Close-up of a woman winding her long black hair around a finger.

Trichotillomania, also known as hair-pulling disorder, is a mental health condition characterized by recurrent pulling out of one's hair from anywhere on the body, resulting in noticeable hair loss. People with this condition experience a wide range of emotions, spanning from boredom to anxiety, frustration, and depression that can trigger hair-pulling episodes. Despite repeated attempts to stop, individuals feel unable to control their urges to pull.

Trichotillomania affects approximately 1.14% of the population, with an estimated 1%-2% of people in the U.S. experiencing the condition over a 12-month period. While once thought to be rare, research now shows that between 1.1% and 1.7% of Americans (3-6 million people) have this disorder. Understanding trichotillomania is crucial for both those affected and their loved ones, as proper treatment can significantly improve quality of life.

Table of Contents

  • What Is Trichotillomania?
  • Signs and Symptoms
  • Why Do People Pull Their Hair?
  • Causes and Risk Factors
  • Diagnosis and Assessment
  • Treatment Options
  • Living with Trichotillomania
  • Treatment for Children and Adolescents
  • Frequently Asked Questions
  • How Therapy Can Help

What Is Trichotillomania?

Trichotillomania (TTM), also known as hair-pulling disorder, was first described in ancient Greece, but its current name was coined in the later part of the 18th century. The condition is currently classified under Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

According to the DSM-5, trichotillomania involves five key criteria:

  • Recurrent hair pulling resulting in hair loss
  • Repeated attempts to decrease or stop the behavior
  • Significant distress or impairment in functioning
  • Hair pulling not attributable to another medical condition
  • Symptoms not better explained by another mental disorder

Body-focused repetitive behavior disorders (BFRBs) include Trichotillomania (TTM; Hair pulling disorder) and Excoriation (Skin Picking) Disorder (SPD). BFRBs is an umbrella term for undesirable, repetitive motor activities such as trichotillomania, skin picking disorder, nail biting, cheek chewing, lip biting, finger sucking, finger cracking, and teeth grinding.

Common Hair-Pulling Sites

Trichotillomania is usually confined to one or two areas of the body, but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, and legs. Some less common areas include the pubic area, underarms, beard, and chest.

Signs and Symptoms

Physical Signs

People with trichotillomania often display:- Hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble

  • Visible bald patches or thinning areas- Normal overall hair density with scaling on the scalp not present, and a negative hair-pull test (the hair does not pull out easily)

Hair often pulled out leaving an unusual shape

Behavioral Patterns

Hair pulling may occur across a variety of settings and both sedentary and active activities. There are times when pulling occurs in a goal-directed manner and also in an automatic manner in which the individual is less aware. Many individuals report noticeable sensations before, during, and after pulling.

The behavior can manifest in two primary ways:

  • Automatic pulling: Out of awareness, for example while studying, reading, talking on the phone, sitting at a desk, or on a computer
  • Focused pulling: Intentional, for example done purposely for a purpose (e.g., looking in the mirror and picking acne to smooth skin or pulling hairs that don't "feel right")

Emotional Impact

For some people, trichotillomania is a mild problem, merely a frustration. But for many, shame and embarrassment about hair pulling cause painful isolation and result in a great deal of emotional distress, placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder.

Why Do People Pull Their Hair?

A close-up of a red-headed woman plucking out most of her eyebrow.

A brief positive feeling may occur as hair is removed, which can reinforce the behavior. People with trichotillomania pull their hair for various reasons:

  • Sensory seeking: Some seek specific sensations, such as the feel of a hair root popping out
  • Response to physical sensations: Itching or tingling near targeted hair
  • Perfectionism: Searching for "flawed" hairs to remove
  • Emotional regulation: Emotion regulation is postulated to play an important role in Trichotillomania (TTM). Whilst a growing number of studies have examined the relationship between emotion regulation difficulties and TTM symptoms

There was a moderately sized association between TTM symptoms and emotion regulation difficulties (r adjusted = 0.32, 95% CI [0.28, 0.37]), suggesting that difficulty managing emotions plays a significant role in hair-pulling behaviors.

