Trichotillomania (hair-pulling disorder)

Symptoms and key features

DSM-5-TR lists trichotillomania among the obsessive-compulsive and related disorders. It involves:

• pulling out one's own hair, again and again, leading to hair loss
• repeated attempts to cut down or stop
• real distress or trouble at work, school, or in social life because of it
• no better explanation, like a skin or medical condition, or a delusion about the body

MedlinePlus adds the day-to-day details: rising tension before pulling, relief or pleasure afterward, patchy or thin areas, regrowth that feels like stubble, and pulling from eyebrows, eyelashes, or body hair as well as the scalp.

What it looks like

A 16-year-old pulls from the crown of her head while doing homework. She doesn't notice until there's a small pile of hair on the desk. She's learned to part her hair so the thin patch doesn't show, and she won't go swimming or let her friends do her hair. At night, lying in bed, she sometimes pulls on purpose, hunting for a hair that feels coarse or "wrong," and runs it across her lip before dropping it. Her mom thinks she's just stressed.

Clinicians often describe two styles. Automatic pulling happens during reading, screens, driving, or other absorbing tasks, without awareness. Focused pulling is deliberate, often driven by an urge, a particular hair texture, or a feeling of tension, and followed by relief. Most people do some of both.

The shame is often the heaviest part. Many people hide it for years, even from doctors.

What people often confuse this with

Alopecia areata or other hair loss. Medical causes of hair loss look different on exam, and they don't involve an urge to pull.

OCD. OCD involves unwanted thoughts and rituals to neutralize them. Trichotillomania isn't usually driven by an obsessive fear, and the pulling often feels soothing or satisfying in the moment.

Self-harm. The goal of hair pulling usually isn't to cause pain or cope with overwhelming feelings through injury. That said, some people do both, and a clinician should ask gently.

Body dysmorphic disorder. Some people pull to fix a perceived flaw, like an uneven eyebrow. When pulling is driven by appearance concerns, body dysmorphic disorder may be the better fit.

What research says

• Behavior therapy has large effects. A 2014 meta-analysis of 11 randomized trials found behavior therapy had a large pooled effect on pulling severity, and more therapy hours meant bigger effects.
• Medications help less. The same meta-analysis found a moderate effect for serotonin reuptake inhibitors. Clomipramine did somewhat better than SSRIs, but the difference wasn't statistically meaningful.
• It's common. MedlinePlus says it may affect as much as 4 percent of people and is about four times more common in women than in men.
• Trials are small. Most studies had few participants, and more research is needed, especially in children and teens.

How it's diagnosed

A doctor, dermatologist, psychologist, or psychiatrist usually diagnoses it from the history and an exam of the hair and skin. MedlinePlus notes a scalp biopsy is sometimes done to rule out other causes of hair loss, like infection.

The clinician will also ask about depression, anxiety, OCD, skin picking, and other repetitive behaviors, since these often come along. They'll ask whether the person swallows or chews hair, because that can cause serious stomach problems.

Why it happens

The causes aren't well understood, as MedlinePlus notes. It often starts in early adolescence, commonly between ages 11 and 13. Pulling seems to work as a way to regulate feelings, whether that's boredom, tension, frustration, or understimulation, which is part of why it's so hard to stop. The relief reinforces the behavior each time. Stress can make it worse. Research into genetic and brain factors is still early.

Treatment

Habit reversal training (HRT). The core behavior therapy. It teaches:

• awareness: noticing when, where, and how pulling happens, and the early warning signs
• a competing response: doing something with your hands that makes pulling impossible, like making a fist or holding a textured object, for a minute or so until the urge passes
• support: someone who encourages and reinforces the practice

Therapists often combine HRT with stimulus control, which means changing the environment: wearing gloves or a hat, keeping hands busy with a fidget, covering mirrors, or adding friction to high-risk moments. Acceptance and commitment therapy and emotion regulation skills help some people handle the urge without acting on it. The TLC Foundation for BFRBs keeps a directory of therapists trained in these approaches.

Medication. There's no FDA-approved medication. Options that have been studied include:

• N-acetylcysteine (NAC), an over-the-counter supplement that affects the brain chemical glutamate. A placebo-controlled trial of 50 adults found it reduced pulling more than placebo over 12 weeks and was well tolerated. Talk to a clinician before starting it.
• Serotonin reuptake inhibitors, including SSRIs and clomipramine. MedlinePlus notes experts don't agree on medication, though SSRIs and naltrexone have reduced some symptoms. They're also used when depression or anxiety comes along with pulling. See the clomipramine guide on PsychiatryRx.