Trichotillomania: hair-pulling disorder

Trichotillomania is a hair-pulling disorder where a person is unable to stop this behavior despite making attempts to do so.

The main symptoms of trichotillomania are constant hair pulling or having rituals and specific hair preferences. Persons with this disorder usually hide hair pulling from others. However, hair loss and other problems with hair and skin become noticeable and visible to other people.

The condition has a major impact on a person’s quality of life, it can worsen the mental health of a patient, and lead to other risky behaviors such as hair eating. 

Besides recurrent hair-pulling, the condition is indicated by a sense of relief and pleasure after hair is pulled out. 

Treatment of trichotillomania usually revolves around behavioral therapy, especially habit reversal training. Some medications can also help e.g. antidepressants. A person with this disorder also needs a strong support system.

Common areas of the body where hair-pulling may occur include the scalp, eyebrows, eyelashes, arms, trunk, or legs.

What is trichotillomania?

Trichotillomania is a mental health disorder indicated by a compulsive urge to pull out hair from the scalp, eyelashes, eyebrows, or other parts of the body. This compulsive behavior becomes so severe that a person has visible hair loss. If you’re wondering, “why do I pull my hair out strand by strand” the answer is trichotillomania. 

The term trichotillomania derives from Greek words for hair, to pull, and madness. French dermatologist, Francois Henry Hallopeau, coined the term trichotillomania in 1889, but the condition dates back to ancient years.

Aristotle was the one who first documented hair-pulling behavior in the 4^th century BC, according to a 2018 paper by Rachel LV Waas and  Paul Devakar Yesudian from the International Journal of Trichology.

What is the cause of trichotillomania?

The cause of trichotillomania is unknown and it’s also unclear why pulling hair out feels good to certain people. A combination of genetic and environmental factors could play a role. Trichotillomania tends to develop in preadolescence and it’s also associated with mental health disorders such as OCD, anxiety, depression, autism, and ADHD.

However, not every person with these conditions will also develop the disorder . A lot more research on what causes trichotillomania is necessary to uncover underlying mechanisms that lead to the development of the hair-pulling disorder.

What are the characteristics of trichotillomania?

The characteristics of trichotillomania often involve body-centric repeated behaviors. The main characteristics of trichotillomania are listed below.

• Recurrent pulling out of one’s hair
• Hair pulling not associated with any other medical condition
• Hair pulling induces clinically significant distress such as impairment in occupational, social, and other areas of functioning 
• Repeated efforts to stop pulling out one’s hair without success
• Compulsive urge to pull hair out not explained by symptoms of another mental disorder

Trichotillomania is characterized by a strong urge or craving to pull out hair. Not every act of hair pulling is considered trichotillomania. Characteristics of trichotillomania also include:

• Feeling satisfied after pulling hair
• Absence of other medical problems that could explain hair-pulling behavior
• Mental health problem doesn’t explain the hair-pulling behavior entirely

Patients with trichotillomania may pull their hair in a focused or automatic manner. Focused pulling is performed intentionally to alleviate stress or tension. Some people may even have specific rituals and hair preferences. 

On the other hand, the patient may pull hair without realizing it, almost automatically, when watching TV, reading, or when bored. One person can exhibit both types of hair-pulling behavior depending on the mood and situation.

What are the signs and symptoms of trichotillomania?

The symptoms of trichotillomania represent the observable manifestations of the condition. The most common signs and symptoms of trichotillomania are listed below.

• Pulling hair out repeatedly, primarily from the scalp, eyelashes, and eyebrows, but other areas can also be affected including beard, pubic hair
• Unsuccessful attempts to stop pulling hair out
• Pleasure and satisfaction after pulling hair out e.g. pulling eyelashes feels good
• Sense of tension before or when trying to resist pulling hair out
• Eating, chewing, or biting pulled-out hair
• Having a preference for a specific type of hair or patterns and rituals associated with hair pulling
• Problems at school or work due to hair pulling 
• Social withdrawal 
• Significant and noticeable hair loss, thinning or bald areas, shortened hair
• Hiding hair-pulling behavior from others

Trichotillomania shares many characteristics with obsessive-compulsive disorder, a 2016 paper on trichotillomania from the American Journal of Psychiatry reports. Main manifestations of this condition include:

• Strong urge to pull out hair 
• Inability to stop pulling out hair or picking eyelashes, even when trying 
• Experiencing problems in life, work, and school due to this disorder

Patients with pulling hair out disorder also break off pieces of hair and pick on their skin, chew lips, or bite their nails. Additionally, some persons with this disorder may also pull hairs from pets, dolls, blankets, clothes, and other materials.

How to overcome trichotillomania?

The ways on how to overcome trichotillomania involve strategies and approaches that individuals with hair-pulling disorder can use to manage and reduce their symptoms. The most effective ways to overcome trichotillomania are listed below.

