Hair Pulling Disorder (Trichotillomania)

Hair pulling disorder, also known as trichotillomania, is a mental health condition that typically begins in adolescence or early adulthood. Symptoms of trichotillomania include a compulsive urge to pull hair from areas of the body, and it is typically treated with therapeutic interventions.

What is trichotillomania?

Hair pulling disorder, also called trichotillomania, is a psychological disorder, characterized by recurrent urges to remove hair from the body. People with trichotillomania pull out their hair using their fingers, tweezers, or other devices. The most common place for hair pulling to occur is the head, but hair is also often removed from eyelashes, eyebrows, armpits, beards, and genitals ^[1].

Many people experience a feeling of tension, resulting in an uncontrollable urge to remove hair that can only be appeased by the pulling of hair ^[2]. Others may pull out their hair with little or no awareness of the behavior, as an automatic or subconscious action ^[3]. Episodes of hair pulling can last between seconds and hours and may result in significant hair loss ^[1].

Trichotillomania is included in the Diagnostic and Statistic Manual of Mental Disorders, 5^th Edition (DSM-5) ^[4], within the chapter on Obsessive-Compulsive Disorders and Related Conditions, having previously been listed under Impulse-Control Disorders in the preceding edition, the DSM-IV ^[5]. Despite certain similarities, trichotillomania and OCD are different conditions ^[1].

Trichotillomania typically begins in adolescence or early adulthood and is significantly more common amongst females than males ^[6][7]. Left untreated, it can result in several severe physical and mental health problems.

Symptoms of trichotillomania

Symptoms of trichotillomania may vary from person to person, but may include ^[2][3][7]:

• A recurrent urge to pull out hairs on the body, including head hair, eyelashes, eyebrows, armpit hairs, or pubic hairs
• A sense of relief following an episode of hair pulling
• Bald patches on the head, potentially concentrated in an area on one side if the same hand is used repeatedly
• Head hair may appear thinned if hairs are pulled from various areas of the head
• Hair pulling may be done intentionally or as a subconscious action with no awareness of the behavior
• Usually 1 or 2 hairs are pulled out at a time, with several hairs pulled out in one episode
• Unsuccessful attempts to reduce or stop hair pulling
• Wearing hats, scarves, or make-up to hide bald patches
• Ritualistic behavior, including pulling specific kinds of hair, pulling the hair in a certain manner, and performing actions with the hair once pulled, such as rolling hair into a ball or biting hair
• Swallowing hair after pulling, which is known as trichophagia
• Symptoms of other body-focused repetitive behaviors, such as skin picking or nail biting
• Feelings of shame, low self-esteem, and poor body-image
• Social withdrawal due to feeling embarrassed about hair loss and fear of stigmatization
• Impaired functioning at school or work, due to a desire to avoid others or because of difficulties concentrating
• Symptoms may be worse for women just prior to menstruation

Causes of trichotillomania

Genetic

Research has found that there is a significantly increased risk of developing trichotillomania in those with a relative who has the condition ^[8]. There is also an increased risk in those with a relative who has OCD or an anxiety disorder ^[7].

Brain structure and function

Several studies have found a link between brain function and the development of trichotillomania. For example, research has shown that there is a difference in the amount of gray and white matter in parts of the brain in those with trichotillomania, as well as other structural abnormalities in areas that impact emotion regulation and habit forming, suggesting that this may cause the disorder ^[3][9][10].

Also, studies have suggested that trichotillomania may be caused by chemical imbalances in the brain, related to levels of the neurotransmitters, serotonin and dopamine. However, these studies are based on the results of utilizing medications that impact these neurotransmitters and have not found conclusive results, prompting the need for further research in this area ^[3].

Hormonal changes

Trichotillomania often begins in adolescence or early adulthood, typically emerging after puberty, thereby prompting the theory that changes in hormones can contribute to its development ^[2][7].

Similarly, studies focused on female hormones have found that symptoms of trichotillomania are worse in the week prior to menstruation and may also be linked to low levels of progesterone ^[10][11].

Response to stress

Many people with trichotillomania report feelings of stress or tension prior to episodes of hair pulling, followed by a feeling of relief after an episode. This suggests that, in these cases, hair pulling behaviors may be a response to distress and a form of emotion regulation ^[10].

Higher rates of hair pulling have been found in college students than other groups ^[3], reinforcing the idea that high levels of stress can cause symptoms of trichotillomania as a coping strategy.

Childhood trauma

Research has found that rates of childhood abuse and trauma are considerably higher amongst those diagnosed with trichotillomania than those without a mental health diagnosis, suggesting that traumatic childhood experiences play a significant part in the development of the condition ^[12].

Other mental health conditions

High rates of coexisting mental health conditions have been found amongst people with trichotillomania, such as major depressive disorder, anxiety disorders, OCD, and mood disorders, suggesting that the prevalence of other mental health conditions may contribute to the development of trichotillomania, or may be worsened by the condition ^[7][10].

Diagnosing trichotillomania

A diagnosis of trichotillomania may be delayed by a reluctance to approach family or professionals with concerns, as many people with this condition will keep their symptoms hidden due to shame or fear of stigmatization ^[3].

Similarly, once a professional has been consulted for a diagnosis of trichotillomania, information from the individual about the presenting symptoms may be vague or unreliable, so input from family members may be required to provide a full picture of the condition and the severity of symptoms.

To make a diagnosis of trichotillomania, criteria outlined in the DSM-5 will be used, which include ^[4]:

• Recurrent hair pulling resulting in a loss of hair
• Unsuccessful attempts to reduce or stop the behaviors
• Symptoms that are not due to a medical condition, such as alopecia, or mental health condition, such as body dysmorphic disorder

The doctor will likely ask questions about the family’s physical and mental health history, as well as performing a physical check for hair loss, scarring, pain, or stomach issues.

