Understanding Trichotillomania (TTM)

Trichotillomania (TTM), also known as hair-pulling disorder, is a condition in which hair is repeatedly pulled out, twisted, or broken off from any part of the body for non-cosmetic reasons. People with trichotillomania pull out hair on their heads, eyelashes, eyebrows, and/or other parts of the body, such as the underarm, pubic, chin, chest, or leg areas. They may do this intentionally or unconsciously.

This condition can lead to significant hair loss, but it is treatable. Recognizing the signs early on can ensure that people get the treatment they need to prevent further damage.

Symptoms of Trichotillomania 

According to the TLC Foundation for Body-Focused Repetitive Behaviors, trichotillomania can come and go, stopping for days or even months before reoccurring. The hair-pulling behavior has even rarely been reported to happen during sleep.

While trichotillomania can manifest differently depending on the person, it generally has five distinct characteristics:

1. Recurrent pulling out of one’s hair resulting in noticeable hair loss
2. An increasing sense of tension immediately prior to pulling out the hair or when attempting to resist the behavior
3. Pleasure, gratification, or relief when pulling out the hair
4. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition such as alopecia areata, tinea capitis, traction alopecia, and telogen effluvium.
5. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The following rituals and behavioral patterns often precede pulling:

• Combing through the hair
• Feeling individual hairs
• Tugging at hairs
• Visually searching the scalp and hairline

Research indicates that hair is most commonly pulled from the scalp, eyebrows, eyelashes, and pubic area. However, pulling may also focus on the limbs, underarms, and chest. Such behavior leads to a considerable amount of distress and difficulties in other life areas.

Trichotillomania Causes and Risk Factors

While no one knows for sure what causes trichotillomania, biological forces as well as behavioral, learning, and psychological components are thought to play a role.

Family History

Having a family member or relative with trichotillomania increases the risk for the condition, which suggests that there may be a heritable component to the condition. One twin study suggested a heritability estimate of 76.2%, indicating that genetics plays a significant role. Another twin study conducted in the UK estimated that heritability was around 32%.

Co-Occurring Conditions

Evidence suggests that trichotillomania is highly comorbid with other conditions. As many as 80% of people with hair pulling disorder also have another psychiatric disorder. Conditions that may occur alongside it include:

• Depressive disorders
• Excoriation (skin-picking disorder)
• Tourette's syndrome
• Other obsessive-compulsive disorders

How Is Trichotillomania Diagnosed?

Because trichotillomania can resemble other medical conditions associated with hair loss such as alopecia areata, diagnosis of trichotillomania often requires both a dermatological and psychiatric evaluation. Diagnosis may be complicated as alopecia areata itself can sometimes trigger trichotillomania.

Trichotillomania is a relatively rare illness, affecting 1% to 2% of the population. Trichotillomania can affect people of all ages; however, it appears to be much more common among children and adolescents than adults. Roughly 90% of adults with the condition are female.

Young Children

In very young children, trichotillomania has been compared to other habits such as thumb sucking or nail-biting. Children less than 5 years old often pull their hair out unknowingly. In the same way that thumb-sucking stops spontaneously for most children, the majority of children who begin to pull their hair at this early age will stop on their own.

Preadolescents and Young Adults

Trichotillomania often begins between ages 10 and 13. Interestingly, the majority of people (70% to 90%) affected by trichotillomania at this age are female. Among people in this age group, trichotillomania tends to be chronic in nature.

In addition, these individuals often have oral rituals associated with hair pulling, such as chewing or licking the lips or even eating hair. Studies suggest that around 1% to 3% of adults in the U.S. experience trichotillomania at some point during their lives. However, the exact prevalence is difficult to determine because it is likely underreported.

Treatment for Trichotillomania

Treatment of trichotillomania is often unnecessary for very young children as they usually grow out of it. However, for people with adolescent-onset trichotillomania, treatment may be necessary, especially if it is suspected that the person is also consuming the pulled hair, which can cause dangerous blockages in the gastrointestinal system.

Psychotherapy

Cognitive behavioral techniques have demonstrated some efficacy in treating trichotillomania. Prominent among these is habit reversal therapy, which aims to help people develop skills to reduce their harmful behaviors, including:

• Self-monitoring (awareness training)
• Identification of behavior triggers
• Modifying the environment to decrease the likelihood of pulling behavior
• Identifying a substitution behavior that is incompatible with hair pulling

Habit reversal training (HRT) is another first-line treatment that involves helping people become more aware of their triggers, learn relaxation strategies, and develop competing responses. Other types of therapy that may be helpful include dialectical behavior therapy (DBT), mindfulness training, acceptance and commitment therapy (ACT), and exposure therapy.

Medication

Currently, there is limited evidence that medications such as selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) are consistently effective in treating trichotillomania, so the FDA has not approved any medications for specifically treating the condition.

However, several types of medications have been tried, particularly if there are co-occurring mood, anxiety, or obsessive-compulsive symptoms. These include:

• Anafranil (clomipramine)
• Depakote (valproate)
• Lithobid, Eskalith (lithium carbonate)
• Luvox (fluvoxamine)
• Paxil (paroxetine)
• Prozac (fluoxetine)
• Zoloft (sertraline)
• Naltrexone
• Neuroleptics

Coping With Trichotillomania

While the best way to cope with trichotillomania will depend on your age and severity of symptoms, there are a few strategies you or your child to try:

• Find a healthy replacement habit. Try squeezing a stress ball, handling textured objects, or drawing—or ask your healthcare professional for some other ideas.  
• Practice relaxation techniques. Given that trichotillomania often coexists with other mental illnesses, it’s helpful to learn and practice relaxation techniques, including deep breathing, mindfulness meditation, and progressive relaxation.
• Make a chart. Each day you go without pulling your hair, add a sticker or checkmark and reward yourself after a streak. Try hanging the chart in a room where you tend to pull out your hair.
• Seek support. It’s always helpful to talk with others who understand what you’re going through. The TLC Foundation offers a variety of online support groups as well as a weekly community hangout on Zoom.