What is trichotillomania

Trichotillomania, also known as hair pulling disorder or trich, is when someone can’t resist the urge to pull out their hair. They may pull out the hair on their head or in other places, such as their eyebrows, eyelashes, arms, legs and pubic areas. They may not notice the hair pulling until they need to cover up bald patches with hair clips, a hat, wig or scarf. People with trichotillomania are not able stop pulling their hair.

Trichotillomania (pulling out hair disorder) is more common in teenagers and young adults, and tends to affect girls more often than boys.

As many as 1 person in 100 has the following signs and symptoms of trichotillomania:

• recurrent hair pulling resulting in noticeable hair loss, unrelated to baldness or alopecia
• pleasure, excitement, or relief when pulling out hair
• embarrassment or shame resulting from hair loss
• problems at home, school or work.

Research indicates that about 1 or 2 in 50 people experience trichotillomania in their lifetime. It usually begins in late childhood/early puberty. In childhood, it 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, trichotillomania tends to be a chronic condition; that may come and go throughout a lifetime.

The cause of trichotillomania is not known. For some children, trichotillomania becomes damaging and very difficult to control. Hair pulling can occur anytime but may become worse in stressful situations.

Most children with trichotillomania feel shame, embarrassment or guilt about their hair loss. Younger children may not notice or be bothered by hair loss. Older children and adolescents may be teased, have low self esteem, anxiety or depression.

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 trichotillomania 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 trichotillomania, 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).

Parents can become frustrated, as it is very difficult to understand that children with trichotillomania can’t simply stop pulling their hair. Neither parents nor children are to blame for the hair pulling behavior. Punishing children for pulling hair is unlikely to decrease the behavior and can lead to problems with self-esteem. In order to avoid punishment or embarrassment, children try to hide or deny they are pulling their hair.

Trichotillomania is a long-term (chronic) disorder. Without treatment, symptoms can vary in severity over time. For example, the hormonal changes of menstruation can worsen symptoms in women. For some people, if not treated, symptoms can come and go for weeks, months or years at a time. Rarely, hair pulling ends within a few years of starting.

According to the Diagnostic and Statistical Manual of Mental Disorders (5th edition or DSM V) of the American Psychiatric Association ¹⁾, trichotillomania is defined as meeting the following five DSM-5 diagnostic criteria include::

• Recurrent pulling out of one’s hair, resulting in hair loss.
• Repeated attempts to decrease or stop hair pulling.
• The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
• The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).

Trichotillomania causes

The cause of trichotillomania is unclear. But like many complex disorders, trichotillomania probably results from a combination of genetic and environmental factors.

It’s not entirely clear what causes hair pulling disorder. It could be:

• your way of dealing with stress or anxiety
• a chemical imbalance in the brain, similar to obsessive compulsive disorder (OCD)
• changes in hormone levels during puberty
• a type of self-harm to seek relief from emotional distress

For some people, hair pulling can be a type of addiction. The more they pull their hair out, the more they want to keep doing it.

Risk factors for trichotillomania

These factors tend to increase the risk of trichotillomania:

• Family history. Genetics may play a role in the development of trichotillomania, and the disorder may occur in those who have a close relative with the disorder.
• Age. Trichotillomania usually develops just before or during the early teens — most often between the ages of 10 and 13 years — and it’s often a lifelong problem. Infants also can be prone to hair pulling, but this is usually mild and goes away on its own without treatment.
• Other disorders. People who have trichotillomania may also have other disorders, such as depression, anxiety or obsessive-compulsive disorder (OCD).
• Stress. Severely stressful situations or events may trigger trichotillomania in some people.

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, boys and girls appear to be equally affected.

Trichotillomania complications

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. 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.

Although it may not seem particularly serious, trichotillomania can have a major negative impact on your life. Complications may include:

• Emotional distress. Many people with trichotillomania report feeling shame, humiliation and embarrassment. They may experience low self-esteem, depression, anxiety, and alcohol or street drug use because of their condition.
• Problems with social and work functioning. Embarrassment because of hair loss may lead you to avoid social activities and job opportunities. People with trichotillomania may wear wigs, style their hair to disguise bald patches or wear false eyelashes. Some people may avoid intimacy for fear that their condition will be discovered.
• Skin and hair damage. Constant hair pulling can cause scarring and other damage, including infections, to the skin on your scalp or the specific area where hair is pulled and can permanently affect hair growth.
• Hairballs. Eating your hair may lead to a large, matted hairball (trichobezoar) in your digestive tract. Over a period of years, the hairball can cause weight loss, vomiting, intestinal obstruction and even death.

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.

Trichotillomania symptoms

People with trichotillomania feel an intense urge to pull their hair out and they experience growing tension until they do. After pulling their hair out, they feel a sense of relief.

A person may sometimes pull their hair out in response to a stressful situation, or it may be done without really thinking about it.

Most people with trichotillomania pull out hair from their scalp, but some pull out hair from other areas, such as their:

• eyebrows
• eyelashes
• genital area
• beard or moustache

Bald patches left on the head tend to have an unusual shape and may affect one side more than the other.

Many people who have trichotillomania also pick their skin, bite their nails or chew their lips. Sometimes pulling hairs from pets or dolls or from materials, such as clothes or blankets, may be a sign. Most people with trichotillomania pull hair in private and generally try to hide the disorder from others.