They will also ask questions about the presenting symptoms, such as how often the hair pulling episodes occur, how long each episode typically lasts, how long these symptoms have been present, and what emotions or feelings occur before and after each episode.

They may utilize a medical questionnaire to aid in gathering this information, such as the NIMH Trichotillomania Scale, which asks about behaviors, emotions, and impairments in quality of life and functioning, using a rating scale to measure the severity of the symptoms ^[3].

After gathering this information, the doctor will have a better understanding of the condition, allowing them to make appropriate suggestions or referrals for treatment.

Treatment for trichotillomania

Treatment for trichotillomania will likely involve a multidisciplinary approach, involving collaborative care from several professionals, such as a dermatologist, mental health professional, and physician ^[3].

Psychological intervention is the most effective treatment for trichotillomania and may involve habit reversal training (HRT), cognitive behavioral therapy (CBT), or dialectical behavior therapy (DBT), or a combination of these ^[10].

Habit reversal training

Habit reversal training involves first monitoring hair pulling symptoms to increase awareness of these behaviors. This may be with the use of a symptom diary, sessions with a therapist, or by asking family members to help increase awareness of these behaviors.

Once triggers and behaviors are recognized, habits are then replaced with less harmful behaviors, such as fist clenching. Throughout HRT, support from professionals and family members is crucial to help prompt habit changes and reinforce positive behaviors through praise ^[1][3].

Behavioral therapies

While HRT may be effective in reducing hair pulling behaviors, it does not manage the underlying emotional causes of the condition ^[3], which can be achieved with the use of CBT or DBT. Behavioral therapies can help to improve distress tolerance and emotion regulation, while providing necessary skills and coping strategies to reduce negative emotions and the associated behaviors ^[1][10].

Medication

There is varying research available about the effectiveness of treating trichotillomania with medications. Some studies suggest that the use of antidepressant medications, selective serotonin reuptake inhibitors (SSRIs), is an effective treatment, but these findings have been questioned and contradicted, prompting a reduction in the use of SSRIs for this condition ^[6][13].

Studies have also found that olanzapine, clomipramine, and n-acetylcysteine may be effective medications for the treatment of trichotillomania, although further research is needed to confirm these findings ^[3][13].

Due to the lack of clarity in this area, medication is not typically used in the treatment of trichotillomania, but may be prescribed to treat coexisting conditions, such as depression, anxiety, and OCD ^[1].

Self-care for trichotillomania

If you have trichotillomania, you can manage your symptoms by ^[1][2]:

• Setting goals: Having goals to aim for can help with reducing your symptoms, such as aiming to reduce the occurrence of hair pulling, increase the length of time between episodes, and increase social interactions.
• Replacing actions: It can be useful to have a behavior or action that can replace or distract from hair pulling urges, such as squeezing a stress ball, spinning a fidget toy, or repeating a mantra or phrase.
• Blocking behaviors: You can make it more difficult to perform hair pulling behaviors by wearing a tight hat or bandana, covering your fingers with plasters, or cutting your hair short.
• Speaking to others: Talking to your family or friends can make managing your condition feel less challenging, as others can help to distract you from harmful behaviors and encourage positive behaviors, as well as provide emotional support.
• Attending a support group: You may find it useful to attend a support group with others who also have trichotillomania, as this can help to increase understanding and acceptance of the condition, reduce negative feelings, and provide support in managing your behaviors.
• Relaxation exercises: Engaging in relaxation exercises, such as breathing exercises, meditation, or walking, can help to reduce negative emotions and anxieties, helping to reduce the symptoms and behaviors of your condition.

Frequently asked questions about trichotillomania

Are there any complications of trichotillomania?

Trichotillomania can cause several social, physical, and emotional complications, such as ^[7][10]:

• Permanent hair loss if hair pulling behaviors are prolonged and recurrent
• Severe stomach issues if hair is swallowed, such as bowel obstruction
• Worsening mental health, including depression, anxiety, and low self-esteem
• Alcohol and substance abuse, as a coping strategy for emotional distress
• Relapse if treatment is not successful or maintained
• Job loss if there is continued avoidance or impairment in work and professionalism

How common is trichotillomania?

Various studies suggest that trichotillomania occurs in between 1-3% of the population, although it is believed to be significantly underreported and underdiagnosed, so the true figure may be higher ^[3][10].

Trichotillomania is believed to occur in females up to 10 times more often than males in adulthood, while in childhood it occurs equally in males and females ^[7][10].

Trichotillomania vs Obsessive-Compulsive Disorder – What is the difference?

Trichotillomania is included in the DSM-5 under Obsessive-Compulsive Disorder and Related Disorders, and there are similarities in the two conditions, such as repetitive and compulsive behaviors that are difficult to control and manage ^[4]. However, trichotillomania and OCD are two separate conditions and have many differences related to symptoms and treatment.

OCD involves intrusive and unpleasant thoughts that prompt behaviors and repetitive actions, which do not result in pleasure or relief but are engaged in out of necessity, to reduce the feeling that something bad is going to happen. Conversely, intrusive thoughts do not occur in the context of trichotillomania and the associated behaviors often relieve distress or tension, or are engaged in without awareness ^[1][3].

Also, OCD is often treated with antidepressant medications, particularly SSRIs, which are not considered an effective treatment for trichotillomania, suggesting that brain chemicals differ between the two conditions, requiring varying treatments ^[3].