Trichotillomania, sometimes referred to as hair-pulling disorder, TTM, or just trich, is a state in which a person has powerful, compulsive urges to pull out hair from the body. The location on the body can vary, as can the severity and the way a person responds to treatment. Treatment options for trichotillomania typically include forms of behavioral therapy. In some cases, a qualified professional may also recommend medication.
Trichotillomania is a condition in which a person repeatedly pulls hair from his or her head (scalp, eyebrows, eyelashes, or beard), arms and underarms, chest, pubic area, legs, or other body parts. The affected area usually displays visible bald patches. Hair pulling may start in one area of the body, such as the scalp, and shift to other areas over time.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies this mental health issue under obsessive-compulsive and related disorders, which is a shift from previous editions that categorized trichotillomania as an impulse-control disorder.
Trichotillomania's prevalence is difficult to predict because it is believed to be grossly underreported due to its social implications. Available research estimates that between 0.6% and 4% of the world’s population experience the condition. TTM predominantly affects women and young girls, beginning in adolescence or young adulthood, with peak onset occurring between the ages of 9 and 13. However, the condition can sometimes affect children and has been documented in children as young as 1 year of age.
This condition has similarities with dermatillomania, or compulsive skin-picking—a state of repetitive touching, scratching, rubbing, or picking at skin, with the intent to remove perceived irregularities or imperfections.
Many people experiencing trichotillomania try to conceal hair loss and balding of the scalp by wearing wigs, scarves, makeup, or hairstyles that hide the signs. Other common signs and symptoms include:
- Excessive touching, playing with, or pulling hair.
- Feeling tension before pulling hair and relief after pulling it.
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- Eating, chewing, or biting pulled-out hair.
- Avoiding situations that could expose bald patches, such as swimming or exposure to rain or wind.
- Anxiety, depression, preoccupation, or a decline in work performance.
- Noticeable changes in social behavior.
Some who experience TTM will pull hair exclusively in solitude, while others pull their hair in public.
According to the Trichotillomania Learning Center, a non-profit organization, there is no identified singular cause of TTM and research on potential causes of this state is still in early stages. Some preliminary studies indicate it may be a neurological condition that is influenced by genetics, though environmental factors likely play an important part in its development.
One available theory suggests trichotillomania occurs when hormone levels change, which is a normal occurrence in adolescence. TTM also commonly occurs in conjunction with an underlying mental health issue. Depression, anxiety, and obsessions and compulsions (OCD) are frequently associated with trichotillomania. Posttraumatic stress (PTSD) has also been known to trigger this state. Sometimes TTM occurs in isolation, without an underlying mental health issues.
The primary psychotherapy treatment for TTM is habit reversal training (HRT), which is a type of cognitive behavioral therapy. It was developed in the 1970s for treating repetitive behaviors such as skin picking, hair pulling, nail biting, or tics.
HRT treats hair pulling as a conditioned response to specific events and situations. A person experiencing trichotillomania is usually unaware of these triggers. The therapy primarily focuses on developing habit awareness, which is facilitated by the affected person keeping records of circumstances in which he or she usually pulls hair. The next step is to teach a person to adopt alternative behaviors in response to these events and situations. During the course of treatment, a person is encouraged to increase his or her awareness of the emotional states, places, times of day, and other circumstances that can encourage hair pulling.
Other psychotherapy options include cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), exposure and response prevention (ERP), and stimulus control techniques. Because people experiencing this issue may feel embarrassed, ashamed, or alone in their experience, they may find comfort and social support from participating in group therapy or joining a support group for people experiencing trichotillomania.
In cases where symptoms are severe, a doctor may prescribe medications—usually antidepressants. Medications usually have a temporary effect on treating trichotillomania, and their usage often occurs in conjunction with some form of psychotherapy.
- Anxiety and Hair Pulling: Roberta, 23, experienced severe anxiety throughout most her adolescence. She developed a habit of playing with her long hair, completely unaware that she was doing so, when feeling anxious and stressed. Over time, she began to pull some of her hair out. The development of this habit was very slow, and she was unaware that she was losing most of her longer hair as a result. When her mother pointed out a large balding spot toward the back of her head, Roberta was afraid that she had a dangerous physiological disease, but then her doctor helped her realize she was experiencing a form of trichotillomania. Roberta was referred to a therapist by her doctor at 21 and came to realize this behavior had been present for almost three years. Her therapist helped her learn how to cope with anxiety through breathing exercises and how to recognize circumstances and conditions that triggered hair pulling. Roberta still struggles with the urge to play with her hair from time to time, but is better equipped to cope with the emotions that cause the compulsion.
- National Health Service. (n.d.). Trichotillomania. Retrieved from http://www.nhs.uk/Conditions/trichotillomania/Pages/causes.aspx
- OCD-UK. (n.d.). Trichotillomania (TTM). Retrieved from http://www.ocduk.org/trichotillomania
- Stein, D. J., Grant, J. E., Franklin, M. E., Keuthen, N., Lochner, C., Singer, H. S., and Woods, D. W. (2010). Trichotillomania (Hair Pulling Disorder), Skin Picking Disorder, and Stereotypic Movement Disorder: Toward DSM-V. Depression and Anxiety. 27: 611–626. Retrieved from http://www.dsm5.org/Research/Documents/Stein_Trich.pdf
- Trichotillomania Learning Center. (n.d.). What Is Compulsive Hair Pulling? Retrieved from http://www.trich.org/about/hair-pulling.html