What Is Trichotillomania, And How Does It Affect You?
Trichotillomania is often a serious disorder that can be difficult to overcome. In simple terms, trichotillomania generally refers to hair-pulling, but it can be more complicated than it sounds. Those with this disorder may often experience an uncontrollable impulse that causes them to pull on their hair to get relief. Often, the best type of treatment options for trichotillomania involves a combination of habit reversal training and acceptance and commitment therapy. You can seek out a licensed therapist who has experience with these types of therapy in your local area, or you may connect with one through an online therapy platform.
This article explores risk factors that might trigger trichotillomania, potentially related disorders, and options like cognitive therapy.
What is trichotillomania or hair-pulling disorder?
You may have a sibling who used to tug on your hair as a sign of affection or a way of teasing, or you may be someone who twists or plays with their hair when feeling embarrassed, frustrated, or nervous. These situations are usually not signs of trichotillomania (hair-pulling disorder).
Trichotillomania can be quite rare. It’s sometimes referred to as “hair-pulling disorder” and has traditionally been classified as an impulse-control disorder. The American Psychological Association defines impulse-control disorders as those “characterized by a failure to resist impulses, drives, or temptations to commit acts that are harmful to oneself or to others.” Other examples of impulse-control disorders can include kleptomania, intermittent explosive disorder, and pyromania, among others.
However, trichotillomania is increasingly being listed as a form of obsessive-compulsive disorder (OCD) and is believed to be related to anxiety disorders. OCD disorders can include several mental health disorders that typically revolve around repeated thoughts or activities.
Neuroimaging studies have found that trichotillomania may be connected to certain aspects of the brain, such as the thickening of the right inferior frontal gyrus.
Meanwhile, neurochemical studies have found a potential relationship between the condition and the serotonin 2A receptor.
Trichotillomania, according to the TLC Foundation for Body-Focused Repetitive Behaviors
According to the Trichotillomania Learning Center, or the TLC Foundation for Body-Focused Repetitive Behaviors, trichotillomania is a rare disorder characterized by the repeated pulling out one’s hair. Other mental health conditions related to body-focused repetitive behaviors might include skin conditions like skin picking, nail biting.
Symptoms of trichotillomania
Someone with this disorder may have several symptoms that you can look for, but this disorder tends to be a very secretive one. Most who live with trichotillomania try to hide their behaviors when engaging in their social life, including hair loss and any additional activities they engage in with the hair they pull out.
The most important aspect of this disorder may be that the individual is likely pulling hair follicles out to the extent that it can cause noticeable hair loss or bald patches. They may attempt to cover this hair loss in various ways. Changing their hairstyle, wearing hats, or even using wigs may be just a few of the ways they may try to conceal this symptom. They may also wear false eyelashes if the behavior isn’t centered on hair on the scalp.
An individual with trichotillomania usually feels a sense of tension before they engage in hair-pulling or if they are attempting to resist pulling their hair. In contrast, they usually feel gratification or pleasure when they engage in the activity.
Many try to avoid the behavior, knowing that it can be unusual or that it may not be good for them. They may try to cut down on the number of times they engage in the activity or attempt to stop it altogether, but hair-pulling can be a type of obsessive-compulsive disorder, and it can be difficult to resist a compulsion.
Those who engage in hair-pulling may feel distressed or impaired because of it. It may seem as if they have no control, or they may start to experience shame or embarrassment due to the disorder. This can affect their abilities when it comes to work, school, and personal aspects of their lives, as they may try to avoid situations where someone might find out about the disorder. The resulting stress and strain may also lead to negative side effects.
Finally, someone with trichotillomania may engage in other behaviors that revolve around the hair they pull out. They may play with or examine the hair, chew or eat it, or engage in other habits. Individuals who eat their hair may experience additional harmful symptoms such as developing large, matted hairballs in their digestive tracts.
It can be important to watch for these behaviors and help the individual who is experiencing symptoms seek treatment. Though it may not seem like a serious disorder or problem, pulling hair out can be unhealthy, and those living with trichotillomania deserve proper support.
When does trichotillomania start?
For most, trichotillomania tends to appear between the ages of nine and 13, although it can develop at other ages in some people. It can be more common among those who may have experienced difficult emotional states, boredom, or anxiety, as well as those who have a history of abuse* or other trauma in their lives or family histories. In addition, trichotillomania can contribute to other challenges.
Because trichotillomania normally involves pulling hair out, it can be noticed by others, and it often comes with a stigma. Someone who lives with this disorder may be likely to feel shame or guilt due to the hair pulling. In situations where entire of patches of hair are pulled out, it can be especially stressful as it becomes noticeable, and it may result in teasing. This can lead to even more trauma from the disorder and may contribute to additional developmental concerns. The younger the individual, and the more sensitive they may be, the more important it can be to seek treatment quickly.
