What is trichotillomania?
Trichotillomania is a condition where a person feels compelled to pull their hair out.
They may pull out the hair on their head or in other places, such as their eyebrows or eyelashes.
Trichotillomania is an impulse-control disorder (a psychological condition where you are unable to stop yourself carrying out a particular action).
You will experience an intense urge to pull your hair out and growing tension until you do. After pulling out your hair, you will feel a sense of relief. Pulling out hair on the head leaves bald patches.
Trichotillomania can cause negative feelings, such as guilt. You may also feel embarrassed or ashamed about pulling your hair out, and may try to deny it or cover it up. Sometimes, trichotillomania can make you feel unattractive and can lead to low self-esteem.
Read more about the symptoms of trichotillomania.
What causes trichotillomania?
It is not known what causes trichotillomania, but there are several theories.
Some experts think hair pulling is a type of addiction. The more you pull your hair out, the more you want to keep doing it.
Trichotillomania may be a reflection of a mental health problem. Psychological and behavioural theories suggest that hair pulling may be a way of relieving stress or anxiety.
In some cases, trichotillomania may be a form of self-harm, where you deliberately injure yourself as a way of seeking temporary relief from emotional distress.
Read more about the causes of trichotillomania.
Seeing your doctor
Visit your doctor if you are pulling your hair out or if you notice that your child is.
Your doctor may examine areas where the hair is missing to check nothing else is causing the hair to come out, such as a skin infection. In trichotillomania, bald patches are an unusual shape and may affect one side more than the other.
Read more about how trichotillomania is diagnosed.
Little medical research has been conducted into different treatments for trichotillomania.
The most effective treatment is therapy to change your hair-pulling behaviour, combined with a network of emotional support.
Psychotherapy is a type of talking therapy that can be used to treat emotional problems and mental health conditions. It involves discussing emotional issues with a trained therapist.
In particular, cognitive behavioural therapy (CBT) is a type of psychotherapy that may be recommended. It helps you manage your problems by changing how you think and act.
CBT often involves behavioural therapy, also known as habit-reversal therapy, which aims to help you change the way you behave – for example, reducing your hair-pulling behaviour.
Read more about treating trichotillomania.
Trichotillomania can have a significant impact on your quality of life, and can also cause medical problems.
Trichotillomania can often cause feelings of guilt, shame, isolation or embarrassment, which can affect your social life and have an impact on your performance at school or work.
Read more about complications of trichotillomania.
If you have trichotillomania, it is important you receive emotional help and support. This can be from family, friends or self-help groups.
Symptoms of trichotillomania
Most people with trichotillomania pull out hair from their scalp, but some pull out hair from other areas.
- genital area
- underarm area
- chest or tummy
- face, such as a beard or moustache
People with trichotillomania feel an intense urge to pull their hair out and growing tension until they do. After pulling their hair out, they feel a sense of relief.
Hair pulling may sometimes be a response to a stressful situation, or may be done without really thinking about it.
Trichotillomania can cause negative feelings, such as guilt. You may feel embarrassed or ashamed about pulling your hair out, and may try to deny it or cover it up. Trichotillomania can also make you feel unattractive and may lead to low self-esteem.
Trichotillomania may be a reflection of emotional or psychological distress, although the person with the condition may not always be aware of this.
For example, hair pulling may be a way to cope with feelings of stress or self-loathing. In this way, it may be seen as a type of self-harm, where you injure yourself on purpose as a way of coping with emotional distress or anxiety.
Some people with trichotillomania chew and swallow the hair they pull out. This is known as trichophagia. Eating your hair causes hair balls called trichobezoars to form in your stomach or bowel.
The hair balls can cause other symptoms including:
- feeling sick
- stomach pain
- bleeding in your stomach, which can cause anaemia
Read more about the complications of trichotillomania.
Sometimes, people with trichotillomania will have other related mental disorders such as:
- an anxiety disorder
- a mood disorder, such as depression
- an eating disorder
- a substance misuse disorder, such as drug misuse
- a personality disorder
If the hair pulling takes place in response to a delusion (when you believe things that are not true) or a hallucination (when you see or hear things that are not really there), you may have a different condition and should seek advice immediately from your doctor.
