What is Trichotillomania?

It is estimated that around 350,000 people in the UK are affected by Trichotillomania. But what is Trichotillomania? Trichotillomania is also known as hair pulling disorder, hair picking disorder, TTM or just “Trich” (pronounced “trick”) for short.

It is characterised by the urge to pull out hair at the root from the scalp, eyebrows, eyelashes or other areas of the body. The disorder was first named in the late 19^th century by combining three Greek words to describe this condition – thrix (hair), tillein (pulling) and mania (madness) – but it was not formally recognised as a disorder until 1987.

Trichotillomania is not an impulse that sufferers can easily control, often despite the desire to stop. They can experience a growing tension until they do it, and even the consequences, including the pain and the patchy bald spots left when pulling out hair from their scalp, do not prevent them from doing it.

Some people with the condition pull out large handfuls of hair, which can leave bald patches on the scalp. Other people pull out their hair one strand at a time. They might inspect or play with the strand after pulling it out. About half of people with Trichotillomania put the hair in their mouths after pulling it and approximately 60% of those that put hair in their mouth, ingest the hair.

There are several different forms of Trichotillomania:

• Focused hair pulling – When someone pulls out hair intentionally. This type of Trichotillomania can include specific rituals, including pulling certain types of hair from specific areas of the body. Some people engage in focused hair pulling with the intention of experiencing tension relief from pulling.
• Automatic hair pulling – When people pull hair without being fully conscious of what they are doing. This can occur when they are reading, studying, talking on the phone, watching TV, bored or engaged in other monotonous activities.
• Mixed hair pulling – Which combines aspects of both the focused and automatic types.

Trichotillomania is more common in teenagers and young adults although some younger children have developed the disorder, and it tends to affect girls more often than it affects boys. Studies show that the age of onset for Trichotillomania is variable, with an average age of starting between the ages of 9 and 13 years, and it reaches peak prevalence at 12–13 years. The start of hair pulling most often coincides with or follows the onset of puberty.

Although many young people with Trichotillomania develop the condition in early adolescence, the condition may affect some people continually or intermittently throughout adulthood. It has been estimated that 0.5–3 per cent of people will experience the condition at some point during their lifetime.

In younger children, Trichotillomania tends to be benign and most children usually outgrow the condition. In adolescents and adults, Trichotillomania may be episodic but tends to be chronic.

What causes Trichotillomania?

Some experts think the urge to pull hair happens because the brain’s chemical signals, called neurotransmitters, don’t work properly and that this creates the irresistible urges that lead people to pull their hair. Others think that people who have other compulsive habits or Obsessive-Compulsive Disorder (OCD) may be more likely to develop Trichotillomania.

Stress, depression or anxiety may also play a part. According to an article in the American Journal of Psychiatry, some people may pull their hair as a way to deal with adverse emotions or even childhood trauma; however, there is not enough research to support this theory.

Another school of thought is that it may be genetic and that a person who has a first-degree relative, i.e. a parent or sibling, with Trichotillomania is more likely to have the condition themselves. The Duke University in North Carolina, USA studied 44 families where at least one member had Trichotillomania to look for common genetic traits.

The study found that the SLITRK1 gene was mutated (abnormal) in the family members with the condition, but not in the family members who did not have Trichotillomania. Their evidence appeared to show a definite connection between genetic differences and the onset of Trichotillomania in the people studied. However, the researchers believe that mutations of the SLITRK1 gene only account for about 5 per cent of all existing cases of Trichotillomania.

This result could mean that other genes factor into the development of the condition, or that additional environmental and biological risk factors also play a significant role in the emergence of Trichotillomania. The gene studies continue.

In rare cases, it is believed that Trichotillomania may be linked to types of self-harm, due to the pain associated with pulling out your own hair and the psychological relief it provides once the hair has been removed. It may also be a symptom of another undiagnosed or unknown underlying issue.

The truth is that no one knows exactly why some people develop Trichotillomania. The condition is rare and as such appears to be under researched.

What triggers Trichotillomania?

Hair pulling may be triggered by or accompanied by a number of emotional states such as anxiety, boredom, stress or tension, and can result in feelings of satisfaction, relief, pleasure or guilt following the hair pulling. Major upheavals in life such as abuse, bullying, divorce or death can often trigger Trichotillomania. Exam stress is often quoted as a trigger too.

With stress and anxiety being common triggers, the coronavirus (COVID) crisis and associated restrictions may have created a difficult environment for Trichotillomania sufferers. A lot of people are finding this to be a very tough time; the lack of things to distract themselves with, concerns about the future, finances, or a fear of becoming unwell with COVID all add to the pressures.

It has been reported that some Trichotillomania sufferers who had been “pull free” for some time prior to lockdown, have started to feel the urges again and have returned to hair pulling as a way of dealing with the stress of some of the most difficult months during the pandemic. It appears to be very typical to have setbacks in stressful situations.