Causes and Risk Factors

Genetic Factors

Trichotillomania (TTM) and excoriation disorder (ED) run in families and are thought to have shared etiological underpinnings. Research shows:- Genetics play a role: Research suggests that OCD and BFRBs share genetic risk factors, meaning if someone in your family has one of these conditions, you might be more likely to develop it as well. Around 17-18% of people with BFRBs have a family member with OCD. This number is higher than in the general population, showing that OCD and BFRBs can run in families

Neurobiological Factors

StatPearls Publishing; 2023 Jan reports that recent neuroimaging studies have identified brain differences in people with trichotillomania:

  • Altered grey and white matter volumes
  • Changes in neural circuits involving motor control and emotion regulation- Many behavioral models have been developed in an attempt to explain the emergence and continuity of BFRBs, focusing on studies referring to stimulus regulation models, sensorial processing, emotion regulation, prevented action, and behavioral addiction

Hormonal Influences

In a study of adolescent girls with trichotillomania, researchers found that lower progesterone was associated with worse hair-pulling severity (NIMH Trichotillomania Symptom Severity Scale, NIMH-TSS), and that lower levels of all three hormones were associated with greater psychosocial dysfunction. Progesterone is believed to modulate the adaptive response to stress, mainly through the effect of its neurosteroid metabolite allopregnanolone on GABAA receptor activity.

Age of Onset

Both conditions onset frequently in adolescence, with TTM typically beginning around 13 years of age. Trichotillomania and Excoriation most often have an onset of adolescence, often coinciding with puberty.

Diagnosis and Assessment

Clinical Assessment Tools

Mental health professionals use several standardized tools to assess trichotillomania:

1. Clinical Interview: The Trichotillomania Diagnostic Interview (TDI) is a semi-structured interview that provides a 3-point clinician rating of each Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for TTM. Its format ensures that each criterion is investigated and allows for ratings to indicate threshold, subthreshold, and absent symptomatology. The TDI takes approximately 10–15 min to administer

2. Severity Scales:- The National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS) consists of five questions related to the following aspects of TTM: average time spent pulling, time spent pulling on the previous day

The MGH-HS is a seven-item self-report measure of hair pulling severity over the previous week. Items assess the frequency, intensity, and perceived control of hair-pulling urges, as well as the frequency, resistance, perceived control, and distress related to hair pulling. Each item is scored on a Likert-type scale from 0 to 4 and summed to produce a total severity score (range = 0–28). A higher score indicates higher symptom severity

Determining Treatment Response

A 45% decrease or a seven-point reduction in the MGH-HPS and a 30–40% or a six-point reduction on the NIMH-TSS were the optimal cut-points corresponding to being "very much improved" or "much improved" on the CGI.

Treatment Options

Behavioral Therapy: The Gold Standard

Behavioral therapy with habit-reversal training components (BT-HRT) demonstrated a large benefit compared to control conditions (standardized mean difference [SMD] [95% CI] = -1.22 [-1.71, -0.73], p <.0001) for improving TTM symptoms.

Habit Reversal Training (HRT)

One of the two primary interventions for BFRBs is Habit-Reversal Training (HRT). In this treatment, patients focus on engaging in behaviors that prevent them from doing the BFRB. This is done through psychoeducation and functional analysis, awareness training, stimulus control, and competing response training.

Acceptance-Enhanced Behavior Therapy (A-EBT)

When considering both the magnitude of effect sizes and replication, strong support was found for the efficacy of three interventions: behavioral therapy with habit reversal, Acceptance and Commitment Therapy-enhanced habit reversal therapy, and N-acetylcysteine.

Consistent with a priori hypotheses, 64% of the adults treated with AEBT-TTM were classified as clinical responders at post-treatment relative to 38% treated with PST. Clinical responders were identified by a score of 1 or 2 on the Clinical Global Impressions-Improvement (CGI-I) scale.

Comprehensive Behavioral Treatment Model (ComB)

The other therapy for BFRBs is the Comprehensive Behavioral Treatment Model (ComB). With ComB, people learn to identify five components to their BFRBs – sensory, cognitive, affect, motoric, and place – and by changing some of those, improve the BFRB.

Pharmacological Treatment

N-Acetylcysteine (NAC)

Strong support was found for the efficacy of N-acetylcysteine as a treatment option.

Other Medications

Grant JE, Chesivoir E, Valle S, Ehsan D, Chamberlain SR. Double-blind placebo-controlled study of memantine in trichotillomania and skin-picking disorder. Am J Psychiatry. 2023;180:348-56 showed promising results for memantine in treating trichotillomania.

Systematic review: Pharmacological and behavioral treatment for trichotillomania found that while some medications show promise, behavioral therapy generally produces superior outcomes.

Novel Treatment Approaches

Brain Stimulation

A new protocol that included intensified and repeated stimulation during 16 sessions, every other day, 2 sessions one day, current intensity of 2 mA for 20 minutes, with regions dorsolateral prefrontal cortex (DLPFC) and supplementary motor area (SMA): Anodal (F3) and cathodal (SMA) were selected as stimulation target areas. The results showed that after the electrical stimulation intervention and also in the follow-up phase, there was a significant improvement in hair pulling behavior and psychiatric evaluations such as depression and anxiety.

