Overview

• Trichotillomania (trik-o-til-o-MAY-nee-uh), also called hair-

pulling disorder, is a mental disorder that involves recurrent,
irresistible urges to pull out hair from your scalp, eyebrows or
other areas of your body, despite trying to stop.
• Hair pulling from the scalp often leaves patchy bald spots, which
causes significant distress and can interfere with social or work
functioning. People with trichotillomania may go to great lengths
to disguise the loss of hair.
• For some people, trichotillomania may be mild and generally
manageable. For others, the compulsive urge to pull hair is
overwhelming. Some treatment options have helped many people
reduce their hair pulling or stop entirely.
 Symptoms
•Repeatedly pulling your hair out, typically from your scalp,
eyebrows or eyelashes, but sometimes from other body areas,
and sites may vary over time
•An increasing sense of tension before pulling, or when you
try to resist pulling
•A sense of pleasure or relief after the hair is pulled
•Noticeable hair loss, such as shortened hair or thinned or bald
areas on the scalp or other areas of your body, including
sparse or missing eyelashes or eyebrows
•Biting, chewing or eating pulled-out hair
•Playing with pulled-out hair or rubbing it across your lips or
face
•Repeatedly trying to stop pulling out your hair or trying to do
it less often without success
•Significant distress or problems at work, school or in social
situations related to pulling out your hair
 For people with trichotillomania, hair
pulling can be:
• Focused. Some people pull their
hair intentionally to relieve tension
or distress — for example, pulling
hair out to get relief from the
overwhelming urge to pull hair.
Some people may develop elaborate
rituals for pulling hair, such as
finding just the right hair or biting
pulled hairs.
• Automatic. Some people pull their
hair without even realizing they're
doing it, such as when they're bored,
reading or watching TV.
 Trichotillomania can be related to
emotions:
• Negative emotions. For many people with trichotillomania, hair pulling is
a way of dealing with negative or uncomfortable feelings, such as stress,
anxiety, tension, boredom, loneliness, fatigue or frustration.
• Positive feelings. People with trichotillomania often find that pulling out
hair feels satisfying and provides a measure of relief. As a result, they
continue to pull their hair to maintain these positive feelings.

Trichotillomania is a long-term (chronic) disorder. Without treatment,

symptoms can vary in severity over time. For example, the hormonal
changes of menstruation can worsen symptoms in women. For some
people, if not treated, symptoms can come and go for weeks, months or
years at a time. Rarely, hair pulling ends within a few years of starting.
When to see a doctor
• If you can't stop pulling out your
hair or you feel embarrassed or
ashamed by your appearance as a
result of your hair pulling, talk to
your doctor. Trichotillomania is
not just a bad habit, it's a mental
health disorder, and it's unlikely
to get better without treatment.
 Causes
• The cause of
trichotillomania is
unclear. But like many
complex disorders,
trichotillomania
probably results from a
combination of genetic
and environmental
factors.
 Risk factors
• Family history. Genetics may play a role in the development of
trichotillomania, and the disorder may occur in those who have a close relative
with the disorder.

• Age. Trichotillomania usually develops just before or during the early teens —

most often between the ages of 10 and 13 years — and it's often a lifelong
problem. Infants also can be prone to hair pulling, but this is usually mild and
goes away on its own without treatment.

• Other disorders. People who have trichotillomania may also have other

disorders, such as depression, anxiety or obsessive-compulsive disorder (OCD).

