Hair pulling disorder or trichotillomania (trick-o-till-o-may-nee-uh) (TTM or “trich”) is characterized by the repetitive pulling out of one's hair. Trichotillomania is one of a group of behaviors known as body-focused repetitive behaviors (BFRBs), self-grooming behaviors in which individuals pull, pick, scrape, or bite their hair, skin, or nails, resulting in damage to the body. Hair pulling can occur on any part of the body that grows hair.
Research indicates that approximately 1 or 2 in 50 people experience trichotillomania in their lifetime.
Trichotillomania usually begins in late childhood/early puberty, and occurs about equally in boys and girls. By adulthood, 80-90% of reported cases are women. Hair pulling varies greatly in its severity, location on the body, and response to treatment. Without treatment, this hair pulling disorder tends to be a chronic condition; that may come and go throughout a lifetime.
Signs and Symptoms
Trichotillomania is currently classified under Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Hair pulling may occur across a variety of settings and both sedentary and active activities.
There are times when pulling occurs in a goal-directed manner and also in an automatic manner in which the individual is less aware. Many individuals report noticeable sensations before, during, and after pulling. A wide range of emotions, spanning from boredom to anxiety, frustration, and depression can affect hair pulling, as can thoughts, beliefs, and values.
Although the severity of hair pulling varies widely, many people with hair pulling disorder have noticeable hair loss, which they attempt to camouflage. Thinning or bald spots on the head may be covered with hairstyles, scarves, wigs, or makeup. Those with missing eyelashes, eyebrows, or body hair, may attempt to camouflage with makeup, clothing, or other means of concealing affected areas.
Due to shame and embarrassment, individuals not only try to cover up the effects of hair pulling, but may avoid activities and social situations which may lead them to feel vulnerable to being “discovered” (such as windy weather, going to the beach, swimming, doctor’s visits, hair salon appointments, childhood sleepovers, readying for bed in a lighted area, and intimacy).
The DSM-5 diagnostic criteria include:
- Recurrent hair pulling, resulting in hair loss.
- Repeated attempts to decrease or stop the behavior.
- Clinically significant distress or impairment in social, occupational, or other area of functioning.
- Not due to substance abuse or a medical condition (e.g., dermatological condition).
- Not better accounted for by another psychiatric disorder.
The DSM-5 diagnostic criteria include:
- Recurrent hair pulling, resulting in hair loss.
- Repeated attempts to decrease or stop the behavior.
- Clinically significant distress or impairment in social, occupational, or other area of functioning.
- Not due to substance abuse or a medical condition (e.g., dermatological condition).
- Not better accounted for by another psychiatric disorder.
Impacts and Effects
For some people, trichotillomania is a mild problem, merely a frustration. But for many, shame and embarrassment about hair pulling causes painful isolation and results in a great deal of emotional distress, placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder. The most successful management strategies make use of a variety of therapeutic techniques that address actionable emotional and behavioral components. While learning how to manage the behavior, it is important to remember that emotional discomfort that influences the behavior is subjective rather than objective. This realization empowers you to choose how you experience these emotions and enables you to alter your behavior.
Physical effects such as pruritus, tissue damage, infection, and repetitive motion injuries to the muscles or joints are not uncommon. Those who ingest the pulled hair or parts thereof may experience gastrointestinal distress or develop a trichobezoar (hairball in the intestines or stomach), which could lead to gastrointestinal blockage and require surgical removal. Although trichobezoars are rare, they are a serious risk for those who ingest hair.
Hair pulling can lead to great tension and strained relationships with family members and friends. Family members may need professional help in coping with this problem.
Treatment
Research into treatments for BFRBs, particularly hair pulling and skin picking, has grown steadily over the past decade. Although no one treatment has been found to be effective for everyone, a number of evidence-based treatment options have shown promise for many people.
Choosing a therapeutic provider to support your BFRB journey is a process that takes time. Patience and persistence are key to finding your own level of success.
Medications used for OCD and other anxiety disorders have been tested on subjects with BFRBs with limited success. There has not yet been any single medication or combined medications approved by the Food and Drug Administration (FDA) for the treatment of BFRBs.