Trichotillomania can be linked to other disorders, such as obsessive compulsive disorder (OCD). Visit your doctor if you have repeated thoughts and urges you cannot get out of your mind, or behaviours you have to repeat in a compulsive way.
Causes of trichotillomania
There is no single cause of trichotillomania (hair pulling), but there are a number of theories about why it may occur.
Mental health problem
Trichotillomania may be a reflection of a mental health problem. Psychological and behavioural theories suggest a person may pull their hair out as a way of relieving stress or anxiety.
As trichotillomania involves compulsive behaviour, some experts think it is closely related to obsessive compulsive disorder (OCD).
OCD is a condition that tends to run in families. It is thought to be caused by both biological and environmental factors, which may lead to a chemical imbalance in the brain. Neurotransmitters are chemicals that send messages from your brain to your nervous system.
If something goes wrong with the way neurotransmitters work, it can cause problems, such as compulsive and repetitive behaviours.
Trichotillomania may be a type of self-harm, where a person deliberately injures themselves to seek temporary relief from emotional distress.
The pain associated with self-harm makes the brain release endorphins (natural painkilling chemicals), which cause a short-lived sense of wellbeing. Self-harm is often accompanied by feelings such as:
- low self-esteem
- low mood
As well as pulling your hair out, you may also self-harm in other ways – for example, by cutting yourself.
Someone may start self-harming as a way to cope with a traumatic experience, such as sexual, physical or emotional abuse.
If you have been sexually abused, trichotillomania may be seen as a way of making yourself less attractive or less feminine (if you are female). Making yourself less attractive confirms your negative view of yourself and the cycle of self-loathing and self-harm continues.
Some other theories about what causes trichotillomania include:
- abnormalities in the brain – brain scans have revealed brain abnormalities in some people with trichotillomania
- genetics – an alteration in a particular gene may lead to trichotillomania in some people, and a tendency to pull hair out may be inherited
- a lack of serotonin (the 'feel-good' chemical in the brain) – treatment with a selective serotonin reuptake inhibitor (SSRI), which boosts serotonin levels, has been effective in some people with trichotillomania
- changes in hormone levels – trichotillomania is more common around ages when hormone levels frequently change, such as during puberty
You should visit your doctor if you are pulling your hair out, or if you notice that your child is.
Your doctor may ask about:
- your symptoms
- feelings you have before and after pulling your hair out
- whether you have noticed anything that triggers your hair pulling
Your doctor may also examine bald patches where you have pulled your hair out. They will need to check nothing else is causing your hair to come out, such as a skin infection. In trichotillomania, bald patches are an unusual shape and may affect one side more than the other.
Trichotillomania is defined as a type of mental and behavioural disorder by both the ICD-10 classification system and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
Your doctor may use some of the following criteria to diagnose your condition.
- You repeatedly pull your hair out, which causes noticeable hair loss.
- You feel increasing tension before you pull your hair out.
- You feel relief or pleasure when you have pulled your hair out.
- There is no underlying medical condition causing you to pull your hair out, such as a skin condition.
- Pulling your hair out causes you distress or affects your everyday life – for example, your family relationships or your work.
Sometimes, a person may be diagnosed with trichotillomania even if they do not meet all of the above criteria.
Treatment for trichotillomania
Therapy to change your hair-pulling behaviour is the most effective method of treating trichotillomania.
This should be combined with a network of emotional support (see below).
There are also a number of other possible treatments for trichotillomania, although little in the way of medical research has been conducted to determine how effective they are.
Psychotherapy is a talking therapy often used to treat emotional problems and mental health conditions. You or your child can discuss emotional issues with a specially trained therapist.
Cognitive behavioural therapy (CBT) is a type of psychotherapy that may be recommended. It can help you address your thoughts about yourself, your relationships with others and how you relate to the world around you.
