richotillomania, often abbreviated as TTM and commonly referred to as hair-pulling disorder, is a mental health condition characterized by the compulsive urge to pull out one’s own hair, resulting in noticeable hair loss. It is categorized under obsessive-compulsive and related disorders in the DSM-5, and it can significantly impact a person’s emotional well-being and social functioning.
Though it might seem like a habit, trichotillomania is far more than just a nervous tic—it is a serious psychiatric disorder that often requires clinical intervention. The condition can be both conscious and unconscious, meaning some people may be fully aware of their actions while others may pull without realizing it.
Key Symptoms
The hallmark symptom of trichotillomania is repeated hair pulling from various parts of the body. The scalp, eyebrows, and eyelashes are the most common targets, though hair may also be pulled from the beard, arms, legs, or pubic area.
Other associated signs include:
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Uneven or patchy hair loss
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Stubble or broken hair in bald spots
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Denial or secrecy about hair pulling
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Increased tension before pulling
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Feelings of relief or gratification after pulling
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Emotional distress like guilt, embarrassment, or shame
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Eating the pulled hair (trichophagia), which may lead to digestive issues
Hair-pulling episodes can last from a few minutes to several hours and often occur in private, contributing to the hidden nature of the condition.
Common Causes
While the exact cause of trichotillomania is still unknown, researchers believe it results from a combination of genetic, neurological, behavioral, and environmental factors.
Some individuals report pulling hair as a way to cope with:
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Stress or anxiety
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Boredom
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Tension or restlessness
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Negative emotions like anger or sadness
Others may do it automatically, without any clear emotional trigger. This dual nature—focused pulling vs. automatic pulling—complicates diagnosis and treatment.
Risk Factors
Several risk factors have been identified, including:
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Age of onset: Typically begins between ages 10 and 13
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Gender: More women than men are diagnosed, though this may reflect higher help-seeking behavior in women
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Family history: There may be a genetic component, as trichotillomania sometimes runs in families
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Other mental health conditions: Such as anxiety, depression, or obsessive-compulsive disorder (OCD)
There’s no clear evidence that socioeconomic status, ethnicity, or environment plays a significant role, although personal trauma or childhood adversity may increase risk.
How It’s Diagnosed
Diagnosing trichotillomania typically involves a comprehensive psychiatric evaluation by a mental health professional. The DSM-5 criteria require:
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Recurrent hair pulling that leads to hair loss
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Repeated attempts to decrease or stop the behavior
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Significant distress or impairment in social, occupational, or other areas of functioning
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The hair pulling isn’t caused by a medical condition (like alopecia areata)
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The behavior isn’t better explained by another mental disorder
A physical examination may be conducted to:
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Rule out dermatological conditions
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Look for signs of trichophagia (such as abdominal masses)
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Perform trichoscopy (microscopic imaging of the scalp)
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Conduct a scalp biopsy if needed
Because trichotillomania is underdiagnosed and misunderstood, people may receive incorrect diagnoses such as anxiety disorders, body dysmorphic disorder, or even substance use disorders.
Effective Treatment Options
Though trichotillomania can be distressing, the good news is that treatment can be highly effective, especially when tailored to the individual.
Behavioral Therapies
Behavioral therapy is the first-line treatment, particularly:
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Habit Reversal Training (HRT): Teaches individuals to recognize the urge and replace hair pulling with alternative behaviors (e.g., clenching fists, using fidget tools)
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Cognitive Behavioral Therapy (CBT): Helps address negative thinking patterns and emotional triggers that contribute to the behavior
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Acceptance and Commitment Therapy (ACT): Focuses on mindfulness and accepting urges without acting on them
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Group Therapy or Peer Support: Provides emotional reinforcement from others facing similar struggles
Medications
Currently, there are no FDA-approved medications specifically for trichotillomania, but several drugs used to treat other psychiatric conditions have shown promise:
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SSRIs (e.g., fluoxetine, sertraline): Often used to treat anxiety or depression
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Tricyclic antidepressants (e.g., clomipramine)
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Antipsychotics (e.g., olanzapine)
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N-acetylcysteine (NAC): A supplement that may help reduce urges by affecting glutamate levels in the brain
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Naltrexone: Commonly used in substance use treatment, sometimes prescribed to reduce compulsive behaviors
It's worth noting that behavioral therapy is typically more effective than medication, and a combined approach often yields the best outcomes.
Preventing Episodes
Preventing trichotillomania episodes involves:
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Adherence to treatment plans
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Identifying and avoiding triggers
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Building self-awareness using journals or apps
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Relaxation techniques such as:
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Deep breathing exercises
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Progressive muscle relaxation
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Meditation or yoga
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Wearing gloves or hats to reduce access to hair during high-risk times
Developing a support system and practicing self-compassion can go a long way in managing relapses.
Related Conditions
Trichotillomania is frequently comorbid with:
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Depression
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Social anxiety
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Obsessive-compulsive disorder (OCD)
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Post-traumatic stress disorder (PTSD)
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ADHD
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Excoriation disorder (skin picking)
These overlapping conditions can intensify symptoms or interfere with treatment. In one study, up to 79% of patients with trichotillomania had at least one other psychiatric diagnosis. Comprehensive care must consider these comorbidities.
Living With Trichotillomania
Living with trichotillomania can be emotionally exhausting. Many individuals report:
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Low self-esteem
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Shame and guilt
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Social withdrawal
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Impaired quality of life
Stigma remains a major barrier to care, with over half of those affected never seeking treatment. Yet, when people do seek help, symptoms often improve within three to six months.
Advancements in technology, like smart bracelets and mobile tracking apps, are helping patients track urges and stay accountable. Increasing awareness and decreasing stigma are key to helping more people access care.
When to Seek Help
You should consider speaking with a healthcare provider if:
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Hair pulling is interfering with your daily life
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You feel distress, shame, or isolation because of the behavior
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You’ve tried to stop but haven’t been successful
Early intervention is important. The sooner treatment begins, the more likely it is to reduce long-term impacts.
Support and Resources
Many people benefit from joining online support groups or seeking guidance from advocacy organizations like:
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The TLC Foundation for Body-Focused Repetitive Behaviors
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Mental Health America (MHA)
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National Alliance on Mental Illness (NAMI)
Support from friends, family, and therapists plays a critical role in recovery. Encouragement, empathy, and education help create a safe environment for healing.
Final Thoughts
Trichotillomania is a real and treatable disorder, not simply a bad habit or attention-seeking behavior. Though it may bring emotional and social challenges, with the right combination of therapy, support, and self-care, many people can achieve meaningful recovery.
With growing awareness and improved therapeutic approaches, more individuals are finding hope and healing beyond hair pulling.