OCD
Trichotillomania: causes, symptoms and treatment
Trichotillomania, or hair-pulling disorder, explained: how it is defined, how common it is, how it differs from OCD, and what habit reversal and medication studies show.
Trichotillomania is repeatedly pulling out your own hair, from the scalp, eyebrows, eyelashes or elsewhere, to the point of hair loss. It is a recognised mental health disorder, not a “bad habit” or a matter of willpower. The treatment with the most evidence is a specific behavioural therapy called “habit reversal”. Medication plays a smaller role.
How it is defined
In the American diagnostic manual DSM-5, a diagnosis requires all five of the following:
repeated hair pulling that leads to hair loss
repeated attempts to reduce or stop it
significant distress or difficulty in social life, at work or in other areas
the hair loss is not due to another condition, for example a skin condition
it is not better explained by another mental disorder, such as constant preoccupation with a perceived “flaw” in appearance (body dysmorphic disorder)
DSM-5 placed it in the same group as obsessive-compulsive disorder, excoriation disorder (repeated skin picking), body dysmorphic disorder and hoarding disorder.
How common is it, and when does it start?
Frequency: small studies in the general population find rates of 0.5% to 2%. In a 2020 online survey of 10,169 adults in the US, 1.7% had trichotillomania at the time.
Men and women: older studies in adults found four women for every man. In the 2020 survey the rates were almost the same (1.8% in men, 1.7% in women).
Age of onset: most studies find onset at 10 to 13 years of age. In the 2020 survey the average was 17.7 years: 14.8 in women and 19 in men.
Without treatment, trichotillomania often lasts for years, with better and worse periods. In two studies of adults, its average duration was almost 22 years.
What it looks like in everyday life
The most common site is the scalp (72.8% in one study), followed by the eyebrows (56.4%) and the pubic area (50.7%). Pulling takes two forms, which often occur together:
“Automatic”: it happens without full awareness. Some people only notice when they see the hairs around them.
“Focused”: it starts when a hair looks or feels “wrong”: coarse, irregular, “out of place”.
What triggers pulling can be a sensation (the thickness or length of a hair), a feeling (anxiety, boredom, tension, anger) or a thought about your hair and appearance. One explanation researchers give: pulling brings temporary relief from unpleasant feelings, and that relief keeps it going.
Hair loss often brings shame, low self-esteem and social anxiety. Almost one in three adults report low or very low quality of life. In a study with 1,048 people, only 27.3% had sought help from a psychiatrist.
Shame does not cure pulling. Self-compassion is not self-pity; it is recognising your own strength. A question that helps: “What would I say to a child struggling with the same thing?”
Is it obsessive-compulsive disorder?
No, although the two are often confused. They are similar in the repeated movements, but they differ in important ways:
In OCD, compulsions usually start from unwanted thoughts. Hair pulling rarely starts from obsessive thoughts.
Trichotillomania usually starts in early adolescence, OCD later.
In OCD the psychotherapy is exposure and response prevention; in trichotillomania it is habit reversal.
SSRI antidepressants help in OCD, while in trichotillomania they have not shown a clear benefit.
At the same time, OCD is more common in people with trichotillomania (13% to 27%) than in the general population (1% to 3%). Other repetitive behaviours, such as skin picking and nail biting, often occur as well.
What else occurs alongside it
In the 2020 survey, 79% of people with trichotillomania had another mental health difficulty as well. The most common were anxiety and depression, OCD, post-traumatic stress disorder (PTSD) and ADHD. That is why the assessment looks at the whole picture, not just the hair.
How it is treated
Habit reversal. It is the first-choice psychotherapy. It includes:
self-monitoring: when, where and how much you pull
awareness training, so that you catch the movement before it happens
a “competing” hand movement that makes pulling impossible
changes to your surroundings, so that there are fewer triggers
It is usually done once a week, over 4 to 22 sessions, in person, online or in a group. In a pooled analysis of 24 randomised studies with 857 participants, behaviour therapy with habit reversal had the largest benefit and the strongest evidence. The benefits usually last from three to six months.
A new movement is learned like driving: manually at first, with effort, and then it happens on its own.
Medication. No medicine is considered a general first choice. Clomipramine, N-acetylcysteine (NAC) and olanzapine showed benefit over placebo in individual studies that need confirmation.
NAC: in a study with 50 adults, 56% were much or very much improved, compared with 16% on placebo. The improvement appeared after about 9 weeks. In children and adolescents, however, no difference from placebo was found.
Antidepressants: clomipramine has some evidence of benefit; for SSRIs there is no strong evidence.
Olanzapine: one small study showed benefit, but its metabolic side effects weigh in the decision.
Do not start any preparation on your own. If it concerns a child or adolescent, see a child psychiatrist; the researchers of the study in children recommend behavioural therapy first.
The order I follow: I present the options and we decide together. We try psychotherapy first. If that is not enough, medication is a trial with a clear timeline, which can be stopped if it does not help.
The physical side
If the hair loss is not clearly explained by pulling, a check for skin causes is needed. Tweezers or scissors can injure the skin.
Some people eat the hairs they pull (trichophagia). In rare cases the hairs form a ball in the stomach or intestine (trichobezoar), which may need surgery. If you eat the hairs, tell your doctor, even if you have no symptoms.
When to ask for help
Gaps are visible in your hair, eyebrows or eyelashes from pulling.
You have tried to stop without success.
You avoid people or activities because of how you look.
It comes with low mood, severe anxiety or a need for alcohol or other substances to cope.
Safety: If you eat the hairs and have pain in the abdomen or below the chest, vomiting, very dark stools, diarrhoea or constipation, or you are losing weight for no reason, get a medical examination quickly. If the pain is severe, call 166 (ambulance, EKAV) or 112. If you have thoughts of harming yourself, call 166, 112 or the Suicide Prevention Line 1018.
How I can help
Book an assessment, at the practice in Trikala or online. See also the page on obsessive-compulsive disorder. If you are wondering which specialist to choose, read the article Psychiatrist or psychologist in Greece? The first conversation can also take place from your home: see how working with an online psychiatrist works, or book an appointment.
This article is educational and does not replace individual clinical assessment. Do not change or stop any treatment you are already taking without talking to your doctor.
Sources
Grant JE, Chamberlain SR. Trichotillomania. Am J Psychiatry. 2016. https://doi.org/10.1176/appi.ajp.2016.15111432
Grant JE, Dougherty DD, Chamberlain SR. Prevalence, gender correlates, and co-morbidity of trichotillomania. Psychiatry Res. 2020. https://doi.org/10.1016/j.psychres.2020.112948
Farhat LC, et al. Pharmacological and behavioral treatment for trichotillomania: An updated systematic review with meta-analysis. Depress Anxiety. 2020. https://doi.org/10.1002/da.23028
McGuire JF, et al. Treating trichotillomania: a meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors. J Psychiatr Res. 2014. https://doi.org/10.1016/j.jpsychires.2014.07.015
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. 2009. https://doi.org/10.1001/archgenpsychiatry.2009.60
Bloch MH, 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. 2013. https://doi.org/10.1016/j.jaac.2012.12.020