Digital Interventions

Of participants in the treatment condition, 52.8% met treatment responder status compared to 15% in the waitlist condition from pre- to posttreatment. From pretreatment to follow-up, 30.5% met treatment responder status in the treatment condition compared to 10% in the waitlist condition. This study provides support for the efficacy of A-EBT in a fully automated format, which may have notable implications for treatment accessibility.

Living with Trichotillomania

Impact on Daily Life

Individuals with TTM or ED experience distress and impairment in psychosocial functioning due to their behaviors. They may spend considerable amounts of time engaged in these body-focused repetitive behaviors (BFRBs) and feel ashamed, causing them to avoid activities and interfering with daily tasks.

Coping Strategies

Although the severity of hair pulling varies widely, many people with hair pulling disorder have noticeable hair loss, which they attempt to camouflage. Thinning or bald spots on the head may be covered with hairstyles, scarves, wigs, or makeup.

Long-term Outcomes

Mixed-effects regression models showed a significant decrease in symptom severity from baseline to posttreatment, with gains maintained up to the 12-month follow-up. Substantial and durable improvements were also seen on self-reported symptoms, self-reported depression, and global functioning.

Treatment for Children and Adolescents

Body-focused repetitive behavior disorders, including trichotillomania (hair-pulling disorder) and excoriation (skin picking) disorder, typically emerge in early adolescence. Participants were 63 children and adolescents (51 girls; age range 9–17) with a diagnosis of trichotillomania (n = 33) and/or skin-picking disorder (n = 33).

Pediatric Treatment Outcomes

The optimal cut points to determine treatment response were a 45% reduction on the MGH-HPS, a 35% reduction on the NIMH-TSS, a 25% reduction on the TSC child version (TSC-C), and a 45% or 50% reduction on the TSC parent version (TSC-P).

Twenty-eight adolescents and their caretakers completed measures at pre-treatment, post-treatment, three-, six-, and 12-month follow-up timepoints. Medium to large decreases were found over time for adolescent and parent-reported trichotillomania severity, trichotillomania-related distress, and mental health functioning. Results also indicated small and medium improvements in adolescent-reported trichotillomania-related psychological inflexibility. These results present preliminary and promising long-term outcomes following AEBT for trichotillomania in adolescents.

Frequently Asked Questions

What percentage of people have trichotillomania?

Meta-analyses indicated TTM had a prevalence of 1.14% (95% CI 0.66%, 1.96%), affecting approximately 1 in 88 people. However, if visible hair loss isn't required, 12 in 100 people may engage in some form of hair-pulling behavior.

Does trichotillomania affect men and women differently?

Women and men experience trichotillomania at similar rates, but women are more likely to have hair loss. Although women more frequently self-identify as having Trichotillomania than men, at a ratio of 10:1, there is likely no significant gender difference.

Is trichotillomania related to OCD?

Due to genetic links between trichotillomania and obsessive-compulsive disorder (OCD), trichotillomania is classified as an obsessive-compulsive related disorder (OCRD) in the DSM-5. 22-29% of individuals with trichotillomania also have OCD, highlighting that BFRBs and OCD often occur together. Individuals with OCD are also at greater risk for BFRBs, as 10-30% of individuals with OCD also have a BFRB.

Can trichotillomania go into remission?

Trichotillomania can go into remission-like states where the individual may not experience the urge to pull for days, weeks, months, and even years. However, without treatment, symptoms often return.

What are the most effective treatments for trichotillomania?

Strong support was found for the efficacy of three interventions: behavioral therapy with habit reversal, Acceptance and Commitment Therapy-enhanced habit reversal therapy, and N-acetylcysteine. In general, psychotherapeutic interventions that involved habit reversal were found to be superior to interventions without habit reversal.

How long does treatment typically take?

The standard course of AEBT is 10 sessions. At this time, there are nine studies examining AEBT and one study examining ACT as a standalone treatment for trichotillomania. This study was followed by a small randomized clinical trial (RCT) where AEBT was compared to a waitlist with 25 participants with trichotillomania.

