Trichotillomania (TTM), also known as hairpulling disorder or compulsive hairpulling, is a psychological disorder characterized by a long-term urge that results in the pulling out of one’s hair. This occurs to such a degree that hair loss can be seen. A brief positive feeling may occur as hair is removed and efforts to stop pulling hair typically fail. Hair removal may occur anywhere; however, the head and around the eyes are most common. The hairpulling is to such a degree that it results in distress.

Figure 1. A pattern of incomplete hair loss on the scalp of a person with trichotillomania.

TTM may run in families. The disorder occurs more commonly in those with obsessive-compulsive disorder or anxiety disorders, and episodes of pulling may be triggered by anxiety. People usually acknowledge that they pull their hair and on examination, broken hairs may be seen. Other conditions that may be present include body dysmorphic disorder; however, in that condition, people remove hair to try to improve what they see as a problem in how they look.

Trichotillomania is estimated to affect between 1%-4% of people. The lifetime prevalence of trichotillomania is estimated to be between 0.6% and 4.0% of the overall population. With a 1% prevalence rate, 2.5 million people in the United States may have trichotillomania at some time during their lifetimes. Trichotillomania most commonly begins in childhood or adolescence. Women are affected about 10 times more often than men.

Signs and Symptoms

Trichotillomania is usually confined to one or two areas of the body, but can involve multiple sites. The scalp is the most common pulling site, followed by the eyebrows, eyelashes, face, arms, and legs. Some less common areas include the pubic area, underarms, beard, and chest. The classic presentation is the Friar Tuck form of vertex and crown alopecia. Children are less likely to pull from areas other than the scalp.

People who suffer from trichotillomania often pull only one hair at a time and these hairpulling episodes can last for hours at a time. Trichotillomania can go into remission-like states where the individual may not experience the urge to pull for days, weeks, months, and even years.

Individuals with trichotillomania exhibit hair of differing lengths; some are broken hairs with blunt ends, some new growth with tapered ends, some broken mid-shaft, or some uneven stubble. Scaling on the scalp is not present, overall hair density is normal, and a hair-pull test is negative (the hair does not pull out easily). Hair is often pulled out leaving an unusual shape. Individuals with trichotillomania may be secretive or shameful of the hairpulling behavior. If patients attempt to disguise their symptoms, it can make diagnosis difficult as symptoms are not always immediately obvious, or have been deliberately hidden to avoid disclosure.

An additional psychological effect can be low self-esteem, often associated with being shunned by peers and the fear of socializing, due to appearance and negative attention they may receive. Some people with trichotillomania wear hats, wigs, false eyelashes, eyebrow pencil, or style their hair in an effort to avoid such attention. TTM seems to have a strong stress-related component. In low-stress environments, some exhibit no symptoms (known as pulling) whatsoever. This pulling often resumes upon leaving the low-stress environment. Some individuals with trichotillomania may feel they are the only person with this problem due to low rates of reporting.

For some people, trichotillomania is a mild problem, merely a frustration. But for many, shame and embarrassment about hairpulling 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. Hairpulling can lead to great tension and strained relationships with family members and friends. Family members may need professional help in coping with this problem.

Figure 2. Children may not consciously remember pulling their hair.

Trichotillomania is often not a focused act, but rather hairpulling occurs in a trance-like state; hence, trichotillomania is subdivided into “automatic” versus “focused” hairpulling. Children are more often in the automatic, or unconscious subtype, and may not consciously remember pulling their hair. Other individuals may have focused, or conscious, rituals associated with hairpulling, including seeking specific types of hairs to pull, pulling until the hair feels “just right,” or pulling in response to a specific sensation. Knowledge of the subtype is helpful in determining treatment strategies.

