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Hair-Pulling Disorder

(Trichotillomania)

by Katharine A. Phillips, MD, Dan J. Stein, MD, PhD

In hair-pulling disorder (trichotillomania), people repeatedly pull their hair out, resulting in hair loss.

Hair-pulling is a type of obsessive-compulsive and related disorder (see Obsessive-Compulsive Disorder (OCD)). People with this disorder compulsively pull or pluck out their hair for noncosmetic reasons. They usually pull hair from their scalp, eyebrows, and/or eyelids, but any body hair may be pulled out.

Hair pulling typically begins just before or after puberty. About 1 to 2% of people have the disorder. About 90% of them are female.

Symptoms

How much hair is pulled out and where it is pulled from varies from person to person. Some people have areas of complete baldness. Eyelashes and/or eyebrows may be missing. Other people merely have thinned hair. People may change the spots they pull hair from over time.

Some people pull their hair out somewhat automatically, without thinking about it. Others are more conscious of the activity.

People do not pull out their hair because they are concerned about their appearance (as people with body dysmorphic disorder are—see Body Dysmorphic Disorder). However, they may feel tense or anxious just before they do it, and hair pulling may relieve that feeling. Afterward, they often feel gratified.

Many activities (rituals) may accompany hair pulling. People may painstakingly search for a particular kind of hair to pull. They may roll the hair between their fingers, pull the strands between their teeth, or bite the hair once it is pulled. Many swallow their hair. Many affected people also repeatedly pick at their skin, bite their nails, chew their cheek, or do other repetitive body-focused activities.

Affected people may feel embarrassed by or ashamed of the way they look. They may try to camouflage the hair loss by wearing wigs or scarfs. Some pull out hair from widely scattered areas to disguise the loss. People may avoid situations in which others may see the hair loss. They typically do not pull hair out in front of others, except for family members. People may also be distressed by their loss of control and repeatedly try to stop pulling their hair out.

Some people pull hair from other people or from pets or pull threads from clothing, blankets, or other textiles.

Symptoms typically vary in intensity but may continue throughout life.

Diagnosis

Doctors diagnose hair-pulling disorder based on symptoms:

  • Pulling out enough hair to cause hair loss

  • Repeatedly trying to stop pulling their hair out

  • Feeling greatly distressed or becoming less able to function because of the activity

Treatment

Sometimes doctors prescribe drugs to help control symptoms. Serotonin reuptake inhibitors or clomipramine (types of antidepressants—see Table: Drugs Used to Treat Depression) may help, particularly if the person also has symptoms of depression or anxiety. Acetylcysteine may also be helpful.

Cognitive-behavioral therapy that specifically focuses on this disorder may also lessen symptoms. The form of cognitive-behavioral therapy that is most often used is habit reversal therapy. For this therapy, people are taught to become more aware of what they are doing and to identify situations that trigger the activity. They are also taught strategies to help them stop themselves from pulling hair—for example, by substituting a different activity for hair pulling.

Drugs Mentioned In This Article

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  • ANAFRANIL
  • ACETADOTE