trichotillomania, or hair-pulling disorder, involves persistent urges to pull out one's own hair, often leading to noticeable hair loss. It is most common on the scalp, eyebrows, and eyelashes, but can affect other areas of the body.

• The behavior may occur either intentionally or without awareness, with triggers ranging from stress and anxiety to specific environmental cues. People with this disorder may engage in rituals, such as selecting specific types of hair or examining it after pulling it out.

• Treatment typically involves a multidisciplinary approach, with a subtype of cognitive behavioral therapy known as habit reversal training (HRT) being the most effective modality. While there are no officially approved medications for the disorder, emerging research surrounding existing pharmaceuticals shows promise, and healthcare providers may prescribe them.

What is Trichotillomania?

The phrase "tearing my hair out" is a familiar statement, typically used to express intense frustration or distress. In fact, references to hair pulling as a response to emotional turmoil date back as far as the 19th century. However, when it comes to trichotillomania, this behaviour extends far beyond a momentary expression of stress. ^{[1] [2]}

Trichotillomania is a hair-pulling disorder, where an individual repeatedly pulls out their hair, most commonly from the scalp, eyebrows, eyelashes, as well as other areas of the body. The disorder can range from mild to severe, with some cases involving multiple areas of the body. Hair-pulling is frequently described as soothing by people with the condition. ^{[1] [3]}

Trichotillomania may involve ritualistic behaviors, such as selecting specific hairs (like coarse ones at the hairline) after running the fingers through the hair. After hair pulling, some individuals examine the hair, and 10 - 20% eat all or part of it (which is known as trichophagia). When this occurs, there's a risk of developing a hairball in the digestive tract. ^{[1] [4]}

Episodes of hair pulling may last anywhere from a few minutes to a number of hours and can occur in two ways - automatically (without the individual’s awareness) or in a focused manner (when the individual is fully engaged in the act). Typically, hair is pulled out with the hands, but some individuals use tweezers or other tools. ^{[1] [4]}

That being said, one of the symptoms of trichotillomania is the inability to stop pulling out hair despite having a desire to. Many people struggling with the condition report being entirely unaware of the urge or act of pulling hair, with some individuals even pulling hair in their sleep. Triggers can be sensory, emotional, or cognitive, and vary from person to person. ^{[3] [4]}

People with hair-pulling disorders often report high levels of distress and experience mild to moderate impacts on their quality of life in social, work, school, and mental health areas. Despite this, most people do not seek treatment, and may hide or deny their struggles due to societal stigmas surrounding the condition. ^[3]

How Common Is It?

Hair-pulling disorder is part of a group of conditions known as body-focused repetitive behaviours (BFRBs), which also include compulsive skin-picking and chronic nail-biting. In the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5), these disorders are currently classified as a subtype of obsessive-compulsive disorders. ^[4]

Despite being fairly common, the prevalence of BFRBs (including trichotillomania) remains widely overlooked and under-researched. Due to the stigma and shame surrounding these disorders, people with trichotillomania may not report their condition, meaning the actual prevalence could be much higher than estimates suggest. ^{[1][3] [4]}

Additionally, large population surveys do not typically enquire about disordered hair pulling, with the most reliable data coming from smaller studies. Estimates from these show a prevalence of about 0.5% to 3.5% of the population. However, a larger study of 10,000 people suggested a prevalence rate of 1.7%, which could mean up to 1.1 million people in the UK are affected.^{[3] [4]}

It is important to note that while research surrounding individuals who seek treatment typically shows a higher ratio of women to men (about 4:1), community surveys suggest that hair-pulling disorders affect men and women equally. Trichotillomania appears to be equally common across different cultures, socioeconomic statuses, and education levels. ^[3][4]

Signs and Symptoms

Trichotillomania can present in a variety of ways that may differ from person to person. While some individuals are fully aware of the behavior, others may engage in it automatically, without conscious intent. Below are common signs and symptoms that may indicate the presence of this condition:

• The individual repeatedly pulls out hair, either intentionally or automatically, most often from the scalp, eyebrows, or eyelashes, though other areas of the body can be involved.

• The area from which hair is pulled may change over time.

• A rising sense of tension may be felt before pulling out hair or when attempting to resist the urge.

• Pulling is often followed by a feeling of relief or satisfaction.

• Noticeable hair loss occurs, such as thinning, bald patches, or missing eyebrows or eyelashes.

• Some people follow specific rituals, such as selecting certain types of hair or pulling in a particular pattern or sequence.

• Behaviors may include chewing, biting, or eating the pulled-out hair.

• Some individuals may play with their hair after it has been pulled out, or rub it against their face or lips.

• Despite efforts to stop or reduce hair pulling, the person is often unable to do so.

