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 Body Dysmorphic Disorder Body dysmorphic disorder is characterized by preoccupation with perceived defects in physical appearance that are not apparent or appear only slight to other people. The preoccupation with appearance... read more ) 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. In clinical samples, 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 Bezoars A bezoar is a tightly packed collection of partially digested or undigested material that most commonly occurs in the stomach. Gastric bezoars can occur in all age groups and often occur in... read more (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 Body-Focused Repetitive Behavior Disorder Body-focused repetitive behavior disorder is characterized by body-focused repetitive behaviors other than skin picking (excoriation) or hair pulling (trichotillomania) (eg, nail biting, lip... read more , such as skin picking Excoriation (Skin-Picking) Disorder Excoriation disorder is characterized by recurrent picking of one's skin, resulting in skin lesions. Patients with excoriation disorder repeatedly pick at or scratch their skin; the picking... read more or nail biting. Many also have major depressive disorder Major depression (unipolar disorder) Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more .
Diagnosis of Trichotillomania
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) 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
While alopecia has a range of causes, individuals with trichotillomania typically volunteer that their alopecia is due to hair-pulling.
Treatment of Trichotillomania
Cognitive-behavioral therapy (usually habit reversal training)
Selective serotonin reuptake inhibitors (SSRIs) or clomipramine
N-Acetylcysteine or memantine (glutamate modulators)
Cognitive-behavioral therapy that is tailored to treat the specific symptoms of hair-pulling disorder is the preferred initial therapy (1 Treatment references 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... read more ). 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)
Limited data suggests clomipramine (a tricyclic antidepressant with potent serotonergic effects) may be useful for reducing severity of symptoms (2 Treatment references 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... read more ). Clomipramine appears to be more effective than desipramine (a tricyclic antidepressant that inhibits reuptake of norepinephrine) (3 Treatment references 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... read more ). Studies of SSRIs in patients with trichotillomania are limited by small sample sizes and thus insufficient statistical power.
In randomized trials, the glutamate modulators N-acetylcysteine and memantine were effective for adults (4, 5 Treatment references 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... read more ). However, in a small study in children, N-acetylcysteine was no more effective than placebo (6 Treatment references 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... read more ). There is also limited evidence that low-dose dopamine blockers such as olanzapine are effective, but risk:benefit ratio must be carefully assessed.
1. Farhat LC, Olfson E, Nasir M, et al: Pharmacological and behavioral treatment for trichotillomania: An updated systematic review with meta-analysis. Depress Anxiety 37(8):715-727, 2020. doi: 10.1002/da.23028
2. Hoffman J, William T, Rothbart R, et al: Pharmacotherapy for trichotillomania. Cochrane Database Syst Rev 9(9):CD007662, 2021. doi: 10.1002/14651858.CD007662.pub3
3. Swedo SE, Leonard HL, Rapoport JL, et al: A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med
4. 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
5. Grant JE, Chesivoir E, Valle S, et al: Double-blind placebo-controlled study of memantine in trichotillomania and skin-picking disorder. Am J Psychiatry 180(5):348-356, 2023. doi: 10.1176/appi.ajp.20220737
6. 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
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 an SSRI or clomipramine, N-acetylcysteine, or memantine.
Drugs Mentioned In This Article
|Drug Name||Select Trade|
|Acetadote, CETYLEV, Mucomyst, Mucosil Acetylcysteine|
|Namenda, Namenda XR|
|Zyprexa, Zyprexa Intramuscular, Zyprexa Relprevv, Zyprexa Zydis|