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(Hair-Pulling Disorder)


Katharine A. Phillips

, MD, Weill Cornell Medical College;

Dan J. Stein

, MD, PhD, University of Cape Town

Last full review/revision Jan 2021| Content last modified Jan 2021
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Trichotillomania is characterized by recurrent pulling out of one's hair resulting in hair loss.

Patients with trichotillomania repeatedly pull or pluck out their hair for noncosmetic reasons. Most commonly, they pull hair from their scalp, eyebrows, and/or eyelids, but any body hair may be pulled out. Sites of hair pulling may change over time.

For some patients, this activity is somewhat automatic (ie, without full awareness); others are more conscious of the activity. Hair pulling is not triggered by obsessions or concerns about appearance (as in body dysmorphic disorder) but may be preceded by a feeling of tension or anxiety that is relieved by the hair pulling, which is often then followed by a feeling of gratification.

Patients with hair-pulling disorder try to stop pulling their hair out or to pull less often, but they are unable to do so.

Hair pulling typically begins just before or after puberty. At any given point in time, about 1 to 2% of people have the disorder. About 80 to 90% of adults with trichotillomania are female.

Symptoms and Signs of Trichotillomania

Hair pulling is usually chronic, with waxing and waning of symptoms if untreated.

Patterns of hair loss vary from patient to patient. Some have areas of complete alopecia or missing eyelashes and/or eyebrows; others merely have thinned hair.

A range of behaviors (rituals) may accompany hair pulling. Patients may search fastidiously for a particular kind of hair to pull; they may try to ensure that hair is pulled out in a particular way. They may roll the hair between their fingers, pull the strands between their teeth, or bite the hair once it is pulled. Many patients swallow their hair. Swallowing hair sometimes results in trichobezoars (tightly packed collections of swallowed hair that are unable to exit the gastrointestinal tract), which rarely lead to medical complications (eg, gastric obstruction or perforation) and which may require surgical removal.

Patients may feel embarrassed by or ashamed because of their appearance or their inability to control their behavior. Many try to camouflage the hair loss by covering the bald areas (eg, wearing wigs or scarfs). Some patients pull out hair from widely scattered areas to disguise the loss. They may avoid situations in which other people may see the hair loss; typically, they do not pull hair out in front of others, except perhaps for family members.

Some patients pull hair from others or from pets or pull strands from fibrous materials (eg, clothing, blankets).

Most patients also have other body-focused repetitive behaviors, such as skin picking or nail biting. Many also have major depressive disorder.

Diagnosis of Trichotillomania

  • Clinical criteria

Diagnostic criteria for trichotillomania typically include the following:

  • Removing hair, resulting in hair loss

  • Making repeated attempts to decrease or stop the hair pulling

  • Experiencing significant distress or impairment in functioning from the activity

The distress can include feelings of embarrassment or shame (eg, due to loss of control of one's behavior or the cosmetic consequences of the hair loss).

Treatment of Trichotillomania

  • Selective serotonin reuptake inhibitors (SSRIs) or clomipramine

  • N-Acetylcysteine

  • Olanzapine

  • Cognitive-behavioral therapy (usually habit reversal training)

SSRIs or clomipramine (a tricyclic antidepressant with potent serotonergic effects) may be useful, especially if patients have coexisting depression or anxiety disorders. For hair pulling, clomipramine appears to be more effective than desipramine (a tricyclic antidepressant that inhibits reuptake of norepinephrine). Studies of SSRIs in patients with trichotillomania are limited by small sample sizes and thus insufficient statistical power.

In a controlled trial, N-acetylcysteine (a partial glutamatergic agonist) was effective for adults (1), but in another small study, it was no more effective than placebo in children (2). There is also limited evidence that low-dose dopamine blockers such as olanzapine are effective, but risk:benefit ratio must be carefully assessed.

Cognitive-behavioral therapy that is tailored to treat the specific symptoms of hair-pulling disorder is currently the psychotherapy of choice. Habit reversal training, a predominantly behavioral therapy, is recommended; it includes the following:

  • Awareness training (eg, self-monitoring, identification of triggers for the behavior)

  • Stimulus control (modifying situations—eg, avoiding triggers—to reduce the likelihood of initiating pulling)

  • Competing response training (teaching patients to substitute other behaviors, such as clenching their fist, knitting, or sitting on their hands, for hair pulling)

Treatment references

  • 1. Grant JE, Odlaug BL, Kim SW: N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Arch Gen Psychiatry 66(7):756–763, 2009. doi: 10.1001/archgenpsychiatry.2009.60.

  • 2. Bloch MH, Panza KE, Grant JE, et al: N-Acetylcysteine in the treatment of pediatric trichotillomania: A randomized, double-blind, placebo-controlled add-on trial. J Am Acad Child Adolesc Psychiatry 52(3):231–240, 2013. doi: 10.1016/j.jaac.2012.12.020.

Key Points

  • In trichotillomania, hair pulling is not triggered by obsessions or concerns about appearance but may be preceded by a feeling of tension or anxiety that is relieved by the hair pulling, often followed by a feeling of gratification.

  • Patterns of hair loss vary from areas of thinned hair to missing eyelashes and/or eyebrows to areas of complete alopecia.

  • Patients with trichotillomania try to stop pulling their hair out or to do it less often, but they cannot.

  • Treat using cognitive-behavioral therapy that is tailored to treat specific trichotillomania symptoms (specifically habit reversal training) and possibly clomipramine, an SSRI, N-acetylcysteine, or another drug.

Drugs Mentioned In This Article

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