• The condition can cause significant distress or interfere with daily functioning, including social, academic, or occupational areas.

What Causes Trichotillomania?

The exact cause of trichotillomania remains unknown. However, many individuals report that the onset of the condition coincided with a socially or emotionally distressing life event and describe the act of hair pulling as a source of comfort or relief. The triggers for hair pulling can vary from individual to individual and may include: ^{[1] [3] [5]}

Negative Emotions

The sharp pain from pulling out hair can actually cause the brain to release dopamine (a happiness chemical), which can help the individual to cope with negative emotions. Therefore, hair pulling often provides a sense of relief in the face of negative emotions such as anxiety, boredom, loneliness, tiredness, frustration, or stress. ^[1]

Positive Reinforcement

In light of the temporary relief or satisfaction caused by the effect of hair pulling on the brain’s reward system, the behavior is often reinforced, and a neural pathway is created that encourages its continuation over time. ^[1]

Environmental Cues

In some cases, environmental cues can trigger hair pulling. These include:

• Resting the head on a hand

• Brushing or touching hair

• Periods of stress, boredom, or downtime

• Lying in bed or preparing to sleep

• Watching TV or using a phone/computer

• Reading or studying

• Looking in a mirror

• Feeling certain hair textures

• Wearing or removing hats, headbands, or helmets

• Showering or drying off with a towel

• Being alone or in private spaces

• Sitting in class or meetings

• Riding in a car or on public transport

• Touching areas where hair has been previously pulled

Risk Factors

While the exact cause of trichotillomania is not known, there are a number of risk factors linked to its onset. These include genetics, abnormal brain structures, hormones, and co-occurring psychiatric disorders. ^{[1] [6]}

Genetics

Research has revealed that trichotillomania often runs in families, suggesting that there is a genetic component to the disorder. It has been shown that close relatives of people with the condition are more likely to also have it, which points toward a heritability factor. ^[1]

Brain Differences

Brain scans show that people with trichotillomania tend to have differences in certain areas of the brain compared to those without the disorder. For example, scientists have found shape differences in parts like the amygdala and putamen, which are linked to emotional regulation, habits, and self-restraint. ^[1]

Hormones

Since trichotillomania usually starts around puberty, hormones may play a role. In adolescent girls, lower levels of progesterone (a hormone involved in the menstrual cycle) were linked to more severe symptoms. More than half of adult women also report worse symptoms just before their period. ^[1]

Co-occurring Psychiatric Disorders

Many people with hair-pulling disorder also have other mental health conditions, or co-occurring disorders. In fact, only about 1 in 5 people have trichotillomania without another diagnosis. The most commonly co-occurring psychiatric conditions are: ^[6]

• Anxiety disorders

• Depression

• Obsessive-compulsive disorder (OCD)

• ADHD

• Post-traumatic stress disorder (PTSD)

• Panic disorder

• Bipolar disorder

• Alcohol or drug abuse

• Eating disorders

• Skin-picking disorder (another BFRB)

Complications

When trichotillomania is left untreated, there is a risk of the condition worsening or leading to complications such as:

• Hair loss and skin damage: Repeated hair pulling can lead to infections and scarring in the affected areas if the behavior is continued over time, potentially resulting in permanent hair loss. In some cases, individuals may develop a pattern of hair loss where hair is missing from the crown while remaining intact at the sides and back. ^[4]

• Hairballs (trichobezoars): Eating pulled hair can lead to the formation of hairballs in the digestive tract. Over time, these hairballs can cause serious health issues, including weight loss, vomiting, constipation, and even bowel obstruction or perforation, which may require surgery. ^{[1] [4]}

• Emotional distress: Due to societal stigmas, people with trichotillomania tend to struggle with feelings of frustration, shame, and embarrassment due to their inability to stop pulling out hair, and subsequent hair loss. The condition can worsen low self-esteem, depression, anxiety, and, in some cases, issues with alcohol or drug use.

• Impaired functionality: Hair loss and the uncontrollable urge to pull out hair may cause individuals to withdraw from social activities, as well as avoid educational or career opportunities. In some cases, the person may also avoid close relationships or intimacy in an effort to hide their condition. ^[1]

• Co-occurring psychiatric conditions: Trichotillomania typically begins during childhood or adolescence and often appears before the development of other mental health conditions. Consequently, if the disorder is not treated, it may lead to the emergence of other mental health conditions. ^[7]

Diagnosing Trichotillomania

While trichotillomania is categorized under the “obsessive-compulsive and related disorders” section in the DSM-5, it differs from OCD in several important ways (including how it affects the brain) and is treated with different medications and therapies. With this in mind, it is essential to obtain an accurate diagnosis, although co-occurring conditions can complicate this. ^{[1] [3]}

