Trichotillomania (Hair-Pulling Disorder)

Signs and symptoms

• repeated pulling of hair, leading to noticeable thinning or bald patches
• repeated attempts to reduce or stop pulling
• tension or urges before pulling, and relief or satisfaction during or after
• rituals: searching for a "right" hair, examining the root, running it across the lips, or biting or eating hair (trichophagia)
• hiding hair loss with hats, scarves, wigs, makeup or false eyelashes
• shame and avoidance of activities like swimming, hairdressers or intimacy
• often other body-focused repetitive behaviors, such as skin picking or nail biting

Focused and automatic pulling

Most people have a mix of both, and treatment addresses each.

Causes and risk factors

The exact cause is not known. Contributing factors include:

• genetics: more common in families with trichotillomania, OCD or other BFRBs
• brain differences in circuits involved in habit and impulse control
• emotional regulation: pulling may soothe stress, anxiety, boredom or frustration
• onset around puberty, hormonal changes
• associated conditions: anxiety, depression, OCD, ADHD

It is not caused by poor willpower, and it is not a form of self-harm in the usual sense.

Diagnosis

A doctor or mental health professional makes the diagnosis by asking about pulling behaviors, urges, attempts to stop and the impact on daily life. A dermatologist may examine the scalp, sometimes with dermoscopy, to distinguish trichotillomania from other causes of patchy hair loss, such as alopecia areata or fungal infection (tinea capitis). A scalp biopsy is rarely needed.

Treatment

Habit reversal training (HRT)

The best-supported treatment. It includes:

• awareness training: noticing when, where and how pulling happens, and early warning signs
• competing response: a physically incompatible action, such as making a fist or holding an object, for about a minute when the urge arises
• stimulus control: changing the environment to make pulling harder, such as wearing gloves, keeping hands busy with fidget toys, putting on a hat or bandage, cutting nails short, dimming mirrors
• social support: a trusted person who encourages progress

Comprehensive behavioral (ComB) model and other therapies

• ComB tailors strategies to sensory, cognitive, emotional, motor and environmental triggers
• acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT) skills help with urges and emotions

Medicines

No medicine is FDA-approved for trichotillomania, but some help some people:

• N-acetylcysteine (NAC), a supplement, has shown benefit in some studies
• SSRIs may help co-occurring anxiety or depression
• olanzapine and other medicines in selected cases

Discuss options with your doctor.

Children

Young children who pull hair often stop on their own. Gentle redirection and keeping hands busy help. Older children and teens benefit from behavioral therapy with family involvement.

Complications

• permanent hair loss from damaged follicles
• skin infections or irritation
• trichobezoar: a hairball in the stomach or intestine from swallowing hair, which can cause obstruction and may need surgery. See bezoars
• repetitive strain in the hand or wrist
• low self-esteem, social isolation and depression

Living with trichotillomania

Relapses are common and are part of recovery, not failure. Support groups, such as those organized by the TLC Foundation for BFRBs, and online communities can reduce shame and isolation.

Frequently asked questions

Why do I pull my hair out?

Hair pulling often helps relieve tension, anxiety, boredom or uncomfortable feelings, or happens automatically during sedentary activities. It is a recognized condition, trichotillomania, linked to brain circuits for habits and impulses, and is not a lack of willpower.

Can trichotillomania be cured?

There is no single cure, but many people greatly reduce or stop pulling with habit reversal training or comprehensive behavioral therapy. Urges may return in stressful times, so ongoing strategies and support help maintain progress.

Will my hair grow back after trichotillomania?

Usually, yes. Hair typically regrows once pulling stops, although it may take months and the texture can change temporarily. Years of repeated pulling from the same spot can damage follicles and cause permanent thinning.

Is trichotillomania a form of OCD?

It is classified alongside OCD in the "obsessive-compulsive and related disorders" group, but it is a separate condition. Unlike OCD, pulling is often pleasurable or soothing rather than driven by intrusive thoughts. Treatments differ somewhat as well.