How Therapy Can Help

Despite the efficacy of habit reversal training (HRT) and ACT-enhanced behavior therapy (A-EBT), there is a significant knowledge gap among providers about evidence-based treatments. This study aimed to bridge this gap by evaluating the feasibility, acceptability, and effects of internet-delivered therapist training in A-EBT for trichotillomania. A randomized waitlist-controlled implementation trial was conducted with 119 licensed mental health providers assigned to either immediate training or waitlist cohorts. The immediate training group participated in a 1-day online workshop followed by 6 months of consultation. Compared to the waitlist cohort, the immediate training cohort showed significant improvements in knowledge of trichotillomania, its treatments, and self-efficacy in providing the therapy.

If you or someone you know is struggling with trichotillomania, finding a therapist experienced in treating body-focused repetitive behaviors is crucial. Dissemination of information about trichotillomania and its treatment remains a critical next step in the field, since many affected individuals and their families experience difficulties with finding local treatment providers with sufficient knowledge to deliver interventions known to reduce hair pulling behaviors and associated symptoms.

Treatment can help you:

  • Learn to identify and manage triggers
  • Develop healthy coping strategies
  • Reduce hair-pulling frequency and severity
  • Address underlying emotional difficulties
  • Improve quality of life and self-esteem
  • Build a support network

The path to recovery is possible with the right support and evidence-based treatment approaches.

Find a Therapist

Ready to take the first step toward managing trichotillomania? Use the GoodTherapy directory to find a qualified therapist in your area who specializes in treating body-focused repetitive behaviors. Many therapists now offer both in-person and teletherapy options, making treatment more accessible than ever before.

Search for a Therapist

References:

