Trichotillomania (TTM), commonly referred to as the “hair pulling” disorder, is a debilitating anxiety disorder related to obsessive-compulsive disorder involving recurrenting behaviors of pulling your own hair. Pulling one’s own hair out is the essential feature of the diagnostic criteria as the behavior tends to result in consistent hair loss and repeated attempts to decrease or eliminate hair pulling. 

The hair pulling behaviors exhibited may result in ritualistic manners expressed differently on a case by case basis. Some common rituals include searching for a particular kind of hair to pull (e.g., hair with specific texture and color), attempting to pull hair out in a specific way (eg., pulling so root is extracted), and/or examining, touching, or tasting released hair by running it between fingers, putting strands between teeth, biting and swallowing strands. 

Regions of the body with hair growth can be targeted areas for pulling. Hair isn’t necessarily from the scalp but also eyebrows, eyelids, face, arms, legs, pubic region, underarm, beard, and chest. 

The following are some common experiences of TTM:

✅ excessive touching, playing with, or pulling hair
✅ pulling brings tension relief 
✅ eating, biting, chewing hair after pulled out
✅ avoiding bald spot exposure
✅ noticeable social behavior changes

TTM can cause permanent damage to a person’s hair- preventing regrowth, becoming frail,and thinning. This can also cause shame, humiliation, medical complications related to digesting hair.

TTM is a long term development, as the act of pulling hair does not occur instantly. Instead, individuals may experience different intensities of the behavior, such as increased pulling during emotional distressing moments. During moments in life where individuals are able to soothe emotions effectively and manage daily tasks, hair pulling decreases significantly.

Causes of Trichotillomania

Research is as yet undetermined the cause of TTM. Genetics tend to be the leading cause for developments in mental health diagnoses, and TTM seems to be no exception. Some preliminary results indicate the TTM may be a neurological condition influenced by genetics. While other causes are thought to be related with hormone changes at puberty, childbirth, and menopause.

Misrepresentations of TTM can gravely affect an individual’s treatment process and is important to be aware of “what is “and “what is not” the diagnosis. Below are factors that may contribute to TTM and may not contribute: 

💡 diagnosis of OCD
💡 family history of OCD
💡 direct parent with TTM
💡 genetics
💡 onset of hormonal changes
💡 body dysphoria
💡 emotional distress

❌ immunization
❌ hair treatments
❌ diet
❌ other medical illness
❌ cancers/ chemotherapy
❌ medication changes
❌ substances

Misconceptions About Trichotillomania

Misconceptions associated with TTM are usually based on the lack of education. It is also critical to remember the stigmas associated around hair, specifically related to beauty. Individuals managing TTM experience the shame associated with their behaviors though their inability to control the pulling causes a consistent feedback loop that continuously repeats. 

Below are a list of common myths and misperceptions about TTM:

🚫 behaviors are noticeable 
🚫 uncontrollable 
🚫 solely occurs on head and scalp region
🚫 only found in older females
🚫 attributed to a dermatological condition (alopecia)
🚫 will not admit to behaviors
🚫 related to substance use
🚫 can be managed alone
🚫 individuals can stop behavior
🚫 does not cause other psychological concerns

Signs and Symptoms of Trichotillomania

While signs and symptoms of TTM are distinctive to specific behaviors, individuals presenting with TTM symptoms may describe their experience differently. Many individuals with a TTM diagnosis are also diagnosed with OCD as well. However one diagnosis does not preclude the other. It is critical to remember with all mental health diagnoses, the symptoms and changes are not always visible to families and loved ones. Here are the key signs and symptoms to be aware of:

🚩 pulling out hair
🚩 ritualistic behaviors towards pulled hair
🚩 pulling due to emotional change
🚩 isolation 
🚩 emotional distress
🚩 increased stress
🚩 hair loss / baldness
🚩 thinned hair / alopecia
🚩 low self-esteem
🚩 pulling of pets and/or doll hair 
🚩 pulling fabrics
🚩 struggling to engage in work or school
🚩 biting nails
🚩 lip chewing 
🚩 skin picking
🚩 hair pulling brings pleasure or relief
🚩 scalp sensations such as tingling
🚩 stomach issues due to ingesting hair
🚩 hiding where hair was pulled
🚩 neck, shoulder, or upper back pain
🚩 attempts to conceal hair loss
🚩 pulling hairs in all areas of body
🚩 feeling a loss of control
🚩 embarrassment / shame

Diagnosing Trichotillomania

If the signs and symptoms above validate a potential diagnosis of TTM, consider seeking a psychiatric evaluation completed by a licensed doctor, such as a psychiatrist or psychologist. These mental health professionals specialize in the diagnosing specifically related to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) disorders and hold the knowledge from experience to distinguish distinctive characteristics. 