Trichotillomania can usually be diagnosed through a medical history and physical exam, although in some cases, a scalp biopsy might be done to rule out other causes, although this is not generally required. Instead, the amount of visible hair loss helps healthcare providers determine how severe the condition is. ^[4]

That said, in the early stages of the disorder, mental health providers may not notice hair loss. Additionally, it is important to evaluate the behavioral components of trichotillomania such as guilt, low self-esteem, or a sense of relief after pulling. While these emotional responses are not necessary for making a diagnosis, they can help inform and tailor the treatment approach. ^[4]

According to the DSM-5, trichotillomania can be diagnosed if: ^[4]

• The individual repeatedly pulls out hair, which may lead to noticeable hair loss in specific areas or spread across the body.

• Despite efforts to stop, the individual is unable to reduce or control the hair-pulling behavior.

• The behavior causes significant distress or disrupts daily activities, such as social, academic, or work-related functioning.

• The hair loss is not caused by another medical condition, such as alopecia or a fungal infection.

• The behavior cannot be better explained by another mental health disorder.

Treatment Options for Trichotillomania

Trichotillomania is a complex psychiatric condition that typically requires a multidisciplinary treatment approach. Patients may be treated by primary care providers, dermatologists, psychiatrists, and psychologists. ^[4]

If left untreated, trichotillomania often leads to significant impairment and, in rare instances, life-threatening medical issues. However, a combination of therapy and medication can improve symptoms and potentially prevent the condition from becoming chronic. ^{[1] [4]}

Therapy

Cognitive behavioral therapy (CBT) is considered the most effective and widely recognized treatment for trichotillomania. In traditional CBT, a patient might notice that stressful group activities at work trigger the urge to pull out hair because it temporarily relieves their anxiety. ^[4]

This creates a pattern where the thought that all social interaction is stressful becomes linked to hair pulling as a coping mechanism. CBT helps the individual identify and challenge this cognitive distortion and break the cycle of negative reinforcement that strengthens the behavior. ^[4]

Here are a few subtypes of CBT that are commonly used to treat hair-pulling disorder: ^{[1] [4]}

• Habit Reversal Training (HRT) is the first-line treatment for trichotillomania and has been shown to be effective. HRT involves awareness training to help individuals recognize when and why they pull hair, learning a competing response to replace the behavior, and receiving social support to encourage consistent use of the technique.

• Acceptance and Commitment Therapy (ACT) is often used alongside HRT and works by encouraging patients to confront negative emotions and accept the urge to pull out their hair without giving in to it. Through this practice, individuals can begin to realize they have control over their responses, which can help reduce hair-pulling over time.

• Dialectical Behavior Therapy (DBT) includes mindfulness training, where patients learn to observe urges or negative emotions in the moment and let them pass without acting on them. It also focuses on developing emotional regulation skills and building the ability to tolerate distress or stress-inducing situations without resorting to hair pulling.

• Exposure Therapy is sometimes adapted from OCD treatment, and helps to identify hair-pulling patterns, create a hierarchy of triggering situations, expose the individual to these situations gradually, and ultimately work on managing emotional responses, all based on the idea that pulling is reinforced by temporary relief from distress.

Medication

Currently, there are no medications that have been officially approved for the treatment of trichotillomania, though several have shown potential benefits in limited studies. Therapy remains the first-line treatment for hair-pulling disorder, and research states that larger-scale, long-term trials are needed to evaluate the efficacy and safety of medications for the condition. ^{[1] [4]}

That said, promising medications include: ^{[1] [4]}

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are commonly prescribed antidepressants used for conditions like depression, anxiety, and OCD. However, SSRIs taken without therapy appear to be less effective for trichotillomania than they are for OCD. Meta-analyses suggest a moderate benefit, especially when combined with therapy.

Tricyclic Antidepressants (TCAs)

TCAs are an older class of antidepressants, sometimes used to treat OCD and chronic pain. When it comes to treating hair-pulling disorder, research has revealed that clomipramine is more effective than other TCAs and shows some efficacy in treating the condition. However, these findings are not significant enough to be considered concrete evidence.

Atypical Antipsychotics

These medications are primarily used for schizophrenia and bipolar disorder, but have been studied as a treatment for trichotillomania. Olanzapine, aripiprazole, and quetiapine have shown some preliminary positive effects, though studies are limited and need replication. Furthermore, it is important to note that the side effects of olanzapine include the risk of metabolic syndrome.

Glutamatergic Agents

These pharmaceuticals target glutamate regulation in the brain and are considered experimental for psychiatric use. When studied as a potential treatment for hair-pulling disorder, N-acetylcysteine (NAC) has shown promise in adult studies, though it was found ineffective in children.