Because trichotillomania can fall under the obsessive-compulsive umbrella, other OCD-related symptoms may be present at the same time. Individuals who live with this disorder may experience counting, washing, or other compulsive behaviors, which can interfere with day-to-day life. Depression and anxiety can also be common alongside trichotillomania.
*If you or a loved one is witnessing or experiencing any form of abuse, please know that help is available. You can call the National Domestic Violence Hotline anytime at 1-800-799-SAFE (7233).
Treatment of trichotillomania and obsessive-compulsive disorder
Trichotillomania treatments are similar to those related to other forms of impulse control disorders and obsessive-compulsive disorder. Some home options might include deep breathing or using a stress ball when you feel the urge to pull out your hair. These options can help soothe the emotional distress that leads to an increasing sense of urgency to engage in hair pulling behavior.
If you or someone you know may be living with this disorder, it can be best to seek professional treatment as soon as possible. It may seem like something you can overcome on your own, but you may find that moving past trichotillomania can be easier with support.
Psychotherapy with a licensed mental health professional can be an excellent place to start. There may be several types of therapy used to help people with trichotillomania overcome their urges. One of the most common therapy methods for this condition is generally called habit reversal training (HRT), which can help you identify situations in which you’re most tempted to pull your hair, and then learn other ways to respond to that urge.
A second type of therapy – acceptance and commitment therapy (ACT) – can also be used, and it typically teaches individuals how to accept the urges to pull hair without acting on them.
Research has shown that combining HRT and ACT can be particularly effective in decreasing hair-pulling, as well as alleviating depression and anxiety symptoms. You can complete these types of therapy in person or online.
Benefits of online therapy
An online therapy platform can make it simple to find a licensed mental health professional with experience working with people who have trichotillomania, as well as therapists who use principles of habit reversal training and acceptance and commitment therapy. With BetterHelp, you can meet with a licensed therapist via video, phone call, or online chat, and these options may help you feel more comfortable opening up about a potentially vulnerable topic.
A 2022 feasibility trial looked into the potential efficacy of online acceptance-based behavior therapy for trichotillomania and skin-picking disorder. It found that the majority of participants were satisfied with the treatment, and significant decreases in hair-pulling and skin-picking severity were demonstrated and maintained at the 12-month follow-up point. If you’re living with trichotillomania or a similar disorder, online therapy may be a valid treatment option for you.
Takeaway
Is trichotillomania an OCD or anxiety?
Trichotillomania, a hair-pulling disorder, is classified with obsessive-compulsive disorder (OCD) by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). This condition has many features with more well-known manifestations of OCD, including:
- Compulsive, repetitive behavior
- Recognition that a habit is harmful but feeling unable to stop
- Ritualized actions
- A sense of tension leading up to a compulsive act, and relief afterward
- Obsessive thoughts
There is also some evidence that similar neurological mechanisms may be at work between these conditions. They’re not identical, however, and some researchers believe that trichotillomania should be regarded as a different type of mental health disorder.
Although trichotillomania (also known as TTM) is not considered an anxiety disorder, feelings of stress, fear, and worry are commonly associated with this condition. Often, people with trichotillomania report that periods of high anxiety increase their hair-pulling behavior.
It’s common for people to be diagnosed with both TTM and an anxiety disorder. Other disorders frequently associated with TTM include depression, post-traumatic stress disorder (PTSD), and substance use disorders.
Can trichotillomania be cured?
Though there is not currently a definitive cure for trichotillomania, many people can significantly reduce their symptoms with appropriate treatment. Several evidence-based therapies have been shown to help large percentages of patients stop pulling out their hair or greatly reduce the frequency and intensity of pulling.
The current best practice in trichotillomania treatment involves a combination of cognitive-behavioral therapies. Habit reversal training is one effective method that’s designed to help clients become aware of and redirect the automatic actions often associated with hair pulling. This type of therapy may be enhanced by interventions aimed at reducing the unhelpful thoughts and feelings that may push an individual with TTM to pull out their hair.
There are no medications currently approved for treating trichotillomania. However, some have shown potential effectiveness in clinical trials, including:
- N-acetylcysteine, which inhibits excitatory neurons in the brain
- Olanzapine, an atypical antipsychotic that may help stabilize moods and reduce manic behavior
- Clomipramine, a tricyclic antidepressant sometimes used in treating obsessive-compulsive disorder
Why is trichotillomania a mental disorder?
Trichotillomania can be considered a mental disorder because it involves unwanted, difficult-to-control behavior that can cause significant distress for affected individuals. Though episodes of hair-pulling may involve brief positive feelings such as relief or satisfaction, they can lead to intensely negative effects on a person’s long-term well-being.