• Stress. Severely stressful situations or events may trigger trichotillomania in

some people.
 Complications
• Emotional distress. Many people with trichotillomania report feeling
shame, humiliation and embarrassment. They may experience low self-
esteem, depression, anxiety, and alcohol or street drug use because of their
condition.
• Problems with social and work functioning. Embarrassment because of
hair loss may lead you to avoid social activities and job opportunities.
People with trichotillomania may wear wigs, style their hair to disguise bald
patches or wear false eyelashes. Some people may avoid intimacy for fear
that their condition will be discovered.
• Skin and hair damage. Constant hair pulling can cause scarring and other
damage, including infections, to the skin on your scalp or the specific area
where hair is pulled and can permanently affect hair growth.
• Hairballs. Eating your hair may lead to a large, matted hairball
(trichobezoar) in your digestive tract. Over a period of years, the hairball
can cause weight loss, vomiting, intestinal obstruction and even death.
 Diagnosis
An evaluation to determine if you have trichotillomania may include:

• Examining how much hair loss you have

• Asking questions and discussing your hair loss with you
• Eliminating other possible causes of hair pulling or hair loss through
testing determined by your doctor
• Identifying any physical or mental health problems that may be
associated with hair pulling
• Using the diagnostic criteria in the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5), published by the American Psychiatric
Association
 Treatment
• Research on
treatment of
trichotillomania is
limited. However,
some treatment
options have helped
many people reduce
their hair pulling or
stop entirely.
 Therapy
• Habit reversal training. This behavior therapy is the primary
treatment for trichotillomania. You learn how to recognize
situations where you're likely to pull your hair and how to
substitute other behaviors instead. For example, you might clench
your fists to help stop the urge or redirect your hand from your
hair to your ear. Other therapies may be used along with habit
reversal training.
• Cognitive therapy. This therapy can help you identify and
examine distorted beliefs you may have in relation to hair pulling.
• Acceptance and commitment therapy. This therapy can help
you learn to accept your hair-pulling urges without acting on
them.
 Coping and support
• Many people with trichotillomania report
feeling alone in their experience of hair pulling.
It may help to join a support group for people
with trichotillomania so that you can meet
others with similar experiences who can relate
to your feelings.
• Ask your doctor or mental health professional
for a recommendation or consider searching
online for a trichotillomania support group.
 Differential Diagnosis
• Normative hair removal/manipulation: Trichotillomania should not be diagnosed when hair

removal is performed solely for cosmetic reasons (i.e., to improve one's physical appearance). Many

individuals twist and play with their hair, but this behavior does not usually qualify for a diagnosis

of trichotillomania. Some individuals may bite rather than pull hair; again, this does not qualify for a

diagnosis of trichotillomania.

• Other obsessive-compulsive and related disorders: Individuals with OCD and symmetry concerns

may pull out hairs as part of their symmetry rituals, and individuals with body dysmorphic disorder

may remove body hair that they perceive as ugly, asymmetrical, or abnormal; in such cases a

diagnosis of trichotillomania is not given. The description of body-focused repetitive behavior

disorder in other specified obsessive-compulsive and related disorder excludes individuals who meet

diagnostic criteria for trichotillomania.

• Neurodevelopmental disorders: In neurodevelopmental

disorders, hair pulling may meet the definition of

stereotypies (e.g., in stereotypic movement disorder).

Tics (in tic disorders) rarely lead to hair pulling.

• Psychotic disorder: Individuals with a psychotic

disorder may remove hair in response to a delusion or

hallucination. Trichotillomania is not diagnosed in such

cases.
• Another medical condition: Trichotillomania is not diagnosed if the

hair pulling or hair loss is attributable to another medical condition

(e.g., inflammation of the skin or other der- matological conditions).

Skin biopsy or dermoscopy can be used to differentiate individuals

with trichotillomania from those with dermatological disorders.

• Substance-related disorders: Hair-pulling symptoms may be

exacerbated by certain substances for example, stimulants but it is less

likely that substances are the primary cause of persistent hair pulling.
 Comorbidity
• Trichotillomania: is often accompanied by other mental
disorders, most commonly major depressive disorder and
excoriation (skin-picking) disorder. Repetitive body-focused
symptoms other than hair pulling or skin picking (e.g. nail
biting) occur in the majority of individuals with trichotillomania
and may deserve an additional diagnosis of other specified
obsessive-compulsive and related disorder (i.e., body-focused
repetitive behavior disorder).
References:
• https://
www.mayoclinic.org/diseases-conditions/trich
otillomania/diagnosis-treatment/drc-2035519
3
• DSM 5