A guide to Trichotillomania

Trichotillomania, also known as TTM or hair-pulling disorder, is one of the body-focused repetitive behaviors (BFRBs) in which a person compulsively pulls out their hair.1 About 1 in 50 people suffer from TTM. Although common in children and adolescents, TTM affects people of all ages, most of whom are women. The disorder can result from a stressor in a person's life, genetics, or alterations in brain chemistry.

Regardless of the cause, it has severe physical and emotional impacts, leading to decreased quality of life, isolation, and poor mental health. Without proper intervention and treatment, TTM can become a chronic condition.2 Read on to find out more about TTM, its symptoms, and the treatments available for this disorder.

Trichotillomania is a BFRB classified under obsessive-compulsive disorder (OCD) in the DSM-V. It involves the compulsive pulling out of hair one strand at a time. Most commonly, hair is plucked from the scalp, eyebrows, eyelids, and pubic areas. Those suffering from the disorder typically pick from one spot, often resulting in bald patches.3 The DSM-IV considered trichotillomania an impulse control disorder, but a better understanding of the disorder has changed how we view and treat it.

In the same vein, healthcare providers have begun to move away from using “trichotillomania” and are instead referring to hair-pulling disorder as “trichotillosis” as recently as 2021. This is because the suffix “mania” might — incorrectly — imply the condition is a type of psychosis or bipolar mania. However, we will use the term trichotillomania in this guide as it is still more recognizable.

Medical experts and researchers aren’t sure what causes TTM. However, there are risk factors that may increase the probability of developing the disorder. It is important to note that trichotillomania often occurs in conjunction with other health problems and rarely, if ever, is an isolated behavior.

A reaction to an extreme stressor or addiction

People who experience a stressful life event might turn to hair-pulling as a form of coping, especially if they have not been taught or have not yet developed healthy coping skills. TTM provides a sense of control and relief, as it’s used to cope with stress, like some kinds of self-harm.2

TTM may also be a sign of substance abuse. Those with addictions to stimulants, such as cocaine, tend to develop TTM from using hair-pulling to cope with tactile hallucinations. For example, the sensation of insects crawling on the body might be temporarily relieved by hair-pulling. If this behavior continues and is habitual after the drug has worn off, it can become trichotillomania. Conversely, those with TTM resulting from another cause may turn to depressants, such as alcohol or smoking, to suppress the urge to pull out their hair and cope with the emotional and physical distress of living with TTM.4

Obsessive compulsive disorder (OCD)

Part of the new research about trichotillomania is its relation to OCD. While TTM is classified under OCD, it is better to think of it as being on the OCD spectrum or related to the disorder than as a symptom of OCD.5 While healthcare providers and researchers have mostly accepted the classification, trichotillomania has several differences from OCD. OCD often involves intrusive or unwanted thoughts and obsessions that frustrate and cause despair to the person suffering from it. TTM is often motivated by strong urges that chase the feeling of reward or relief associated with hair-pulling.3 Those who suffer from OCD are more likely to develop trichotillomania as a compulsion, and medications used to treat OCD are also helpful in treating TTM.

Genetics

Genetics may play a role in the risk of developing TTM, and some research indicates that if a person has a parent or sibling with a BFRB disorder, such as TTM or something else, they are more likely to develop it. However, more research is needed to conclusively state whether the disorder can be inherited, or if it’s a learned coping strategy.1

Brain and hormones

TTM is rarely an isolated disorder and is more common in those with abnormal hormone levels or brain chemistry imbalances. Those with depression, anxiety, and obsessive-compulsive disorder are more likely to develop TTM. Anxiety and depression can cause periods of heightened distress or stress, which can also exacerbate TTM.2 Clinical research has also shown that TTM patients have larger than normal volumes of white matter in the parts of the brain responsible for impulse control, which directly impacts their ability to suppress the urge to pull out hair.6

Self-harm

Prolonged hair-pulling as a means of discreet self-harm can become trichotillomania. People resorting to hair-pulling experience relief from it, which encourages and reinforces the behavior. It is possible that those who choose to self-harm this way may choose more discreet areas of the body to pull hair from, hide the areas affected under clothing (such as a hat, scarf, or gloves), or even isolate themselves further.2

Trichotillomania was once thought to be uncommon. However, recent research has found that it is significantly underreported and actually affects every one to two in 50 people (3% of the population, or about 10 million Americans). TTM is more common in children, and if it starts before age six, it is more likely to resolve on its own as the child grows and develops. The more insidious form of TTM that requires medical attention tends to start in late childhood, between 9 and 13 years old. TTM in childhood affects boys and girls equally.

In adults, TTM affects more women than men, with 80-90% of reported cases being women.1 Due to underreporting, TTM is often left untreated; there may still be an equal number of men and women experiencing it, but women are more likely to report their symptoms. A lack of treatment may turn TTM into a chronic condition that can flare up at different times, worsening, disappearing, then flaring up throughout a person's life. Trichotillomania is more common in those with obsessive-compulsive disorders, depression, and anxiety.

