Definition of Trichotillomania
Trichotillomania (trik-o-til-o-MAY-nee-uh) is a disorder that involves recurrent, irresistible urges to pull out hair from your scalp, eyebrows or other areas of your body, despite trying to stop.
Hair pulling from the scalp often leaves patchy bald spots, which causes significant distress and can interfere with social or work functioning. People with trichotillomania may go to great lengths to disguise the loss of hair.
For some people, trichotillomania may be mild and generally manageable. For others, the compulsive urge to pull hair is overwhelming. Some treatment options have helped many people reduce their hair pulling or stop entirely.
Symptoms of Trichotillomania
Signs and symptoms of trichotillomania often include:
- Repeatedly pulling your hair out, typically from your scalp, eyebrows or eyelashes, but can be from other body areas, and sites may vary over time
- An increasing sense of tension before pulling, or when you try to resist pulling
- A sense of pleasure or relief after the hair is pulled
- Shortened hair or thinned or bald areas on the scalp or other areas of your body, including sparse or missing eyelashes or eyebrows
- Preference for specific types of hair, rituals that accompany hair pulling or patterns of hair pulling
- Biting, chewing or eating pulled-out hair
- Playing with pulled-out hair or rubbing it across your lips or face
Most people who have trichotillomania also will pick their skin, bite their nails or chew their lips. Sometimes pulling hairs from pets or dolls or from materials, such as clothes or blankets, may be a sign. Most people with trichotillomania pull hair in private and generally try to hide the disorder from others.
For people with trichotillomania, hair pulling can be:
- Focused. Some people pull their hair intentionally to relieve tension or distress — for example, pulling hair out to get relief from the overwhelming urge to pull hair. Some people may develop elaborate rituals for pulling hair, such as finding just the right hair or biting pulled hairs.
- Automatic. Some people pull their hair without even realizing they’re doing it, such as when they’re bored, reading or watching TV.
The same person may do both focused and automatic hair pulling, depending on the situation and mood. Certain positions or rituals may trigger hair pulling, such as resting your head on your hand or brushing your hair.
Trichotillomania is a long-term (chronic) disorder. Without treatment, symptoms can vary in severity over time. For example, the hormonal changes of menstruation can worsen symptoms in women. For some people, if not treated, symptoms can come and go for weeks, months or years at a time. Rarely, hair pulling ends within a few years of starting.
The cause of trichotillomania is unclear. But like many complex disorders, trichotillomania probably results from a combination of genetic and environmental factors. Also, abnormalities in the natural brain chemicals serotonin and dopamine may play a role in trichotillomania.
These factors tend to increase the risk of trichotillomania:
- Family history. Genetics may play a role in the development of trichotillomania, and the disorder may occur in those who have a close relative with the disorder.
- Age. Trichotillomania usually develops just before or during the early teens — most often between the ages of 11 and 13 — and is often a lifelong problem. Infants also can be prone to hair pulling, but this is usually mild and goes away on its own without treatment.
- Negative emotions. For many people with trichotillomania, hair pulling is a way of dealing with negative or uncomfortable feelings, such as stress, anxiety, tension, loneliness, fatigue or frustration.
- Positive reinforcement. People with trichotillomania often find that pulling out hair feels satisfying and provides a measure of relief. As a result, they continue to pull their hair to maintain these positive feelings.
- Other disorders. People who have trichotillomania may also have other disorders, such as depression, anxiety or obsessive-compulsive disorder (OCD).
Although far more women than men are treated for trichotillomania, this may be because women are more likely to seek medical advice. In early childhood, boys and girls appear to be equally affected.
Complications of Trichotillomania
Although it may not seem particularly serious, trichotillomania can have a great impact on your life. Complications may include:
- Emotional distress. Many people with trichotillomania report feeling shame, humiliation and embarrassment and experience low self-esteem, depression and anxiety because of their condition.
