HomeTrichotillomania: Definition, causes, diagnosis and treatment

Trichotillomania: Definition, causes, diagnosis and treatment

woman with trichotillomania pulling her eyelashes out

Trichotillomania (pronounced trik-o-till-o-MAY-nee-uh) is a stress-induced disorder that gives someone the urge to pull out the hair from their head, eyebrows, eyelashes or other parts of the body.

While not life threatening, trichotillomania can cause serious mental and emotional distress.

What is trichotillomania? 

Trichotillomania, also known as “TTM” or “trich,” is a mental health disorder characterized by obsessive-compulsive behavior. 

Those who have TTM regularly have unexplained, uncontrollable urges to pull out their hair, even though they make many attempts to stop or decrease the behavior. 

While the scalp is the most common area for hair pulling, the eyelashes, eyebrows and other facial hair can also be affected. 

Over time, continuous hair pulling can cause partial or complete removal and loss of the eyebrows and eyelashes. The scalp may also become patchy and have bald spots of varying degrees.

Cases of trich fall on a large spectrum of severity, affected areas and responsiveness to treatment. The disorder may also become chronic, with symptoms appearing for weeks, months or years at a time.

If professional help isn’t received, TTM can become a lifelong struggle for those affected.

Prevalence 

Researchers suggest approximately 1 or 2 in every 50 people experience some level of trich in their lifetime.

Many times, symptoms begin in late childhood and affect males and females equally. However, 80-90% of reported adult cases are women. 

Some studies have looked into whether hormonal changes that occur at the beginning of a woman’s menstrual cycle, or during pregnancy, impact trichotillomania. While research has provided some evidence of this, the reason behind it is still a mystery.

Risk factors

  • Genetic history – Someone with an immediate relative, such as a parent or sibling, with trichotillomania is more likely to show symptoms of the condition themselves. However, most individuals with trich do not fall under this category.

  • Other mental health conditions – People with trichotillomania often also have a preexisting condition, such as anxiety, depression or obsessive-compulsive disorder.

  • Age – Signs of TTM usually begin between the ages of 10 and 13 and may be present for the foreseeable future.

  • Stress – Severely stressful situations often trigger symptoms.

  • Childhood trauma – It’s possible that a person who experiences childhood trauma may be more likely to develop trich, though there is very little research to support this theory.

SEE RELATED: Trichiasis (ingrown eyelashes)

Causes

The exact cause of trichotillomania is unknown, though there are several theories for what triggers symptoms. These include:

  • Genetic predisposition

  • Chemical imbalance in the brain associated with other mental conditions, such as obsessive compulsive disorder (OCD)

  • How an individual deals with stress

  • Changes in hormone levels during puberty

Emotional states

There can be many reasons someone would begin pulling their hair. Boredom, tension, anxiety, or stress can fuel it, and performing the act can cause a sense of relief, pleasure or gratification.

The act of hair pulling usually falls into one of three emotional states:

  • Automatic hair pulling – The act of pulling the hair when performing a mindless task, such as watching TV, or when bored. The affected person may not even notice they’re pulling their hair out. 

  • Focused hair pulling – Purposefully pulling the hair for the feeling of tension relief. This type of emotional state may include certain rituals, such as pulling hair from specific areas of the body. 

  • Mixed hair pulling – Many of those affected by TTM experience a mixture of emotional states. They may begin pulling the hair automatically, then once they recognize the damage it’s done to their scalp, eyebrows or eyelids, it can cause them anxiety or shame, which may trigger focused hair pulling. 

Symptoms of trichotillomania

People with trich often describe having a feeling on their scalp or skin, such as a tingle or itch, that will only go away by pulling the hair in that area. After pulling the hair, they may have a moment of relief or satisfaction.

Other symptoms of trichotillomania include:

  • Frequent pulling of the hair, causing noticeable hair loss

  • Breaking off pieces of hair

  • Visually examining the hair, rolling it through the fingers, biting or eating the hair after they have pulled it (trichophagy)

Hair pulling typically occurs from the following areas:

  • Scalp

  • Eyelashes

  • Eyebrows

  • Beards or other facial hair

  • Pubic hair

SEE RELATED: Eyelash lice and Eyelash mites

How is trichotillomania diagnosed?

