What Is Trichotillomania?

Trichotillomania is a hair-pulling disorder where individuals have the urge to pull their hair out from any region of the body. Trichotillomania is considered a mental disorder and is a behaviour in response to stress, anxiety, or depression.

Overview

Trichotillomania is a mental condition that causes the uncontrolled urge to pull out your hair. The term trichotillomania comes from the Greek words for hair (“tricho”), pull (“tillo”), and madness (“mania”).¹ Trichotillomania is classified as a form of obsessive-compulsive disorder (OCD) by The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).² OCD is a disorder where people experience cycles of obsessions and compulsive thoughts. The repeated hair-pulling behaviour of trichotillomania is in response to stress and causes a significant impact on the person’s daily life. This article will discuss the symptoms, diagnosis, treatments and coping strategies for trichotillomania.

Symptoms of trichotillomania

Trichotillomania commonly involves hair pulling from the:

• Scalp
• Eyelashes
• Eyebrows
• Beard
• Arms
• Legs
• Pubic area

The symptoms and behaviours of trichotillomania include:

• Hair pulling
• Hair loss and bald spots from repeated hair-pulling
• Skin irritation and infection
• Attempting to stop pulling hair but being unable to
• Hair pulling causes distress and disrupts other aspects of life
• Biting or eating pulled hair (trichophagia)
• Hair in the intestines from eating hair can obstruct the intestines over time (trichobezoars)³

Hair pulling can occur both without deliberate awareness of the behaviour or as a more focused behaviour that the person does to deal with stress or another trigger. Hair pulling can occur in both of these types in one individual.⁴

Clinical features

• Age: Individuals generally experience symptoms from around ages 10 to 13.³
• Sex: Trichotillomania mainly affects people assigned to females at birth (AFAB), with a ratio of 4:1 of AFAB to people assigned to males at birth (AMAB).² 

Causes and risk factors

Genetics

Genetics seems to have some effect on the risk of trichotillomania. Genetic studies in twins have shown there is a genetic component involved in trichotillomania. One study estimated the heritability of trichotillomania was high at 76%. This means that most of the risk of trichotillomania comes from genetics, while the remaining 24% comes from environmental factors, such as stress or lifestyle factors.⁶

Initial sequencing studies have also shown that mutations in the SLIT and NTRK-like family, member 1 (SLITRK1) gene, can occur in trichotillomania and are also associated with OCD. Genetic mutations in SLITRK1 appear to be rare, and further research is necessary to understand their effects.⁶

Although these initial studies show a genetic component is involved in trichotillomania, further research is necessary to fully understand the genetics of the disorder.

Other associated disorders

Trichotillomania is associated with multiple psychiatric conditions, which include OCD, anxiety, depression, substance abuse, post-traumatic stress disorder, personality disorders, and eating disorders.^2,3

Diagnosis

Diagnosis of trichotillomania involves using the DSM-5 criteria. Symptoms are evaluated against these criteria and should include:

• Recurrent pulling out of one’s hair, resulting in hair loss
• Repeatedly attempting to decrease or stop hair-pulling
• The hair-pulling cannot be explained by the symptoms of another mental disorder
• The hair pulling or hair loss is not from another medical condition
• The hair pulling causes clinically significant distress or impairment in social, occupational, or other areas of life

The doctor will also determine if there are other underlying psychiatric conditions involved, which may influence symptoms and behaviours. If the person has been eating hair, it is also important to check for blockages in the stomach and intestines.³

Impact on daily life

Beyond the physical impact of hair loss, people with trichotillomania are impacted psychologically by their repetitive hair pulling. This may include feeling:

• Low self-esteem
• Anxiety
• Social anxiety³

The urge to pull hair and the impact it has on mental health means that around 1/3 of people with trichotillomania report having a low quality of life.³ Trichotillomania in children and young adults can also affect their social life, often from shame or embarrassment from hair loss.⁴ Although symptoms can initially feel difficult to manage, there are effective treatments and coping strategies available.

Treatment options

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is a type of therapy that aims to treat behaviours and ways of thinking by talking through them. CBT can be used to work on the urges and habits of hair pulling in trichotillomania. Habit reversal training within CBT offers techniques for managing triggers for hair pulling and redirecting attention to something else. The first step of CBT is to become aware of one’s actions and thought patterns that lead to hair pulling. With further social support, CBT can be very effective in managing trichotillomania.⁵

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that increases serotonin levels. SSRIs are sometimes prescribed to treat the underlying causes of trichotillomania, such as depression or anxiety. However, there is little evidence that SSRIs are beneficial for directly managing hair pulling and trichotillomania.^3,7

N-acetylcysteine (NAC)

N-acetylcysteine (NAC) is a glutamate agent which has been shown to improve trichotillomania symptoms.³ NAC is a good first line of treatment and has minimal side effects.² A dose of 1200 mg twice a day shows improvements in symptoms and urges to pull hair.³

Coping strategies

In combination with treatment, other management strategies can help to deal with the urge to pull out hair. Identifying when you have the urge to pull out hair, such as during a stressful time, suggests that dealing with the stress first could help. Redirecting your attention from your hair to a fidget toy or stress ball may also help. Covering your hair with clothing or a hat so that it is more difficult to reach may be beneficial. Recognising when the urge to pull hair arises is important to be able to deal with the triggers.

Summary

Trichotillomania is a mental disorder that involves the urge to pull out one’s hair. Hair pulling can occur in various regions of the body. Trichotillomania is classified as a type of obsessive-compulsive disorder (OCD) and often arises as a response to stress, anxiety, or depression. Trichotillomania predominantly affects individuals with AFAB and usually occurs between ages 10 to 13. It is associated with several psychiatric conditions, including OCD, anxiety, depression, and eating disorders. Diagnosis involves an assessment of symptoms using the DSM-5 criteria for trichotillomania. Trichotillomania significantly impacts daily life, leading to low self-esteem and social anxiety. Effective treatments include cognitive behavioural therapy (CBT) and N-acetylcysteine (NAC). Coping strategies involve identifying triggers and redirecting attention away from hair-pulling. Overall, recognising and addressing the psychological and behavioural aspects of trichotillomania can lead to effective management and improved quality of life. It is important to seek help if you are dealing with trichotillomania.

FAQs

What is the main cause of trichotillomania?

The main cause of trichotillomania remains unclear, but it is believed to arise from a combination of factors. Genetics may play a role, as individuals with a family history of the disorder are more susceptible. Additionally, psychological triggers like stress or anxiety can contribute to the development of trichotillomania.

Is trichotillomania a mental disorder?

Yes, trichotillomania is a mental disorder. It is categorised as a type of obsessive-compulsive disorder (OCD) in the DSM-5, which is a widely recognised diagnostic manual for mental health professionals. Trichotillomania can occur alongside other mental disorders, such as depression, anxiety, substance abuse, and eating disorders. 

What are the main symptoms of trichotillomania?

The main symptoms of trichotillomania include recurrent and uncontrollable urges to pull out one's hair, often resulting in noticeable hair loss. This can lead to skin irritation or infection and affects other aspects of life. People with trichotillomania may attempt to stop pulling hair, but the urges mean they are unable to stop without treatment and management strategies. Biting or eating pulled hair (trichophagia) and the build-up of hair in the digestive tract from eating hair occurs in some individuals. Hair pulling can occur both without deliberate awareness of the behaviour and as a more focused behaviour that the person does to deal with stress or another trigger.