What Is Trichotillomania?
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Medically reviewed by Dakari Quimby, PhD
Trichotillomania, also known as TTM or hair-pulling disorder, is a rare disorder in which someone repeatedly pulls their hair out, resulting in hair loss. Trichotillomania falls under the umbrella of obsessive-compulsive disorders (OCD), which refer to a large number of disorders that are characterized by repeated thoughts and actions that can interrupt daily life.
It’s estimated that approximately 3-4% of people experience trichotillomania, with onset generally before age 17; the most common age of onset is approximately 12-13 years old. Some data suggest that women are four to nine times more likely to experience trichotillomania than men, but other research suggests that women are simply more likely to seek help.
Due to the stigmatization of the disorder, many people with trichotillomania resist seeking help, avoid social situations, and experience low self-esteem. Luckily, treatment methods have been shown to decrease symptoms rather quickly–three to six months, on average.
Symptoms
The identifying symptom of trichotillomania is hair loss due to repeated hair pulling. The most common places that people with trichotillomania pull are their scalp, eyebrows, and eyelashes, but any spot with hair can be pulled. It’s common to pull from multiple spots, and pulling episodes generally last a few minutes to several hours. If someone pulls at their scalp, hair loss can come out in patches or across the scalp, resulting in an uneven appearance.
Other signs and symptoms associated with trichotillomania include:
Denial of hair pulling
Regrowth of hair stubble in bald spots
Scarring leading to permanent hair loss
Sadness, depression, anxiety, poor self-image, or other self-harming behaviors
Some people with trichotillomania eat the hair they pull, which can also cause constipation.
What Causes Trichotillomania?
Research is still being done to understand the mechanisms that lead to hair pulling. Some people with trichotillomania identify stress, boredom, anxiety, or other triggers before they pull their hair. When they pull their hair, they experience a sense of release, which creates a cycle in which they continue to pull their hair to feel better. Other people don’t realize that they’re pulling their hair–they do so automatically. Most people with trichotillomania pull consciously sometimes and subconsciously at other times.
We’re still not sure what causes trichotillomania, but there are a few working hypotheses. Some researchers believe that hair pulling is a coping behavior, while others think it may be a subconscious response to a perceived threat. Other researchers hypothesize that differences in brain structure may make certain people susceptible to trichotillomania.
Risk Factors
Some research shows that there may be a genetic component to trichotillomania, but evidence at this point is limited. As prevalence does not differ by gender, sex, income level, race, ethnicity, or any other characteristic, no demographic risk factors are currently identified.
Diagnosis
Diagnosis of trichotillomania is based on a psychiatric evaluation by a mental health provider such as a psychiatrist or therapist, as well as a physical examination. For the psychiatric evaluation, your provider may use a variety of questionnaires and other tools to ask you about your experience.
Specifically, they must identify that all of the following are true to make a trichotillomania diagnosis:
You are removing hair from a part of your body.
You have tried to stop or decrease removing your hair.
You are experiencing significant distress or functional impairment as a result of your hair removal.
Your hair loss cannot be caused by another medical condition, such as alopecia.
Your hair loss is not better explained by another mental disorder.
In addition, they or another provider, such as your primary care provider, may use the following methods to check for physical signs:
Physical examination of the hair loss location
Physical examination of the abdomen, to determine if there is a mass caused by swallowing hair
Trichoscopy, or imaging of the hair and scalp
Hair pull test, to identify how easily hairs are pulled from the scalp
Scalp biopsy (removing a small area of skin from the scalp) to rule out other causes
Because trichotillomania is a rare and largely misunderstood condition, misdiagnosis is common, with many people receiving diagnoses for OCD, anxiety, body dysmorphic disorder, or a substance use disorder.
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Treatments for Trichotillomania
Treatment for trichotillomania is aimed at reducing picking behaviors and is often determined by a team of healthcare providers, including a primary care provider, dermatologist (a doctor who specializes in skin conditions), psychiatrist (a medical doctor who specializes in mental health and can prescribe medications), and clinical psychologist (a doctor who specialized in mental health but who cannot prescribe medications).
Currently, there is no one determined way to treat the disorder, but most often, the treatment team will identify a combination of behavioral therapy and prescription medications. Cases in children under age six often resolve without treatment.
Behavioral Therapy
Behavioral therapy has been identified as the most effective treatment for trichotillomania, with multiple types of therapy shown to be effective. They include:
Cognitive behavioral therapy: A type of structured talk therapy that aims to change harmful thought patterns
Habit reversal therapy: A type of therapy specific to people who want to spot unwanted behaviors where they intentionally replace the behavior with a new one
Acceptance and commitment therapy: An action-oriented, interventional therapy that focuses on mindfulness and acceptance
Peer support groups: Organized groups of people who are working through similar problems
Your treatment team may also include family members, school counselors, and close friends to encourage you in your recovery and identify signs of relapse.
Prescription Medications
There isn’t currently a medication approved by the FDA for trichotillomania, but prescription medications used for other mental health conditions can help improve symptoms. For example, selective serotonin reuptake inhibitors (SSRIs), which are generally used to treat depression and anxiety, are the most common type of medication prescribed to treat trichotillomania.
Other types of medications used include:
Antipsychotic medications
Tricyclic antidepressants
Lithium salts
N-acetylcysteine (NAC)
Naltrexone
However, research is limited on all of these, and medication for trichotillomania has not been shown to be as effective as behavioral therapy.
How to Prevent Trichotillomania Episodes
If you have trichotillomania, you should follow treatment guidelines from your healthcare providers to reduce the frequency and severity of your episodes. In addition, you may find stress reduction techniques helpful to alleviate underlying stress, anxiety, or tension. Limited research suggests that diaphragmatic breathing, progressive muscle relaxation, and yoga may be helpful.
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Related Conditions
Adults with trichotillomania often also experience other psychological conditions, while children with trichotillomania usually do not.
Among adults, research shows that trichotillomania is closely linked with other mental health disorders, including other types of OCD and anxiety disorders, as well as substance use. In one study, 79% of respondents with trichotillomania also reported having major depressive disorder, social anxiety disorder, OCD, post-traumatic stress disorder (PTSD), and attention deficit hyperactivity disorder (ADHD).
It’s important for treatment to identify if there’s a relationship between cooccurring mental health disorders and trichotillomania. For example, if depressive symptoms are leading to hair pulling, treating the depression with antidepressants or therapy may help reduce it.
People with trichotillomania may also engage in nail biting or skin picking. They may experience headaches, carpal tunnel syndrome, and scalp injuries due to their hair pulling.
Living With Trichotillomania
People with trichotillomania often report lower self-esteem and quality of life, as well as higher levels of depression, guilt, shame, and anxiety, than people without the disorder.
The stigma associated with the disorder may stop people from seeking necessary treatment. Over half of the people with trichotillomania will never seek treatment, but among those who do, they can expect to see their symptoms improve quickly–sometimes within three to six months.
New technologies, such as mobile apps and motion sensor bracelets, as well as ongoing research into the causes and symptoms of trichotillomania, suggest that we will know more about the disorder in the future.
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