Can Damaged Hair Follicles be Repaired?

Hair follicles are small, tunnel-like structures in the skin where hair grows. Each follicle anchors a single hair and extends down into the dermis, the deeper layer of the skin. When hair is pulled out from the root, several things happen to the hair follicle depending on how often and how forcefully it is pulled.

If hair is gently pulled out only on occasion, the follicle typically remains intact. The follicle may enter a short resting phase, then eventually start a new growth cycle and produce a new hair. However, with repeated or chronic pulling, hair follicles can become inflamed or damaged. Over time, repeated trauma may cause the follicle to shrink or even become inactive, leading to:

• Thinner, finer hairs

• Slower regrowth

• Permanent hair loss occurs if the follicle is destroyed

With severe or prolonged pulling (especially if it leads to infection or scabbing), scarring of the hair follicle can occur. This means that the follicle is replaced with scar tissue, and hair can no longer grow in that area. Therefore, regrowth can only occur once inflammation or damage to the hair follicles is healed, provided no scarring is present. ^[4]

Emerging treatments to promote hair regrowth include: ^[8]

• Low-Level Laser Therapy (LLLT): Uses gentle light energy to stimulate hair follicles and improve blood flow, encouraging hair growth.

• Microneedling: Involves tiny needles creating micro-injuries in the scalp to trigger healing and activate hair follicle stem cells.

• Fractional Radiofrequency (FRF): Delivers controlled heat below the skin to boost collagen and stimulate follicle activity.

• Platelet-Rich Plasma (PRP): Uses a concentrated part of an individual’s blood, rich in growth factors, to nourish and repair hair follicles.

• Stem Cell Therapy: Uses stem cells to regenerate and repair damaged hair follicles, promoting new growth and healthier hair.

However, keep in mind that hair follicle growth cycle can be influenced by several factors, including malnutrition, lack of essential vitamins and minerals, chronic health conditions, acute stress, and psychological strain. When this cycle is disrupted, it may lead to increased hair shedding or hair loss. ^[8]

Living with Trichotillomania

If left untreated, trichotillomania can significantly interfere with many aspects of a person’s daily life. Adults, adolescents, and older children with the disorder often experience difficulties with work, school, and social interactions. The disorder can negatively affect family relationships by leading to arguments and secrecy, with this added stress potentially worsening symptoms. ^[7]

Furthermore, prolonged hair pulling leads to hair loss, which can result in spending considerable amounts of money on regenerative treatments. Oftentimes, these treatments are ineffective, and if scarring of the hair follicle has already occurred, then not even emerging hair treatments will stimulate new growth. ^[4][7]

However, if the follicles have not formed into scar tissue, then the treatments mentioned above (particularly platelet-rich plasma therapy) can make a significant difference. That said, it is best to prioritize therapy and medication (which have been found effective in reducing trichotillomania symptoms) before investing in hair regrowth treatments.

As people living with trichotillomania often experience a profound sense of shame that their behavior or bald patches will be judged, it is important for individuals with the condition to seek solace in the form of a support group. Support groups can help individuals with hair-pulling disorder reduce feelings of shame and cope with stigma. ^{[2] [7]}

Additional Support

According to Clare Mackay (Professor of Imaging Neuroscience in the Department of Psychiatry, University of Oxford), who experienced trichotillomania first hand, “many people [with the disorder] suffer in silence; not even feeling able to tell their spouse or closest friends.”

For this reason, online support groups can help to name what has been left unsaid and may offer practical solutions for dealing with triggers and urges. Additionally, support groups provide a sense of belonging, so individuals no longer have to feel alone.

Here are a few support groups that may help:

TLC Foundation for Body-Focused Repetitive Behaviors: A directory of peer-led and professional support groups for trichotillomania and related conditions.

International OCD Foundation BFRB Support Group: Hosts free Zoom meetings on the 1st and 3rd Sundays of each month for individuals with trichotillomania and other BFRBs.

TrichStop.com: Provides an online therapy program based on cognitive-behavioral therapy (CBT) for trichotillomania, including access to therapists and community forums.

HabitAware – BFRB Change Collective: An online community offering support and resources for individuals with trichotillomania and other BFRBs.

Final Thoughts

Trichotillomania is a complex and often misunderstood disorder that can have a significant impact on an individual's physical and emotional well-being. While the exact causes remain unclear, a combination of genetic, emotional, and environmental factors is believed to play a role in its development - with many reporting its onset during a stressful life event.

Living with hair-pulling disorder can cause individuals to struggle with a deep sense of shame, stemming from societal stigmas. Fortunately, with therapy and potentially medication, as well as the encouragement of support groups, individuals with trichotillomania can manage the condition and find a sense of serenity.