People with TTM may experience deep shame about their difficulty controlling their behavior. They may also feel highly self-conscious about their appearance, particularly if they have significant skin and hair damage. Low self-esteem and social withdrawal are common in people with this condition. There may also be physical effects such as infections and scarring, as well as intestinal problems from eating hair after pulling it out.
What triggers trichotillomania?
The initial onset of trichotillomania may be triggered by stress — either a prolonged period of life stress or a particularly traumatic or distressing event. Evidence from research indicates that childhood trauma could trigger trichotillomania in some people, suggesting that this behavior could be an attempt to soothe or vent negative emotions.
Individual episodes of trichotillomania hair pulling can have a variety of triggers. Some are particular sensations related to their hair — a person may be prompted to pull out particularly thick, long, or coarse, or those they can feel in a particular area of their scalp.
Other triggers can be based on thoughts or feelings, especially self-critical thoughts about one’s appearance. Some people may develop a feeling that a particular hair is “wrong” in some way — that it’s located in the wrong spot or that it’s growing incorrectly. Pulling might also be triggered by emotions like anxiety, anger, or boredom.
What is the root cause of trichotillomania?
The cause of trichotillomania is not well understood at this time. The condition has been observed to run in some families. However, the associated genes have not yet been identified, and an individual’s environment, upbringing, and life experiences likely also play an important part. As with most mental illnesses, a combination of genetic and environmental factors is thought to be responsible.
In some individuals, trichotillomania may arise partly due to difficulties managing their emotions. The sensory stimulation associated with hair pulling might serve as a way to suppress or release negative emotions they’re unable to deal with in other ways. For example, people with both post-traumatic stress disorder (PTSD) and trichotillomania appear to exhibit less severe PTSD symptoms during longer periods of hair pulling. This suggests that they may pull their hair as a maladaptive coping mechanism for hard-to-control emotions.
Is trichotillomania an addiction?
Trichotillomania is not currently classified as an addiction. Some researchers have argued that it should be, though, pointing out that its compulsive nature makes it similar to other “behavioral addictions” such as gambling disorder. TTM could involve a dysfunction of the brain’s habit and reward mechanisms, much like substance use disorders.
Evidence for this viewpoint is limited at this time. Neurological studies have not found significant differences in parts of the brain commonly associated with addiction. More research may be needed to determine if an addiction-based model for TTM shows promise.
Can trichotillomania damage the brain?
There’s no indication that trichotillomania or its related behavioral manifestations can cause brain damage. No known mechanism could lead to brain damage from pulling hair.
While differences in brain structure between individuals with and without TTM have been observed, these are not considered evidence of damage to brain cells. It’s more likely that these differences are causes of TTM behavior rather than effects.
How do I stop trichotillomania?
Overcoming trichotillomania may require a focused effort to identify and change your habits. The current gold-standard treatments often involve training patients in skills designed to modify their behavior. You may be able to benefit from practicing things like:
- Accepting emotions without judging or fighting them
- Identifying your personal TTM triggers
- Recognizing when you’re getting ready to start pulling hair
- Coming up with alternate behaviors to replace hair pulling, such as making a fist or sitting on your hands
- Reducing exposure to triggering stimuli
- Developing a mindful awareness of your thoughts, actions, and emotions
It may be significantly easier to find relief from trichotillomania with help from a qualified mental health professional. Studies suggest that the prognosis for untreated TTM is poor. However, with appropriate evidence-based therapy, as many as 80% of people may be able to significantly reduce their symptoms.
What kind of people have trichotillomania?
Mental health surveys suggest that trichotillomania may be fairly common, affecting roughly 1.7% of the U.S. population. While it was formerly thought that this condition was much more common in females than males, more recent research suggests an equal distribution between genders. Women and girls might be more likely to seek treatment for TTM than men and boys, leading to the former perception of a skewed gender distribution.
The prevalence of trichotillomania appears to be relatively equal for different income levels, educational backgrounds, and ethnic groups. Adolescents, young adults, and middle-aged people may be more likely to experience TTM than older adults. The onset of this condition typically occurs during puberty but may also happen at younger ages.
Many people may not realize how widespread trichotillomania is, since individuals with this disorder often try to conceal it. The use of hats, hair coverings, wigs, and false eyelashes is common among people with TTM. They may also avoid situations where their hair loss is likely to be noticed, such as physical intimacy or swimming in public.
Can hair grow back after trichotillomania?
In most cases, the hairs removed in trichotillomania will grow back eventually after the behavior stops. In some cases, though, frequent hair pulling can lead to permanent scarring, preventing hair growth. This is more likely in prolonged and severe cases. For most people with TTM who are concerned about hair loss, the best solution may be to work on overcoming the urge to pull their hair.
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