Epidemiology

Trichotillomania (TTM), or human compulsive hairpulling, is one of the most common psychiatric disorders, affecting approximately 3.5% of women, or 3.7 million people in the United States. TTM patients experience pronounced psychological distress with considerable negative impact in their quality of life.^[1]

Trichotillomania has an estimated lifetime prevalence of approximately 0.5%-1%, and peak age of onset in adolescence (12–13 years of age) and is typically associated with impairment across domains of social, occupational, academic, and psychological functioning.^[2]

Trichotillomania is more common in women than in men, and is currently classified as an OCD-related disorder. However, unlike the repetitive compulsive acts observed in OCD, repetitive behaviors in trichotillomania are not generally driven by intrusive thoughts.^[3]

Patients with trichotillomania can come across a range of medical settings, including family doctors, dermatologists, neurologists, psychiatrists, pediatricians, endocrinologists, and geneticists.^[4]

Etiology

Very little is known about the neurobiological basis of this disorder in humans, but in one study that reviewed available clinical and imaging studies of trichotillomania, previous work suggested an ABC model of trichotillomania, emphasizing the dysfunction of pathways involved in affect regulation, behavioral control, and cognition. In keeping with this, studies have found that trichotillomania is associated with impairment on response inhibition tests and phenomenological studies have found relationships between emotional states (dysphoria, anxiety) and the severity of the hairpulling symptoms.^[5]

One study suggests that hormones may be a potential cause. In a study of adolescent girls with trichotillomania, researchers found that lower progesterone was associated with worse hairpulling severity (NIMH Trichotillomania Symptom Severity Scale, NIMH-TSS), and that lower levels of all three hormones were associated with greater psychosocial dysfunction (Sheehan Disability Scale, SDS). Progesterone is believed to modulate the adaptive response to stress, mainly through the effect of its neurosteroid metabolite allopregnanolone on GABAA receptor activity.^[6]

Some studies which included neuroimaging showed that individuals with trichotillomania had increased grey matter density in several brain regions involving affect regulation, motor habits, and cognition. Additionally, other studies examine the negative reinforcement people have when pulling; when emotional regulation is measured, those with trichotillomania have a harder time with emotional control that those without the disorder. Triggers for pulling include boredom, perfectionism, and frustration (to name a few) and hairpulling may be a way of relieving some of the stress and tension associated with these negative feelings.^[7]

Causes and Comorbidity

Environment is a large factor that affects hairpulling. Sedentary activities such as being in a relaxed environment, or bored, are conducive to hairpulling. A common example of a sedentary activity promoting hairpulling is lying in a bed while trying to rest or fall asleep. An extreme example of automatic trichotillomania is found when some patients have been observed to pull their hair out while asleep. This is called sleep-isolated trichotillomania.

Anxiety, depression, and OCD are more frequently encountered in people with trichotillomania. Trichotillomania also has a high overlap with post-traumatic stress disorder, and some cases of trichotillomania may be triggered by stress. Another school of thought emphasizes hairpulling as addictive or negatively reinforcing, as it is associated with rising tension beforehand and relief afterward. A neurocognitive model—the notion that the basal ganglia plays a role in habit formation and that the frontal lobes are critical for normally suppressing or inhibiting such habits—sees trichotillomania as a habit disorder.

The most common age of onset of trichotillomania is between ages nine and 13, and a notable peak at ages 12–13. In this age range, trichotillomania is usually chronic and continues into adulthood. Trichotillomania that begins in adulthood most commonly arises from underlying psychiatric causes.

Psychotherapy

Treatment is based on a person’s age. Most preschool age children outgrow the condition if it is managed conservatively. In young adults, establishing the diagnosis and raising awareness of the condition is an important reassurance for the family and patient. Non-pharmacological interventions, including behavior modification programs, are often the first-line mediation; referrals to psychologists or psychiatrists may be considered when other interventions fail. When trichotillomania begins in adulthood, it is often associated with other psychological disorders, and referral to a psychologist or psychiatrist for evaluation or treatment is considered best. The hairpulling may resolve when other conditions are treated.