  1. Anxiety and Depression Association of America. (2023). Body-Focused Repetitive Behaviors (BFRBs). https://adaa.org/understanding-anxiety/co-occurring-disorders/body-focused-repetitive-behaviors
  2. Alexander, J. R., Geller, D. A., Twohig, M. P., Crosby, J. M., & Woods, D. W. (2024). Neurocognitive Functioning in Adults with Trichotillomania: Predictors of Treatment Response and Symptom Severity in a Randomized Control Trial. International Journal of Cognitive Therapy, 17(3), 425-445. https://doi.org/10.1007/s41811-024-00219-5
  3. Capel, L. K., Petersen, J. M., Becker, L. J., Hurtado, C. D., Woods, D. W., & Levin, M. E. (2024). Psychosocial Treatment of Trichotillomania: A Review. Cognitive and Behavioral Practice. https://doi.org/10.1016/j.cbpra.2024.03.001
  4. Capel, L. K., Twohig, M. P., & Levin, M. E. (2026). The efficacy of psychotherapeutic and pharmacological interventions for trichotillomania: A review and meta-analysis. Journal of Psychiatric Research, 176, 145-156. https://doi.org/10.1016/j.jpsychires.2026.01.023
  5. Carlson, E. J., Malloy, E. J., Brauer, L., Golubchik, P., Weizman, A., & Haaga, D. A. F. (2023). Longitudinal outcomes from a pilot randomized controlled trial of telehealth acceptance-enhanced behavior therapy for adolescents with trichotillomania. Journal of Obsessive-Compulsive and Related Disorders, 37, 100800. https://doi.org/10.1016/j.jocrd.2023.100800
  6. Chen, D., Farhat, L. C., Lebowitz, E. R., Silverman, W. K., Bloch, M. H., Fernandez, T. V., & Olfson, E. (2025). Investigating the familiality of trichotillomania and excoriation disorder. Psychiatry Research, 350, 116560. https://doi.org/10.1016/j.psychres.2025.116560
  7. Christensen, R. E., Tan, I., & Jafferany, M. (2023). Recent advances in trichotillomania: a narrative review. Clinical, Cosmetic and Investigational Dermatology, 16, 151-157. https://doi.org/10.2147/CCID.S390017
  8. Crowe, E., Staiger, P. K., Bowe, S. J., Rehm, I., Moulding, R., Herrick, C., & Hallford, D. J. (2024). The association between trichotillomania symptoms and emotion regulation difficulties: A systematic review and meta-analysis. Journal of Affective Disorders, 346, 88-99. https://doi.org/10.1016/j.jad.2023.11.010
  9. Farhat, L. C., Olfson, E., Nasir, M., Levine, J. L. S., Li, F., Miguel, E. C., & Bloch, M. H. (2020). Measuring Treatment Response in Pediatric Trichotillomania: A Meta-Analysis of Clinical Trials. Journal of the American Academy of Child & Adolescent Psychiatry, 59(9), 1083-1096. https://doi.org/10.1016/j.jaac.2019.10.010
  10. Farhat, L. C., Olfson, E., Nasir, M., Levine, J. L. S., Li, F., Miguel, E. C., & Bloch, M. H. (2020). Pharmacological and behavioral treatment for trichotillomania: An updated systematic review with meta-analysis. Depression and Anxiety, 37(8), 715-727. https://doi.org/10.1002/da.23028
  11. Flagstad, E., Hummelen, B., Moen, E., Dammen, T., Haaland, Å., Sunde, T., Hansen, B., Johnsen, D. S., Woods, D., & Grøtte, T. (2025). Early maladaptive schemas in trichotillomania and skin-picking disorder: their relationships with symptom severity and subtypes. BMC Psychology, 13(1), 789. https://doi.org/10.1186/s40359-025-03096-y
  12. Grant, J. E., Chesivoir, E., Valle, S., Ehsan, D., & Chamberlain, S. R. (2023). Double-blind placebo-controlled study of memantine in trichotillomania and skin-picking disorder. American Journal of Psychiatry, 180(5), 348-356. https://doi.org/10.1176/appi.ajp.20220735
  13. Grant, J. E., Dougherty, D. D., & Chamberlain, S. R. (2020). Prevalence, gender correlates, and co-morbidity of trichotillomania. Psychiatry Research, 288, 112948. https://doi.org/10.1016/j.psychres.2020.112948
  14. Grant, J. E., Valle, S., Aslan, I. H., & Chamberlain, S. R. (2021). Statistical predictors of psychosocial impairment in body-focused repetitive behaviors. CNS Spectrums, 26(4), 372-378. https://doi.org/10.1017/S1092852921000468
  15. International OCD Foundation. (2025). Body-Focused Repetitive Behaviors (BFRBs). https://iocdf.org/about-ocd/related-disorders/body-focused-repetitive-behaviors/
  16. Lin, A., Farhat, L. C., Flores, J. M., Levine, J. L. S., Fernandez, T. V., Bloch, M. H., & Olfson, E. (2023). Characteristics of trichotillomania and excoriation disorder across the lifespan. Psychiatry Research, 322, 115120. https://doi.org/10.1016/j.psychres.2023.115120
  17. Pereyra, A. D., & Saadabadi, A. (2023, June 26). Trichotillomania. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493186/
  18. Rautio, D., Andrén, P., Bjureberg, L., Silverberg-Mörse, M., Mataix-Cols, D., & Fernández de la Cruz, L. (2024). Body-Focused Repetitive Behavior Disorders in Children and Adolescents: Clinical Characteristics and Treatment Outcomes in a Naturalistic Setting. Behavior Therapy, 55(2), 376-390. https://doi.org/10.1016/j.beth.2023.07.010
  19. Seyrek, S. K., & Cop, E. (2023). Body Focused Repetitive Behavior Disorders: Behavioral Models and Neurobiological Mechanisms. Turkish Journal of Psychiatry, 34(3), 195-205. https://doi.org/10.5080/u26897
  20. Shabani, M. J., Mohsenabadi, H., Zanjani, Z., Lee, C. T., & Shabani, M. (2024). Safety and Efficacy of an Intensified and Repeated Transcranial Direct Current Stimulation Targeting Supplementary Motor Area and Dorsolateral Prefrontal Cortex in Trichotillomania: A Case Report. Clinical Psychopharmacology and Neuroscience, 22(1), 195-203. https://doi.org/10.9758/cpn.23.1125
  21. Thomson, H. A., Farhat, L. C., Olfson, E., Levine, J. L. S., Bloch, M. H., & Fernandez, T. V. (2022). Prevalence and gender distribution of trichotillomania: A systematic review and meta-analysis. Journal of Psychiatric Research, 153, 73-81. https://doi.org/10.1016/j.jpsychires.2022.06.058
  22. TLC Foundation for Body-Focused Repetitive Behaviors. (2025). Hair Pulling | Trichotillomania | BFRB. https://www.bfrb.org/hair-pulling
  23. Woods, D. W., Twohig, M. P., Saunders, S. M., Franklin, M. E., Compton, S. N., Neal-Barnett, A. M., & Sah, P. K. (2022). Acceptance-Enhanced Behavior Therapy for Trichotillomania in Adults: A Randomized Clinical Trial. Behaviour Research and Therapy, 158, 104191. https://doi.org/10.1016/j.brat.2022.104191
  24. Woolley, M. G., Becker, L. J., Capel, L. K., Levin, M. E., & Twohig, M. P. (2025). The Effectiveness and Feasibility of a Quasi–Stepped Care Approach Using A-EBT for Adults With Trichotillomania: An Open Trial. Behavior Therapy, 56(4), 851-865. https://doi.org/10.1016/j.beth.2024.12.008