To officially diagnose the condition, your doctor will get information on your medical history and discuss your symptoms with you. Using this information, the doctor will compare your symptoms with the criteria established by the Diagnostic and Statistical Manual of Mental Disorders, which are:

  • Consistently pulling out one’s hair, causing hair loss

  • Repeated attempts to minimize or stop hair pulling

  • Significant distress or interference of social and job-related function caused by the hair pulling

  • No other mental health conditions are present, such as OCD, that may explain the behavior

  • The absence of an underlying skin condition that triggers the urge to pull hair

Resources for those with trichotillomania 

While trichotillomania can cause people to feel isolated and withdrawn from others, it’s important for them to understand that they’re not alone in their experience. Resources to help those with the condition include:

  • National Alliance on Mental Illness (NAMI) – An advocacy group that provides support and education for people and families who experience the effects of mental illness. 

  • SAMHSA’s National Helpline – This free, confidential helpline serves those who are looking for a mental health provider in their area. They can also refer you to local treatment facilities, support groups and community-based resources.

  • The TLC Foundation – The TLC Foundation for Body-Focused Repetitive Behaviors offers support and education to people affected by trichotillomania or similar conditions.

Treatment

Trichotillomania is a difficult condition to treat because each case is unique. There is no universal form of treatment that is effective in all cases. However, there are several strategies, including therapy and medication, that can help people control their urges. 

Behavioral therapy

  • Habit reversal training – Primary treatment used, in which patients learn to recognize triggers and replace their pulling habit with another behavior, such as clenching their fists

  • Cognitive training — Exercises that explore and correct inaccurate beliefs related to hair pulling

  • Process-oriented therapy – Working with a therapist to explore what emotions trigger the pulling

Medication

Several studies have looked at certain serotonin reuptake inhibitors (SSRIs) in treating trichotillomania and skin picking. The following medications are FDA-approved for the treatment of depression or OCD or both:

  • Fluoxetine (Prozac)

  • Fluvoxamine (Luvox) 

  • Sertraline (Zoloft)

  • Citalopram (Celexa)

  • Escitalopram (Lexapro)

  • Paroxetine (Paxil)

Things to try on your own

  • Wear a bandana or tight-fitting hat

  • Squeeze a stress ball or a small, fidget-able object

  • Practice deep breathing until the urge to pull passes

  • Keep a short haircut

  • Exercise

  • Ease stress or anxiety with a bath or other soothing activity that does not involve hair pulling

  • Create a saying to repeat out loud until the urge to pull passes

When to see a doctor

If you regularly give into the urge to pull your hair, see a doctor. Trichotillomania is under-reported because of the shame and embarrassment felt by those who suffer from it. However, getting a proper diagnosis from a doctor can provide you with a treatment plan to help with your symptoms.

How to help someone with trichotillomania

If you believe someone close to you is struggling with TTM, the subject can be delicate and uncomfortable to talk about. However, it’s important to let the person know you’re there to help and support them through their experience.

Some suggestions for how to talk to someone about trichotillomania are:

  • Avoid accusatory language, such as, “why don’t you just stop doing it?” or “maybe you should find a better way to deal with stress.” This will only perpetuate the embarrassment or guilt they already deal with.

  • Ask them how you can help and support them through their journey. Emotional support and acceptance from others can help them work through the shame often associated with the condition and encourage them to seek professional help.

READ MORE: Do Eyelashes Grow Back?

What is Trichotillomania? A Closer Look at Hair-Pulling Disorder. PSYCOM. May 2021.

What is Trichotillomania (Hair Pulling Disorder)? The TLC Foundation for Body-Focused Repetitive Behaviors. Accessed May 2021.

Salivary Sex Hormones in Adolescent Females with Trichotillomania. Psychiatry Research. July 2018.

Trichotillomania. National Organization for Rare Disorders. January 2021.

Trichotillomania (Hair Pulling Disorder). National Health Service. January 2021.

Trichotillomania (Hair Pulling). Mental Health America. Accessed May 2021.

Trichotillomania. Treatment in Psychiatry. September 2016.

Medications for Body-Focused Repetitive Behaviors. The TLC Foundation for Body-Focused Repetitive Behaviors. Accessed May 2021.

Four things to not say to a person with trichotillomania. Anxiety & Depression Association of America. July 2016.

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