- Problems with social and job functioning. Embarrassment because of hair loss may lead you to avoid social activities and occupational opportunities. People with trichotillomania may wear wigs, style their hair to disguise bald patches or wear false eyelashes. Some people may avoid intimacy for fear that their condition will be discovered.
- Skin and hair damage. Constant hair pulling can cause abrasions and other damage, including infections, to the skin on your scalp or the specific area where hair is pulled, and can affect hair growth.
- Hairballs. Eating your hair may lead to a large, matted hair ball (trichobezoar) in your digestive tract. Over a period of years, the hair ball can cause weight loss, vomiting, intestinal obstruction and even death.
Preparing for your appointment
Seeking help is the first step in treating trichotillomania. At first you may see your primary care doctor or a dermatologist. He or she may refer you to a mental health provider.
These suggestions may help make your appointment easier:
- Make a list of all the symptoms you’re experiencing, even if they seem unrelated to hair pulling. Trichotillomania can cause both physical and psychological symptoms. Note what triggers your hair pulling, how you’ve tried to deal with the problem, and factors that make it better or worse.
- Bring key personal information, including any major stresses or recent life changes and whether hair pulling runs in your family.
- Make a list of all medications, vitamins, herbs or other supplements that you’re taking, including the dosage and how long you’ve been taking them.
To make the most of your time with your doctor, prepare a list of questions ahead of your appointment. Some questions to ask your doctor include:
- What might have caused me to develop this disorder?
- How do you diagnose this condition?
- Is this something that will go away on its own? Is there anything I can do on my own to improve my symptoms?
- What treatments do you recommend for this disorder?
- What if I can’t afford therapy?
- If I decide to take medications, how long will it take for my symptoms to improve?
- What are the side effects of the medications you’re recommending?
- How much improvement can I realistically expect if I follow your treatment plan?
Don’t hesitate to ask questions anytime you don’t understand something.
Tests and diagnosis
Your doctor will perform a thorough evaluation to determine if you have trichotillomania. This may include:
- Examining how much hair loss you have
- Discussing your hair loss with you and possibly having you fill out a questionnaire
- Eliminating other possible causes of hair pulling or hair loss through testing determined by your doctor
To be diagnosed with trichotillomania, you must meet criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.
DSM criteria for the diagnosis of trichotillomania include the following:
- You repeatedly pull out your hair, resulting in noticeable hair loss.
- You repeatedly try to stop pulling out your hair or try to do it less often.
- Pulling out your hair causes you significant distress or problems at work, school or in social situations.
- Your hair loss isn’t due to another medical or skin condition or the symptom of another mental disorder.
Treatments and drugs
Research on treatment of trichotillomania is limited. However some treatment options have helped many people reduce their hair pulling or stop entirely.
Habit reversal training is the primary psychotherapy for trichotillomania. This type of therapy helps you learn how to recognize situations where you’re likely to pull hair and how to substitute other behaviors instead. For example, you might clench your fists for a period to “freeze” the urge, or redirect your hand from your hair to your ear.
Sometimes elements of other therapies may be blended with habit reversal training, including:
- Cognitive therapy. This therapy can help you challenge and examine distorted beliefs you may have in relation to hair pulling.
- Acceptance and commitment therapy. This therapy can help you learn to accept your hair-pulling urges without acting on them.
No medications are approved by the Food and Drug Administration specifically for the treatment of trichotillomania. However, some medications may help control your symptoms.
For example, your doctor may recommend an antidepressant, such as clomipramine (Anafranil). Other medications that research suggests may have some benefit include N-acetylcysteine (as-uh-tul-SIS-tee-een), an amino acid that influences neurotransmitters related to mood, and olanzapine (Zyprexa), an atypical antipsychotic.
Talk with your doctor about any medication that he or she suggests. The possible benefits of medications should always be balanced against possible side effects.
Coping and support
Many people with trichotillomania report feeling alone in their experience of hair pulling. It may help to join a support group for people with trichotillomania so that you can meet others with similar experiences who can relate to your feelings. You might ask your doctor for a recommendation or visit the Trichotillomania Learning Center website to find a support group.