Signs and symptoms of trichotillomania often include:

• Repeatedly pulling your hair out, typically from your scalp, eyebrows or eyelashes, but sometimes from other body areas, and sites may vary over time
• An increasing sense of tension before pulling, or when you try to resist pulling
• A sense of pleasure or relief after the hair is pulled
• Noticeable hair loss, such as shortened hair or thinned or bald areas on the scalp or other areas of your body, including sparse or missing eyelashes or eyebrows
• Preference for specific types of hair, rituals that accompany hair pulling or patterns of hair pulling
• 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
• Significant distress or problems at work, school or in social situations related to pulling out your hair

For people with trichotillomania, hair pulling can be:

• Focused. Some people pull their hair intentionally to relieve tension or distress — for example, pulling hair out to get relief from the overwhelming urge to pull hair. Some people may develop elaborate rituals for pulling hair, such as finding just the right hair or biting pulled hairs.
• Automatic. Some people pull their hair without even realizing they’re doing it, such as when they’re bored, reading or watching TV.

The same person may do both focused and automatic hair pulling, depending on the situation and mood. Certain positions or rituals may trigger hair pulling, such as resting your head on your hand or brushing your hair.

Trichotillomania can be related to emotions:

• Negative emotions. For many people with trichotillomania, hair pulling is a way of dealing with negative or uncomfortable feelings, such as stress, anxiety, tension, boredom, loneliness, fatigue or frustration.
• Positive feelings. People with trichotillomania often find that pulling out hair feels satisfying and provides a measure of relief. As a result, they continue to pull their hair to maintain these positive feelings.

Trichotillomania may cause feelings of shame and low self-esteem. Those affected may try to keep their condition to themselves.

Trichotillomania diagnosis

An evaluation to determine if you have trichotillomania may include:

• Examining how much hair loss you have
• Asking questions and discussing your hair loss with you
• Eliminating other possible causes of hair pulling or hair loss through testing determined by your doctor
• Identifying any physical or mental health problems that may be associated with hair pulling
• Using the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Trichotillomania treatment

Research on treatment of trichotillomania is limited. Trichotillomania is commonly treated using a type of cognitive behavioral therapy (CBT) called habit reversal training.

This aims to help you replace a bad habit with something that’s not harmful. Treatment usually involves:

• keeping a diary of your hair pulling
• working out the triggers for your hair pulling and learning how to avoid them
• replacing hair pulling with another action, like squeezing a stress ball
• involving loved ones to provide emotional support and encouragement

Antidepressants are no longer considered to be an effective treatment for trichotillomania. However some doctors still prescribe antidepressant, such as clomipramine (Anafranil). Other medications that research suggests may have some benefit include N-acetylcysteine, an amino acid that influences neurotransmitters related to mood, and olanzapine (Zyprexa), an atypical antipsychotic. Talk with your doctor about any medication that he or she suggests. The possible benefits of medications should always be balanced against possible side effects.

An amino acid, N-acetylcysteine, often found in commercial anti-oxidant health food supplements, may relieve some compulsive urges for patients suffering from trichotillomania, according to a study from the University of Minnesota Medical School. In a double-blind 12-week trial, 25 patients suffering with trichotillomania, often characterised by compulsive hair-pulling, were given the amino acid N-acetylcysteine and 25 were given a placebo. The average patient age was about 34, of which most had been afflicted with compulsive behaviors since 12. After only 9 weeks, patients who were administered the compound, (1200 mg per day for 6 weeks then 2400 mg per day for the remaining time), had reduced compulsive hair pulling. Only 16 percent of patients receiving the placebo reported improvement, while more than half on the dosage reported improvement. It is though the amino acid lowers levels of the chemical glutamate in areas of the brain responsible for excitement and compulsion.

Therapy

Types of therapy that may be helpful for trichotillomania include:

• Habit reversal training. This behavior therapy is the primary treatment for trichotillomania. You learn how to recognize situations where you’re likely to pull your hair and how to substitute other behaviors instead. For example, you might clench your fists to help stop the urge or redirect your hand from your hair to your ear. Other therapies may be used along with habit reversal training.
• Cognitive therapy. This therapy can help you identify and examine distorted beliefs you may have in relation to hair pulling.
  Acceptance and commitment therapy. This therapy can help you learn to accept your hair-pulling urges without acting on them.

Therapies that help with other mental health disorders often associated with trichotillomania, such as depression, anxiety or substance abuse, can be an important part of treatment.

How to stop trichotillomania

Here are some tips from people with trichotillomania that may help when you feel the urge to pull your hair:

• squeeze a stress ball or something similar
• form a ball with your fist and tighten the muscles in that arm
• use a fidget toy
• wear a bandana or a tight-fitting hat, such as a beanie
• come up with a saying that you repeat out loud until the urge to pull passes
• take a soothing bath to ease any stress or anxiety
• practice deep breathing until the urge to pull goes away
• exercise
• put plasters on your fingertips
• cut your hair short

Getting support

Many people with trichotillomania report feeling alone in their experience of hair pulling. 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.

Ask your doctor or mental health professional for a recommendation or consider searching online for a trichotillomania support group.

It may also help to open up about your trichotillomania to people you trust, as hiding it can sometimes make your anxiety worse.

Many people who have learned to manage their trichotillomania say that speaking to others about the condition led to a reduction in hair pulling.

Family therapies and support groups are also available. Children with trichotillomania should be evaluated by a trained and qualified mental health professional. Treatment is most effective when it is comprehensive and individualized to the needs of the child and family.