The symptoms of TTM include the core behavior of hair-pulling in one spot on the body or in multiple. Depending on the visibility of the areas they pull hair from, the person may choose to cover the areas with hats, scarves, make-up, glasses, gloves, or other items; they may also begin to avoid social situations. If you or a person you know is exhibiting these behaviors, it is time to consult with a physician. These outward symptoms can also overlap with other forms of self-harm.

Healthcare providers use a tool known as the DSM-5, which contains information about all major psychological disorders, to diagnose trichotillomania. To be diagnosed with trichotillomania, you have to meet the following criteria:

• Repeated hair-pulling, resulting in loss of hair or bald patches.
• Repeated, unsuccessful attempts to stop or decrease this behavior.
• Experiencing pleasure, gratification, or relief when pulling out hair.
• Hair pulling behavior significantly impacts quality of life and functioning, whether emotional, occupational, or social.
• The condition is not explained by another dermatological condition, such as alopecia, or psychiatric disorder, such as body dysmorphic disorder.7

Healthcare providers might also choose to do a punch biopsy, where they will take a sample of the affected area and test it to rule out any dermatological problems that cause hair loss. Other things to expect when diagnosing trichotillomania are questions about current mental states and behaviors, and health history. If a person with TTM also ingests their hair (called trichophagia), a doctor will perform imaging to ensure they don’t have any intestinal blockages. Blood tests to rule out problems such as anemia are also common.3

Because of the underreporting of and confusion surrounding TTM, the diagnostic process can feel long and tiresome. The stigma surrounding TTM can make it difficult for patients to come forward due to embarrassment and shame. It is critical that those with TTM feel safe and heard in a clinical setting. Having a strong, empathetic support system can also make a difference in both the diagnostic and healing process.

Trichotillomania can have serious impacts on a person's overall health and well-being. Hair, skin, and tissue damage can result from hair pulling, especially if a tool is used, such as a tweezer. Prolonged use of such a tool can damage skin and the tissue underneath, leading to permanent hair loss, bald patches, scarring, or other injuries that need skin grafting to heal.3 Behaviors other than hair pulling may also emerge, such as picking or scratching the skin (excoriation) and playing with or eating the hair they've pulled out.

Eating one's hair is called trichophagia, a harmful condition affecting 20% of people with TTM. The cause of trichophagia is unclear, but the reasoning can vary from person to person. Rarely, if you ingest enough hair, it can cause blockages in the stomach or digestive tract called trichobezoars or hairballs. Trichobezoars often need surgery to resolve. People with trichophagia are typically very hesitant to tell their doctors about it, often needing assurance they can trust them before divulging the condition.3

Trichotillomania and mental health are closely tied together. A poor mental state or stressor combined with ineffective coping skills can create the perfect storm for TTM to develop. Hair, skin, and tissue damage can further exacerbate depression and anxiety. This can cause people to isolate themselves from loved ones and social situations, often feeling shame or embarrassment. Left untreated, worsening TTM can lead to poorer mental health, potentially exacerbating the symptoms of TTM. Only proper treatment and therapy can break this vicious cycle.

Medical experts strongly advise against self-medicating or self-treating TTM, as it could worsen the condition instead of improving it. While more research and conversation is needed to understand the best course of action to heal TTM, there are treatments in place. Generally, treatment for trichotillomania is a combination of pharmacotherapy (prescription medications) and psychotherapy.

Should a healthcare provider deem pharmaceutical intervention necessary, it’s likely that they’ve prescribed one or more of the following:

Psychotherapy is often used alongside prescription medication and is a vital (and effective) part of the treatment process. (Considering its close ties to OCD, patients' mental health must be supported throughout the treatment process and beyond.) Therapy for trichotillomania can include one or more of the following:

The general prognosis of trichotillomania largely depends on the age of onset. If infants or children under six develop TTM, it will most likely resolve independently without further complication. However, children between 9 and 13, teenagers, and adults can potentially live with TTM for an average of 22 years (that is, if they do not seek medical help).3 Though hardly life-threatening, the longer TTM is left untreated, the greater the risk of developing more serious problems, such as worsening mental health, permanent hair loss, and other injuries or emergent BFRBs.

Even with treatment, the prognosis can vary from patient to patient, depending on the severity of symptoms and emotional distress. It is critical to adhere to advice and treatment given by healthcare providers. They alone can provide the best medications and tools to help take control of trichotillomania.

Living with trichotillomania can be detrimental to mental and physical health. It can also be very isolating, as people with TTM tend to hide their condition for as long as possible due to shame and embarrassment. If you or someone you know is showing the signs and symptoms of trichotillomania, it’s important to see a doctor as soon as possible. Additionally, many support groups, organizations, and online resources exist for people living with TTM.

The TLC Foundation for Body-Focused Repetitive Behaviors is a great resource for those wanting to find a support group for trichotillomania, or other BFRBs, or just to find more information about BFRB conditions.

TrichStop is a popular platform connecting TTM patients of all ages to therapists providing Cognitive Behavioral Therapy. Using webinars and smartphone apps, TrichStop gives patients the tools they need to take control of their condition.

Grow is an online community that provides peer support and coaching to people with TTM. They also provide lesser-known treatments, such as hypnosis and breathwork, as well as classes on trichotillomania.