Since TTN presents with specific criteria of symptoms, it is common to experience other symptoms unrelated. It is critical to be assessed for specific TTN symptoms as well as other potential mental health disorders. The current diagnostic criteria for TTN are:

⚠️ recurrent pulling out of one’s hair

    • widely distributed pattern of hair pulling (e.g., pulling strands)
    • resulting in hair loss
    • hair loss is not visible
    • most common sites include; scalps, eyebrows, and eyelids
    • less common are armpits, facial, pubic, and perirectal 

⚠️ repeated attempts to decrease or stop hair pulling

    • episodes of pulling may vary from minutes to several hours
    • symptoms can vary for months to years

⚠️ hair pulling causes significant distress 

    • impairment in social and occupational
    • impairment in daily functioning 

⚠️ hair pulling or loss is not attributed to another medical condition dermatological condition

    • side effect of medication or treatments 
    • body dysmorphia in attempts to perceive a perceived flaw in appearance 

TTN behaviors are divided between two subtypes/styles known as:

🔸 automatic hair pulling 

    • occurs during sedentary activities
    • lying in bed, watching tv, or reading

🔸 focused hair pulling 

    • occurs when hair is intentionally pulled out
    • searching for specific hairs to pull out

Conditions Commonly Mistaken for Trichotillomania

Within the DSM format, TTM falls under the related disorders subsections in the OCD chapter. As discussed throughout, OCD is a common occurring disorder related to TTM and can potentially lead to other symptoms. Though this statement does not hold true to every life experience. The DSM is aware of these potentially overlaps in disorders and other conditions such as: 

✳️ OCD and other related disorders such as body dysphoria can show hair pulling behaviors as a result of OCD rituals or disapproval towards one’s appearance. 
✳️ normative hair removal / manipulation can be defined as hair twisting and playing with hair, which would not suggest a TTM diagnosis, even with behaviors of biting hair. 
✳️ neurodevelopmental disorders such as tic disorders, hair pulling may act as a result of the movement disorder. 
✳️ psychotic disorder may cause individuals to remove hair in response to experienced  hallucination and delusion. 
✳️ substance related disorders can cause hair pulling behaviors as stimulants may trigger behaviors of hair pulling.

Treating Trichotillomania

Managing everyday life with TTN through treatment options such as therapies can assist in symptom reduction and remission of the disorder. For proper assessment and evaluation, a psychiatrist or psychologist will perform a psychiatric evaluation to complete a questionnaire specific to daily function and lived experiences. While there are many diverse feelings around disclosing personal information to a new provider, symptoms of TTN can be life threatening and physically detrimental causing a need for future testing from the provider. The doctor will either complete or request lab work, a physical exam, and any other tests to rule out medical concerns that arise  from TTN symptoms.  

Diagnosing practitioners may referral individuals to other complementary treatment modalities such as:   

🧬 habit reversal therapy
🧬 behavioral therapy
🧬 psychopharmacology
🧬 family therapy
🧬 medication management
🧬 support groups

Healthcare Professionals Who Treat Trichotillomania

For the best results in a successful treatment of TTN, seek providers that have specialties in the assessment, treatment, diagnosis, and continuing support of patients diagnosed with TTN. 

Many medical and mental health providers are familiar with the diagnosis of TTN.  However if your chosen provider is not, they should always provide a knowledgeable referral source. Specialized providers will have the capabilities to diagnose using various testing methods to decrease the likelihood of misdiagnoses and unnecessary treatments. 

If you choose to utilize medication, psychotherapy should always be incorporated in treatment planning. 

The following are professionals involved in the treatment of TTN:

🧠 psychiatrist
🧠 physician 
🧠 psychologist
🧠 therapist 
🧠 nurse practitioner


Recognizing Immediate Need for Trichotillomania

When it comes to determining a need to seek treatment, best practice is to consider yourself the expert of your body and mind. If you are noticing changes that need to be addressed, follow that intuition and seek support. If there are noticeable changes and difficulties in completing daily tasks and functions then this is a clear sign to connect with a provider. 

The following symptoms are cause for concern that may suggest the need for professional help:

🚨suicidal thoughts
🚨changes in relationships
🚨self harm
🚨intrusive thoughts
🚨social isolation
🚨inability to complete daily tasks
🚨disengagement in hobbies

Trichotillomania Professional Organizations

Provided are some resources to help the start of seeking support for Trichotillomania. Though these are national links, consider narrowing options down by searching in your current location.