The paradox of Trichotillomania is that whilst stress, anxiety and emotional distress can trigger the disorder, so can periods of calm, inactivity and boredom.

What are the signs and symptoms of Trichotillomania?

The length of a Trichotillomania occurrence tends to vary greatly, with some people pulling out just a few hairs over several minutes, or in other cases people spending hours or even a whole night stripping the scalp of hair. The frequency of occurrences also varies from person to person; some may only pull their hair out infrequently, for example at times of excessive stress, whilst others may do it regularly on almost a daily basis.

Hair pulling awareness can also vary considerably. Some people pull quite consciously and deliberately; these people have reported that it gives them a feeling of control which is otherwise lacking in their lives. Others hair pull while engrossed in other activities and sometimes appear to be in a kind of trance.

Common signs and symptoms of Trichotillomania can include:

• Repeatedly pulling your hair out from your scalp, eyebrows or eyelashes or other body areas or pulling of hair from more than one area on the body.
• Increased feelings of tension before pulling your hair.
• Feelings of pleasure, gratification, relief or guilt after the hair is pulled out.
• Struggling with yourself to stop pulling your hair out, usually without success.
• A need to perform other repetitive activities related to the hair, for example counting or twisting hairs.
• Hair loss, thinning or baldness around the head, sometimes in uneven patches or focused on one particular area. Hair loss patterns vary from mild thinning or unnoticeable areas of hair loss to completely bald areas. Hair may look and feel stubbly, with hairs of varying lengths.
• Missing eyelashes or eyebrows.
• Biting or chewing hair.
• Repeated ingestion of hair known as Trichophagia. It can involve eating parts of the hair such as the roots or tips or whole strands of hair. Many individuals diagnosed with Trichotillomania also have other body-focused repetitive behaviours, including skin picking, nail biting, and cheek and lip chewing.

Potential consequences for health and wellbeing of Trichotillomania sufferers 

• Scratches, bruises and Erythema from picking the area around the hair.
• Generalised tingling or itching (Pruritus) in the involved areas.
• Localised skin infections.
• Repeated removal of hair damages the follicles and may lead to irreversible scarring.
• Blepharitis from the extraction of eyelashes.
• Chronic pain due to prolonged abnormal postures whilst hair pulling – some sufferers develop repetitive strain injury (RSI).
• Sufferers who put hair into their mouth or swallow their hair can damage their teeth and even develop potentially fatal Trichobezoar, balls of hair in their stomach which could lead to a gastrointestinal blockage that requires surgical removal. Although Trichobezoars are rare, they are a serious risk for those who ingest hair.
• Disruption to day-to-day life – Hair pulling can take up a lot of time, make it hard to concentrate and can be exhausting.
• Avoiding certain situations that trigger Trichotillomania can lead to the development of phobias.
• Experiencing problems in social situations or at school or work which are related to the condition.
• Having a negative impact on personal relationships.
• Experiencing isolation or loneliness due to feelings of shame, stigma and embarrassment, needing to hide bald patches from others.
• Alcohol and or substance misuse to help cope with negative feelings due to hair pulling.
• Those with chronic Trichotillomania may experience severe and debilitating symptoms that could lead to depression and/or low self-esteem.

Is Trichotillomania a mental illness?

Mental disorders are patterns of behavioural or psychological symptoms that impact multiple areas of life. In some medical and mental health publications, Trichotillomania is classified as a psychological disorder.

However, as with the causes of Trichotillomania, the experts are divided on whether or not the condition is a mental illness. The National Organisation for Rare Disorders (NORD) describes Trichotillomania as a poorly understood mental health condition.

The Diagnostic and Statistical Manual of Mental Disorders (DSM–5), which is the handbook used by healthcare professionals in the United States and much of the world including the UK as the authoritative guide to the diagnosis of mental disorders, lists the condition amongst the rarer mental health conditions.

The mental health charity MIND refers to the condition as an OCD related disorder, as does, for example, OCD Action, because Trichotillomania involves repetitive thoughts, behaviours or urges.

However, the condition has also be described as a symptom of anxiety, and OCD UK says that “whilst there are some compulsive and ritualistic similarities between OCD and Trichotillomania there are also important differences. Primarily, OCD is driven by unwanted intrusive thoughts (the obsessions), for example fears of bad things happening, where compulsions are carried out in an attempt to prevent bad things happening, whereas Trichotillomania is characterised primarily by body-focused repetitive behaviour (pulling at hair) to reduce tension/stress, or even out of habit, rather than being initiated by an unwanted intrusive thought.

People with the problem 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. Sharing similarities with skin picking disorder, a person may sometimes pull their hair out in response to a stressful situation, or it may be done without really thinking about it.”

How is Trichotillomania diagnosed?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria for Trichotillomania include:

• Recurrent hair pulling, resulting in hair loss.
• Repeated attempts to decrease or stop the behaviour.
• Clinically significant distress or impairment in social, occupational or other area of functioning.
• Not due to substance abuse or a medical condition, for example a dermatological condition.
• Not better accounted for by another psychiatric disorder.

