Trichotillomania (hair-pulling disorder)

Trichotillomania (trik-o-til-o-MAY-nee-uh), also called hair-pulling disorder, is a mental health condition. It involves frequent, repeated and irresistible urges to pull out hair from your scalp, eyebrows or other areas of your body. You may try to resist the urges, but you can't stop. Trichotillomania is part of a group of conditions known as body-focused repetitive behaviors.

Pulling out hair from the scalp often leaves patchy bald spots. This can cause a lot of distress and can affect your work, school and social life. You may go to great lengths to hide the hair loss.

For some people, trichotillomania may be mild and can be managed. For others, the automatic or deliberate urge to pull out hair is too much to handle emotionally. Some treatment options may help reduce hair pulling or stop it entirely.

Symptoms of trichotillomania often include:

• Repeatedly pulling out your hair, whether it's automatic or on purpose, usually from your scalp, eyebrows or eyelashes, but sometimes from other body areas. The sites may vary over time.
• An increasing sense of tension before pulling out your hair, or when you try to resist pulling.
• A sense of pleasure or relief after the hair is pulled out.
• Hair loss that's easy to see, such as shortened hair or thinned or bald areas on the scalp or other areas of your body. This may include thin or missing eyelashes or eyebrows.
• Pulling out specific types of hair, taking the same steps in the same way each time hair is pulled out or pulling out hair in certain patterns.
• Biting, chewing or eating pulled-out hair.
• Playing with pulled-out hair or rubbing it across your lips or face.
• Repeatedly trying to stop pulling out your hair or trying to do it less often without success.
• Experiencing a great deal of distress or problems at work, school or in social situations related to pulling out your hair.

Often trichotillomania also includes picking your skin, biting your nails or chewing your lips. Sometimes pulling out hairs from pets or dolls or from materials, such as clothes or blankets, may be a sign. Pulling out hair is usually done in private. An episode can last from a few seconds to hours. You may try to hide your condition from others.

With trichotillomania, pulling out hair can be:

• Automatic. You may pull out your hair without even realizing that you're doing it. This might happen, for example, when you're bored, reading or watching TV.
• Focused. You may pull out your hair on purpose to relieve tension or distress. You may develop specific rituals for pulling out hair, such as finding just the right hair. You may play with, bite or eat pulled-out hairs.

You may do both automatic and focused hair pulling, depending on the situation and your mood. Certain positions or activities may trigger pulling out hair, such as resting your head on your hand or brushing your hair.

Trichotillomania can be related to emotions, including:

• Negative feelings. Pulling out hair may be a way of dealing with negative or uncomfortable feelings, such as stress, anxiety, tension, boredom, loneliness, extreme tiredness or frustration.
• Positive feelings. You may find that pulling out hair feels satisfying and provides some relief. As a result, you may continue to pull out your hair to keep these positive feelings.

Trichotillomania is a long-term disorder. If not treated, symptoms may come and go for weeks, months or years at a time. Also, symptoms can vary in severity over time. For example, hormone changes during the menstrual period can worsen symptoms in some females. Rarely, pulling out hair ends within a few years of starting.

When to see a doctor

If you can't stop pulling out your hair or you feel embarrassed or ashamed by your appearance as a result, talk to your health care provider. Trichotillomania is not just a bad habit, it's a mental health condition. It's not likely to get better without treatment.

The cause of trichotillomania is not clear. But like many complex disorders, trichotillomania likely results from a combination of genetic and learned factors.

These factors tend to increase the risk of trichotillomania:

• Family history. Genetics may play a role in the development of trichotillomania. You may be more likely to have the condition if you have a close relative with trichotillomania.
• Health conditions. Some people may have hair or skin conditions that feel uncomfortable. This may focus their attention toward pulling hair or picking at their scalp.
• Age. Trichotillomania usually develops just before or during the early teens — most often between the ages of 10 and 13 years. It's often a lifelong problem. Babies may pull out their hair, but this is usually mild and goes away on its own without treatment.
• Other mental health conditions. Other conditions, such as depression, anxiety or obsessive-compulsive disorder (OCD) may occur along with trichotillomania.
• Stress. Severely stressful situations or events may trigger trichotillomania in some people.
• Environment. Boredom, isolation and privacy often increase the likelihood of hair pulling.

Although far more women than men are treated for trichotillomania, this may be because women are more likely to seek medical advice. In early childhood, trichotillomania occurs just as often in boys and girls.

