Trichotillomania, or pathological hair pulling, is a common but underdiagnosed psychological disorder. People with trichotillomania experience an overwhelming urge to pull out their hair.

Many people who have trichotillomania may not know that they have a diagnosable condition. They may simply view their hair pulling as a bad habit. Others may experience severe physical and psychological symptoms.

This article outlines the symptoms and causes of trichotillomania, as well as the different treatment options available.

a man wearing a hat to cover up the patches where he has pulled hair out because of trichotillomania.Share on Pinterest
People with trichotillomania have an overwhelming urge to pull out their hair.

People with trichotillomania feel an overpowering desire to pull out their hair.

Most pull out the hair on their scalp. However, some people may also pull hair out of their beards, eyelashes, or eyebrows.

Some people with trichotillomania also eat the hair they pull out. This condition is called trichophagia. It can cause significant problems in the gastrointestinal tract.

Most people with trichotillomania develop the condition in adolescence. Some of these people may then struggle with the condition continually or intermittently throughout adulthood.

Doctors suspect that many people have trichotillomania but never report it.

According to an article in the American Journal of Psychiatry, researchers estimate that trichotillomania affects between 0.5% to 2% of the population.

Trichotillomania appears to be equally prevalent among males and females during adolescence. However, adult females are more likely to report the condition than males.

A person with trichotillomania may experience the following behavioral and physical symptoms:

  • repetitive pulling of their hair, often without any awareness
  • a sense of relief after pulling out hair
  • inability to stop hair pulling, despite repeated attempts to stop
  • anxiety and stress related to hair pulling
  • a need to perform other repetitive activities related to the hair (e.g., counting or twisting hairs)
  • trichophagia
  • skin irritation or tingling at affected sites
  • noticeable hair loss or bald patches due to hair pulling

Doctors do not know what causes a person to develop trichotillomania.

Some people report that hair pulling helps to alleviate boredom or stress. According to an article in the American Journal of Psychiatry, some people may pull their hair as a way to deal with adverse emotions.

Doctors do know that certain factors can increase a person's risk of developing trichotillomania. These risk factors include:

  • Genetic history: A person who has a first-degree relative (parent or sibling) with trichotillomania is more likely to have the condition themselves.
  • Childhood trauma: According to the National Organization for Rare Disorders, a person who has experienced childhood trauma may be more likely to develop trichotillomania. However, there is not enough research to support this idea.

Doctors are also working to identify changes in brain function or chemistry that could lead to trichotillomania. Certain changes may affect a person's ability to control impulsive behaviors, such as hair pulling.

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Learning relaxation techniques may benefit a person with trichotillomania.

Many people who have trichotillomania do not seek treatment for their condition.

Some people may be unaware that they have a recognized medical condition, and may simply view hair pulling as a bad habit. Others may be reluctant to seek a diagnosis for a variety of reasons.

Doctors do not diagnose many cases of trichotillomania, which means there is very little information on effective treatments available.

However, limited research suggests that specific behavioral therapies and medications may be beneficial for people with the condition.

Behavioral therapy

A 2012 case study indicates that habit reversal therapy (HRT), which is a type of behavioral therapy, might be effective in treating trichotillomania. HRT involves five stages:

  1. Awareness training: The person identifies the psychological and environmental factors that can trigger an episode of hair pulling.
  2. Competing response training: The person practices replacing the hair pulling behavior with a different behavior.
  3. Motivation and compliance: The person engages in activities and behaviors that remind them of the importance of sticking with HRT. This may include receiving praise from family and friends for progress made during therapy.
  4. Relaxation training: The person practices relaxation techniques, such as meditation and deep breathing. These help to reduce stress and associated hair pulling.
  5. Generalization training: The person practices their new skills in different situations so that the new behavior becomes automatic.

According to a 2011 review, most experts agree that HRT should be the first-line treatment option for trichotillomania.

Medications

A 2013 review investigated the efficacy of different medications in treating trichotillomania.

The review included eight trials, seven of which were placebo-controlled. The drugs investigated across the eight trials included:

  • selective serotonin reuptake inhibitors (SSRIs), which are a class of antidepressants
  • clomipramine, which is a tricyclic antidepressant
  • naltrexone, which is an opioid antagonist
  • olanzapine, which is an antipsychotic
  • N-acetylcysteine

The reviewers identified olanzapine, N-acetylcysteine, and clomipramine as the only drugs to have a significant treatment effect on trichotillomania.

However, the studies used very small sample sizes and did not report information on side effects.

Further controlled clinical trials are necessary to determine the safest and most appropriate drug treatments for trichotillomania.

Trichotillomania appears in the Diagnostic and Statistical Manual of Mental Disorders Version 5 or the DSM-5. This is the manual most mental health experts use to diagnose mental health-related conditions.

The DSM-5 classifies trichotillomania as an obsessive-compulsive disorder. Previous versions of the manual had classified it as an impulse control disorder.

According to the National Organization for Rare Disorders, some people with trichotillomania also have other conditions, including:

Sometimes, when a doctor treats these conditions, the person's trichotillomania also improves.

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A trichobezoar may cause symptoms of nausea, vomiting, and stomach pain.

According to an article in the American Journal of Psychiatry, around 20% of people who have trichotillomania eat their hair after pulling it out.

One of the most common and serious complications of this behavior is the formation of a hairball in the stomach. Doctors refer to this as a trichobezoar.

A trichobezoar can cause damage to the gastrointestinal tract. Some possible complications of a trichobezoar include:

If a trichobezoar obstructs a person's bowel, they may need surgery to remove it.

According to the American Journal of Psychiatry, almost a third of people with trichotillomania say they have a low quality of life.

People with trichotillomania may experience bouts of depression or anxiety over their inability to control compulsive hair pulling. People who have developed hair loss as a result of the condition may feel additional concerns about their appearance.

According to a 2011 review, some of the emotional responses people experience as a result of pulling out their hair can cause them to miss work, school, and social functions.

Trichotillomania is a rare medical disorder that can greatly affect a person's quality of life.

Many people are unaware that treatments for trichotillomania are available. HRT is often effective and is the first-line treatment in most cases.

Researchers are continuing to evaluate medications that may reduce the symptoms of trichotillomania.

If a person thinks they have trichotillomania, they should see their doctor for a diagnosis. The doctor may refer the person for specialist treatment, such as behavioral therapy. This can improve a person's quality of life.