CBT may also involve behavioural therapy. This aims to help you change the way you behave – for example, reducing your hair-pulling behaviour. It is also known as habit-reversal therapy and could include:
- educating you about your condition and how it is treated
- making you more aware of when and why you pull your hair out – for example, you may tend to pull your hair out when stressed
- learning a new response to carry out when you feel the urge to pull your hair out – for example, clenching your hand into a fist
- creating barriers that prevent you from pulling your hair out – for example, wearing a hat if you usually pull hair from your scalp
- getting your parents or partner involved in your treatment – for example, they could praise and encourage you when you do not pull your hair out
Other possible psychological approaches are discussed below. These have not been studied closely, so their effectiveness in treating trichotillomania is unknown.
Hypnosis can be used to alter your state of consciousness. While you are hypnotised, the hypnotist can suggest you change your behaviour.
In this altered state, you may be more likely to accept suggested changes and stop pulling your hair out.
Strategies that help you relax may be useful for controlling trichotillomania. This may include deep breathing exercises or tensing and then relaxing different muscles.
If you have trichotillomania, it is likely you are experiencing emotional distress, such as feelings of self-loathing and guilt.
It is important you receive emotional support to help you cope with these feelings. This may be from family, friends, or a self-help group.
Trichotillomania can be particularly distressing for families of children and young adults who pull their hair out.
Pulling your hair out may be a way of communicating distress to your family, but they may feel powerless to help you. In this situation, family therapy may be suggested.
A therapist will meet the whole family to explore their views and relationships and understand any problems the family may be having. It helps family members to communicate better with each other.
Family therapy can be particularly useful when a child or young person has a serious problem, such as trichotillomania, that is affecting the rest of the family. The family can work together to address the issue that is causing you to pull your hair out, and seek support for any distress caused to other family members.
Several medications have been used to treat trichotillomania, although there have not been many large-scale clinical trials on them.
If the healthcare professional treating you recommends a particular medication, they should discuss possible risks and benefits with you, including any side effects.
Selective serotonin reuptake inhibitors (SSRIs)
In the past, selective serotonin reuptake inhibitors (SSRIs) have been used to treat trichotillomania, although there is some evidence to suggest they are not effective. SSRIs are often used to treat depression and anxiety disorders.
For children under 18 years of age, the recommended SSRIs are sertraline and fluoxetine. These should only be used under the supervision of a mental health specialist, such as a specialist Child and Adolescent Psychiatrist. This is a qualified medical doctor who has received further training in treating childhood mental health conditions.
Clomipramine is another medicine that may be recommended for trichotillomania. It is often used to treat depression and obsessional states. A child under 18 years of age being treated with clomipramine should be supervised by a specialist child and adolescent psychiatrist.
Clomipramine has been tested as a treatment for trichotillomania and has been found to be effective at reducing hair-pulling behaviours.
Small trials have been carried out for other medicines, but not enough is known about their effectiveness. In particular, there is a lack of research into medicines used to treat children with trichotillomania.
Complications of trichotillomania
Trichotillomania (hair pulling) can have a significant impact on your quality of life. It can also cause further medical problems.
Quality of life
Trichotillomania can be distressing for those with the condition because it can cause feelings of:
- isolation (feeling alone)
This can affect your social life – for example, you may have fewer friends or you may find intimate relationships difficult.
Trichotillomania may also affect how well you perform at school or work. For example, you may end up missing school because you are too embarrassed to go in, or may find it difficult to concentrate at work, which could affect your career progression.
Some people also feel angry or frustrated about being unable to control their urges, and may use alcohol, smoking or drugs as a way of coping.
Alopecia is loss of hair. People with trichotillomania end up losing their hair because they pull it out. This can cause bald patches, or in some cases total baldness. This can affect your confidence and self-esteem.
You may avoid certain activities where the bald patches could be noticed – for example, going to the hairdresser or going swimming.
Trichobezoars are hair balls that can form in your stomach or bowel if you eat the hair that you pull out. The hair balls can cause serious symptoms such as:
- blocking, or making a hole in, your digestive system
- acute pancreatitis – painful inflammation of your pancreas
- obstructive jaundice – the hair ball blocks tubes that remove bile (a fluid that helps digest food), causing a build-up of a yellow substance called bilirubin and resulting in yellow-tinged skin and eyes
In severe cases, stomach or intestinal surgery may be needed to remove the hair ball.