What is hair pulling or trichotillomania?

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. Hair pulling disorder is one of a group of behaviors known as body-focused repetitive behaviors (BFRBs) and are technically classified as Obsessive-Compulsive and Related Disorders. BFRBs can be thought of as self-grooming behaviors in which individuals pull, pick, scrape, or bite their hair, skin, or nails, resulting in damage to the hair or 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 hair pulling disorder in their lifetime. Hair pulling disorder 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, hair pulling disorder tends to be a chronic condition; it may come and go throughout a lifetime.

Signs and Symptoms

Hair pulling disorder is currently classified under Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

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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

Hair pulling may occur across a variety of settings and during both sedentary and active activities. There are times when pulling occurs in a goal-directed manner and it can also occur 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).