It is important when diagnosing Trichotillomania for medical professionals to exclude other causes of hair loss, especially Alopecia. A doctor will usually begin an evaluation by performing a complete medical history and physical examination.

The doctor may then refer the sufferer for a dermatological assessment which may include:

• Hair tests including looking for:
  – Reduced hair density.
  – Broken hairs of uneven length.
  – Trichoptillosis (split/frayed ends).
• Hair biopsy.
• Fungal infection tests.
• A psychiatric evaluation may also be necessary.

What can you do if you have or know someone with Trichotillomania?

People who have Trichotillomania often do not seek help or treatment for their condition as many people who are affected by Trichotillomania may not realise that they have a diagnosable condition and they commonly view their hair pulling as just a bad habit.

Others may be reluctant to seek help or a diagnosis for a variety of other reasons such as embarrassment, being ashamed or depressed about it, and many worry what others will think or say.

• The first step is to open up to someone who you know will be understanding. This may be a friend, teacher, family member, doctor, whoever you choose; communication is a core part of coping with the condition. Working up the determination to discuss your condition is actually one of the hardest parts of dealing with Trichotillomania.
• Asking friends and loved ones to tell you when they see you are pulling can help you recognise when you are pulling at your hair.
• Another option is to look for a local support group to talk to others who know about and understand the condition such as:
  –TrichStop
  –The TLC Foundation
  –Alopecia UK
  –MIND
  –Trichotillomania Support
  –Anxiety UK.

Other suggestions to help you overcome the urge to pull include:

• Keeping your hands busy can help; you could try squeezing a stress toy, playing with play dough, fiddling with worry beads or take up knitting, drawing or colouring in.
• Try resisting pulling for longer and longer each time you feel the urge to pull.
• Try keeping your hair length short.
• Don’t keep tweezers or other implements you use for hair pulling in an easy to access place.
• Putting plasters on your fingertips or wearing gloves makes it almost impossible to hair pull.
• Keeping your nails really short can make it more difficult to pull.
• Practising deep breathing when the urge arises.
• Try hypnotherapy.
• Repeating a mantra out loud to calm down might help.
• Wearing a bandana, a scarf, a hoodie or a hat as a practical barrier.
• Stimulate your senses. Many people that hair pull like the sensation that comes with it. Instead of pulling do other things to stimulate these senses such as washing your hair, brushing your lips on dental floss or string, if you rub the hair on your lips, and massaging your scalp.
• Use a reminder app to track how long you have been pull-free. This can be a useful motivator to see how far you have come. But it is important to remember that a relapse is not failure and it doesn’t undo all your hard work. Trichotillomania won’t just disappear overnight, and every step you take to reducing your pulling is a massive achievement.
• Brush your hair instead of pulling.
• Look at your hair in the mirror everyday with your hands behind your back – this is called exposure therapy. Stare into the mirror until the anxiety to pull has lessened.
• Focus on helping others, which in turn will help you.
• Watch documentaries and read books and articles about Trichotillomania to learn new stopping techniques.
• Spend less time in the areas of the home that you pull in.
• Keep a diary of your feelings and your pulling.

What treatments are available for Trichotillomania? 

Doctors do not diagnose many cases of Trichotillomania, which means there is very little information on effective treatments available. However, limited research suggests that specific behavioural therapies and medications may be beneficial for people with the condition.

These include:

• Cognitive Behavioural Therapy (CBT) – A talking therapy that helps people to explore their beliefs related to hair pulling.
• Habit reversal training – This works by helping the person recognise and be more aware of their hair pulling and what is triggering it. Sometimes this helps a person replace hair picking with a less harmful behaviour. This also means repeatedly learning to tolerate the resulting discomfort of not hair pulling, but experts appear to believe that this is the most effective of the available treatments.
• Self-awareness training – Individuals learn to become more aware of their hair pulling patterns by tracking when they pull and detailing emotions and other important information.
• Family therapy – For children and adolescents, family therapy helps parents learn to better respond to and manage Trichotillomania symptoms in their children.
• Group therapy – Trichotillomania can feel isolating and group therapy can help people connect with others going through a similar struggle and provide support for one another.
• Medication – Whilst there are no Trichotillomania specific medications available, doctors may prescribe medications that are used to treat some of the accompanying symptoms of anxiety, or antidepressants.

Some people with Trichotillomania learn to manage symptoms and triggers with outpatient treatment or professional support, while others may require more intensive treatment. It is important to seek help as soon as possible and continue treatment on an ongoing basis.

In conclusion

Psychological disorders such as Trichotillomania can be a distressing problem that can cause disruptions in daily functioning, relationships, work, school and other important areas of a person’s everyday life. However, with appropriate diagnosis and treatment, people suffering with Trichotillomania can find relief from their symptoms and discover ways to cope effectively.