Trichotillomania (hair-pulling disorder)

Signs and symptoms of trichotillomania often include:

• Repeatedly pulling your hair out, typically from your scalp, eyebrows or eyelashes, but sometimes 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
• Noticeable hair loss, such as 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
• Repeatedly trying to stop pulling out your hair or trying to do it less often without success
• Significant distress or problems at work, school or in social situations related to pulling out your hair

Many people who have trichotillomania also 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 can be related to emotions:

• Negative emotions. For many people with trichotillomania, hair pulling is a way of dealing with negative or uncomfortable feelings, such as stress, anxiety, tension, boredom, loneliness, fatigue or frustration.
• Positive feelings. 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.

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.

When to see a doctor

If you can't stop pulling out your hair or you feel embarrassed or ashamed by your appearance as a result of your hair pulling, talk to your doctor. Trichotillomania is not just a bad habit, it's a mental health disorder, and it's unlikely to get better without treatment.

The cause of trichotillomania is unclear. But like many complex disorders, trichotillomania probably results from a combination of genetic and environmental factors.

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 10 and 13 years — and it's 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.
• Other disorders. People who have trichotillomania may also have other disorders, such as depression, anxiety or obsessive-compulsive disorder (OCD).
• Stress. Severely stressful situations or events may trigger trichotillomania in some people.

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.

Although it may not seem particularly serious, trichotillomania can have a major negative impact on your life. Complications may include:

• Emotional distress. Many people with trichotillomania report feeling shame, humiliation and embarrassment. They may experience low self-esteem, depression, anxiety, and alcohol or street drug use because of their condition.
• Problems with social and work functioning. Embarrassment because of hair loss may lead you to avoid social activities and job 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 scarring and other damage, including infections, to the skin on your scalp or the specific area where hair is pulled and can permanently affect hair growth.
• Hairballs. Eating your hair may lead to a large, matted hairball (trichobezoar) in your digestive tract. Over a period of years, the hairball can cause weight loss, vomiting, intestinal obstruction and even death.

An evaluation to determine if you have trichotillomania may include:

• Examining how much hair loss you have
• Asking questions and discussing your hair loss with you
• Eliminating other possible causes of hair pulling or hair loss through testing determined by your doctor
• Identifying any physical or mental health problems that may be associated with hair pulling
• Using the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

Research on treatment of trichotillomania is limited. However, some treatment options have helped many people reduce their hair pulling or stop entirely.

Therapy

Types of therapy that may be helpful for trichotillomania include:

• Habit reversal training. This behavior therapy is the primary treatment for trichotillomania. You learn how to recognize situations where you're likely to pull your hair and how to substitute other behaviors instead. For example, you might clench your fists to help stop the urge. Other therapies may be used along with habit reversal training. A variant of this technique, called decoupling, involves quickly redirecting your hand from your hair to another location.
• Cognitive therapy. This therapy can help you identify 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.

Therapies that help with other mental health disorders often associated with trichotillomania, such as depression, anxiety or substance abuse, can be an important part of treatment.

Medications

Although no medications are approved by the Food and Drug Administration specifically for the treatment of trichotillomania, some medications may help control certain 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.

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.

Ask your doctor or mental health professional for a recommendation or consider searching online for a trichotillomania support group.

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 professional.

What you can do

Before your appointment 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.
• Key personal information, including any major stresses or recent life changes and whether hair pulling runs in your family.
• All medications, vitamins, herbs or other supplements that you're taking, including the dosages and how long you've been taking them.
• Questions to ask your doctor to make the most of your appointment time.

Questions to ask your doctor may 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?
• 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 other questions during your appointment.

What to expect from your doctor

Your doctor will likely ask you a number of questions. Be ready to answer them to reserve time to go over any points you want to focus on. Your doctor may ask:

• When did your hair pulling first start?
• Have you tried to stop pulling your hair? What was the result?
• Are there times or situations that are likely to trigger your hair pulling?
• What feelings do you have before and after you pull your hair?
• From where on your body do you pull hair?
• Do you bite, chew or swallow the hair?
• How has your hair pulling affected your work, school or social life?
• Have you had treatment (medication or therapy) for hair pulling or other emotional issues?