Although it may not seem serious, trichotillomania can have harmful effects on your life. Complications may include:

• Emotional distress. You may feel frustrated, ashamed and embarrassed because of your condition and hair loss. You may feel that you don't have control over pulling out your hair. You may experience low self-esteem, depression, anxiety, and problems with alcohol or drugs.
• Problems in your social life and with work. Hair loss may lead you to avoid social activities and school and job opportunities. You may wear wigs, style your hair to disguise bald patches or wear false eyelashes. You may avoid intimacy to hide your condition.
• Skin and hair damage. Constantly pulling out hair can cause scarring, infections and other damage to the skin on your scalp or the area where hair is pulled out. This can permanently affect hair growth.
• Hairballs. Eating your hair may lead to a large, matted hairball that stays in your digestive tract. Over a period of years, the hairball can cause weight loss, vomiting, an intestinal block and even death.

To diagnose trichotillomania, you'll likely start by having a physical exam. You may then be referred to a mental health professional with experience in treating trichotillomania. Diagnosing trichotillomania may include:

• Examining your hair loss.
• Checking for possible medical causes of your hair loss. This may include lab tests.
• Talking with you about hair loss, including your behaviors and emotions related to pulling out your hair.
• Identifying any physical or mental health conditions that may occur along with pulling out your hair.

Some treatment options have helped many people reduce hair pulling or stop completely. These include therapy and sometimes medicine.

Therapy

Types of therapy that may be helpful for trichotillomania include:

• Habit reversal training. This behavior therapy is the main treatment for trichotillomania. You learn how to recognize situations where you're likely to pull out your hair and how to substitute other behaviors instead. For example, you might clench your fists to help stop the urge. One form of habit reversal training, called decoupling, involves quickly redirecting your hand from your hair to another location when you feel the urge to pull out your hair. Other therapies may be used along with habit reversal training.
• Acceptance and commitment therapy. This therapy can help you learn to accept your hair-pulling urges without acting on them.
• Cognitive therapy. This therapy can help you identify and examine beliefs you have about hair pulling that are not realistic. You can learn healthy ways to think about your condition.

Therapies that help with other mental health conditions that often occur along with trichotillomania, such as depression, anxiety, or problems with alcohol or drug use, can be an important part of treatment.

Medicines

Although no medicines are approved by the U.S. Food and Drug Administration specifically for the treatment of trichotillomania, some medicines may help control certain symptoms, such as anxiety and depression.

For example, your health care provider may recommend an antidepressant, such as clomipramine (Anafranil). Research suggests that N-acetylcysteine (as-uh-tul-SIS-tee-een), an amino acid that affects mood, also may help. Another option that research suggests may have benefit is olanzapine (Zyprexa). This drug is used to treat certain serious mental health conditions that affect the mind.

Talk with your health care provider about any medicine recommended. The possible benefits of medicines should be balanced against possible side effects.

You may find dealing with trichotillomania challenging. It may help to join a support group for people with trichotillomania so that you can meet others with similar experiences who can relate to your feelings and offer support. Having a family member or loved one join you to learn how to respond to your hair pulling also can be helpful.

Ask your health care provider or mental health professional for a suggestion. The TLC Foundation for Body-Focused Repetitive Behaviors is an excellent resource for education, support and treatment options for trichotillomania.

Seeking help is the first step in treating trichotillomania. At first you may see your primary care provider or a specialist in skin disorders called a dermatologist. Your provider may refer you to a mental health professional with experience in diagnosing and treating trichotillomania.

What you can do

Before your appointment make a list of:

• All your symptoms, even if they seem unrelated to hair pulling. Trichotillomania can cause both physical and mental health symptoms. Note what triggers your urges, how you've tried to deal with them, and what makes the urges better or worse.
• Key personal information, including any major stresses or recent life changes. Include whether anyone else in your family has trichotillomania.
• All medicines, vitamins, herbs or other supplements that you're taking, including the doses and how long you've been taking them.
• Questions to ask to make the most of your appointment time.

Questions to ask include:

• What might have caused me to develop this condition?
• How do you find out if I have this condition?
• Is this something that will go away on its own?
• What treatments do you recommend?
• If I decide to take medicines, how long will it take for my symptoms to improve?
• What are the side effects of the medicines you're recommending?
• What can I do in addition to treatment to improve my symptoms?
• How much improvement can I expect with your treatment plan?

Don't hesitate to ask other questions during your appointment.

What to expect from your doctor

You'll likely be asked a number of questions, such as:

• When did you first start pulling out your hair?
• Do you pull your hair automatically, on purpose, or both?
• Have you tried to stop pulling out your hair? How did that work?
• Are there times or situations that are likely to trigger hair pulling?
• What feelings do you have before and after you pull out your hair?
• From where on your body do you pull out hair?
• Do you bite, chew or swallow the pulled-out hair?
• How has hair pulling affected your work, school or social life?
• Have you had treatment, such as therapy or medicine, for hair pulling or other emotional issues?

Be ready to answer questions so that you'll have time to talk about what's most important to you.