Trichotillomania (hair pulling)
What is trichotillomania?
Trichotillomania is a mental health condition where a person repeatedly pulls out their hair, resulting in noticeable hair loss. In the DSM-5, the manual used for diagnosis of mental health conditions, the condition is listed in the category of Obsessive Compulsive Disorders (OCD).
It’s common for hair to be pulled from the scalp, but it can also involve eyelashes, eyebrows, the pubic area, anywhere else on the body, or pulling hair from other people or pets.
Understandably, the lives of people with trichotillomania are impacted by the condition; many experience distress, anxiety, shame, or embarrassment. A behavioral therapy called Habit Reversal Therapy, however, can help people reduce their trichotillomania symptoms. Learn more about this condition, as well as the most effective treatment options, below.
Prevalence of trichotillomania
Research suggests that from 0.6% to 3% of Americans may have trichotillomania (1), although, most studies are based on small sample groups, making it difficult to generalize and be sure that the rates reflect the prevalence in the broader US population. Researchers have found that the condition:
- Usually starts in childhood
- May be more common in females than males
- Can be accompanied by other mental health challenges, such as anxiety or depression (1).
Symptoms of trichotillomania
The most visible symptom of trichotillomania is hair pulling which results in noticeable hair loss. People with the condition feel an intense urge to pull out their hair, sometimes with feelings of tension, or in response to a stressful situation, but also sometimes without really being aware of what they are doing. During or after pulling their hair, some people experience a sense of relief or pleasure.
The condition, understandably, causes distress and impacts functioning in daily life. For example, people might spend a lot of time trying to conceal their hair loss by wearing hats, wigs, or styling their hair. People often also experience feelings of:
As a result, people with trichotillomania might avoid social situations or being in public, and they often make repeated attempts to stop or reduce the hair pulling (1).
If this experience resonates with you, it’s important to seek an evaluation from a mental health professional. As trichotillomania can seem similar to some other conditions (like OCD or body dysmorphic disorder), accurate diagnosis is important, so that the most effective treatment option can be selected.
Causes of trichotillomania
We don’t know for sure what causes trichotillomania, but it could be:
- A coping mechanism for dealing with anxiety or stress
- Due to changes in hormone levels
- Due to a chemical imbalance in the brain
Treatment options for trichotillomania
If you are worried about hair pulling, consider one or more of the following options:
- Therapy: Therapy can help people to better manage and reduce their trichotillomania symptoms, leading to an improved quality of life. See below for tips about types of therapy and selecting a therapist.
- Check-ups: It’s important to have a check-up with your doctor, who can help you to get treatment for or rule out physical conditions that may contribute to your symptoms. Medical evaluation is particularly important for people with trichotillomania who also ingest their hair, as this could lead to a blockage in the gastrointestinal system. Your doctor will also be able to treat any damage or infection at the site where you pull hair.
- Medication: There is mixed evidence for the effectiveness of medication in the treatment of trichotillomania (2). In some cases, medication may be helpful, particularly with other co-occurring conditions. If you wish to investigate any potential role of medication, seek an assessment from a psychiatrist.
- Support groups: Talking to others about your experience can help, especially with others who also have the condition. Trichotillomania Support is a worldwide support charity, which has online self-help resources and a forum.
- Hotlines: If you’re having thoughts of suicide or need immediate support, call the National Suicide Prevention Hotline at 1-800-273-8255.
Therapy for trichotillomania
With the help of therapy, many people can successfully reduce their trichotillomania symptoms.
Research suggests that Behavioral Therapy is the most efficacious modality for the treatment of trichotillomania. The most common type of behavioral therapy used with the condition is called Habit Reversal Therapy (2).
Habit Reversal Therapy helps reduce symptoms of trichotillomania by increasing awareness of how and when hair-pulling urges develop. Clients learn to intervene and make changes to their environment to reduce the cues for hair pulling, and replace the habit of hair pulling with alternative behaviors.
Therapists delivering Habit Reversal Therapy may integrate helpful elements of other therapies, such as:
- Acceptance and Commitment Therapy (ACT): ACT helps to address the cognitive and emotional experience of Trichotillomania that is not the key focus in HRT. People learn to react differently to the hair-pulling urges by taking an acceptance approach and defusing the power of thoughts.
- Dialectical Behavior Therapy (DBT): DBT may be a good fit for people for whom hair-pulling is a maladaptive self-soothing behavior that helps to regulate emotions. Alternative emotion regulation and self-soothing skills are taught.
- Cognitive Behavioral Therapy (CBT): CBT equips people with alternative coping strategies and more helpful thinking patterns. This can help to change the unhelpful behaviors associated with the old thinking patterns, such as hair-pulling.
What to look for in a therapist for trichotillomania
There are several factors to keep in mind when selecting a therapist for the treatment of trichotillomania, including:
Specialization: It’s particularly important to look for a therapist who has experience and specialized training in behavioral therapies, and Habit Reversal Therapy in particular, as this has a strong evidence-base for the treatment of trichotillomania. Therapists often include this information in their biography on their website or online profile. Trichotillomania and Habit Reversal Therapy are niche specializations, so make sure to ask your provider if this is a condition they have extensive experience treating.
Qualifications: With so many different provider types available, it can be difficult to decide which type of mental health professional to see. The most important thing is to look for a currently licensed therapist. That said, if you are considering medication as a treatment option, make sure you see a psychiatrist. This particular specialization of mental health professional is able to prescribe.
Personal fit: The trusting relationship between you and your therapist, known as the “therapeutic alliance” can have a huge impact on the efficacy of therapy. Many people with trichotillomania struggle with feelings of shame or embarrassment, so it’s important to work with someone you trust and feel understood by.
The best way to judge how you might feel about a therapist is to ask for a preliminary phone call. This also allows you to ask about their experience and what therapy with them will be like. Try to speak to a few different therapists before deciding on a provider.
- (1) Gail Steketee (Ed), 2011, “Obsessive Compulsive Spectrum Disorders in Children and Adolescents”, The Oxford Handbook of Obsessive Compulsive and Spectrum Disorders
- (2) Jon E. Grant & Samuel R. Chamberlain, 2016, “Trichotillomania”, Am J Psychiatry 173(9). PDF accessed online December 2019 at https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2016.15111432
- Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration (SAMHSA), 2016, “Impact of the DSM-IV to DSM-5 changes on the National Survey on Drug Use and Health”. PDF accessed online December 2019 at https://www.ncbi.nlm.nih.gov/books/NBK519697/pdf/Bookshelf_NBK519697.pdf
- Trichstop, “CBT vs DBT vs ACT - Treatments for Trichotillomania”, https://www.trichstop.com/3-treatments-for-trich
- American Psychological Association, Dictionary of Psychology
- National Health Service, UK, “Trichotillomania”, accessed online December 2019 at https://www.nhs.uk/conditions/trichotillomania/