• Join a trichotillomania support group: Support groups allow patients to cope with the disorder in a nonjudgmental environment where they feel safe to share their experiences and get support from others. Some support groups are also based online, thus allowing patients to remain anonymous if they want to.
• Manage stress: Bearing in mind stress is a major trigger for hair-pulling behavior, it’s necessary to manage stress and be proactive about it. Squeezing a stress ball is one way to make it happen. For some people meditation, yoga, reading, writing, and other similar activities can help reduce stress
• Exercise: one of the best ways to reduce the severity and intensity of anxiety, depression, and stress is to exercise. According to a 2017 paper by Mikkelsen et al., from the journal Maturitas, exercise has a positive effect on endorphins and reduces inflammation thus contributing to better health outcomes in persons with mood disorders.
• Deep breathing: This technique helps alleviate stress and could be practical to tackle the urge to pull hair out. Practice deep breathing until the urge to pull hair goes away.
• Mantra: a simple saying to repeat until the urge to pull hair out diminishes. Mantra is something a person can create on their own, which is usually something positive and affirmative.

There’s a lot a patient with trichotillomania can do to decrease the severity of their disorder and reduce hair-pulling behavior. Things that also help overcome hair-pulling include:

• Stress management 
• Regular exercise 
• Support groups
• Fidget toy
• Soothing bath to alleviate stress or anxiety
• Plasters on fingertips
• Finding a hobby or talking to someone

What are the risk factors for trichotillomania?

Risk factors for trichotillomania refer to various factors or conditions that can increase the likelihood of an individual developing the disorder. The main risk factors for trichotillomania are listed below.

• Age: The disorder usually develops between the ages of 10 and 13.
• Family history: The risk of developing trichotillomania is higher for persons whose family members also have this disorder. The hair-pulling disorder could have a genetic component, according to a 2012 review of the genetic factors influencing the development of trichotillomania  published in the Journal of Genetics.
• Stress: For many people, severely stressful situations are a trigger for hair-pulling.
• Mental health disorders: Besides stress, other problems with mental health can increase the risk of trichotillomania. These include OCD, depression, and anxiety.
• Young age, usually adolescence
• Facing severe stress or having other mental health problems
• Being a woman

How do you treat trichotillomania?

Trichotillomania is treated with a combination of therapy and medications. Different types of behavioral therapy are involved in the treatment of this disorder. Examples include habit reversal training, acceptance and commitment therapy, and cognitive behavioral therapy. 

The primary behavioral therapy for the treatment of trichotillomania is habit reversal training, where a person learns how to stop pulling out hair and to recognize triggers that make them pull their hair and how to avoid them. In most cases, patients learn how to substitute other behaviors such as clenching fists instead of pulling out hair.

A 2012 case study on habit reversal training for trichotillomania from the International Journal of Trichology found that habit reversal training helped a 22-year-old woman with trichotillomania attain complete remission. This type of therapy could work through the reduction of  emotional discomfort and alleviation of self-judgments associated with experiencing psychiatric symptoms.

A 2020 paper by Heinicke et al., published in the Journal of Applied Behavior Analysis confirmed that habit reversal training reduces risky behaviors. A major advantage of this therapy is that it puts a strong emphasis on the strong support system that helps patients manage their disorder.

As seen above, other types of therapy are helpful for patients with hair-pulling disorder. Acceptance and commitment therapy helps patients learn to accept and acknowledge the urge to pull hair out, but not act on it. 

On the other hand, cognitive-behavioral therapy helps individuals with this condition identify and evaluate negative, unrealistic, and distorted beliefs associated with hair-pulling. They also learn how to stop trichotillomania by eliminating negative thoughts in favor of positive ones. This type of therapy also enables a person to learn coping mechanisms so they can handle both positive and negative stimuli in a healthy manner.

In addition to the abovementioned therapies, healthcare professionals may also recommend therapies that focus on the management of mental health disorders such as anxiety, substance abuse, or depression.

As far as medications are concerned, there is no specific pharmacotherapy approved by the FDA to treat trichotillomania. Instead, healthcare professionals may prescribe medications to address underlying causes of hair-pulling behavior. 

For instance, a patient may receive antidepressants such as clomipramine (Anafranil) and drugs like N-acetylcysteine, which improve mood. Atypical antipsychotic medication olanzapine (Zyprexa) is also prescribed to some patients with this condition.

Besides doctor-recommended therapy, there are alternative approaches such as hypnotherapy. In fact, imaginative techniques such as hypnotherapy have the potential for the management of trichotillomania in adolescents, according to a 2001 study on three cases of hypnotherapy in adolescents with trichotillomania from the American Journal of Clinical Hypnosis. However, alternative methods aren’t a substitution for standard, doctor-recommended treatment of trichotillomania.

What is the prevalence of trichotillomania?

The prevalence of trichotillomania ranges from 0.5% to 2.0%, according to a 2020 paper by Grant et al., from the American Journal of Psychiatry. In adults, women are more likely to have trichotillomania than men whereas the gender distribution of this condition in childhood is equal.

The same study  also analyzed data from 10,169 adults and found 1.7% or 175 subjects in the sample were classified as currently experiencing trichotillomania. The lifetime rate of this disorder was 2.5% i.e. 253 persons were affected at some point in their life.

 Gender differences in the lifetime prevalence of trichotillomania weren’t significant. Prevalence of this condition in men was 1.8% and 1.7%  in women. Additionally, this disorder was more prevalent in persons under the age of 50. Prevalence ranged from 2.2% to 2.6%.

Factors such as household income, education level, and the racial or ethnic group didn’t have much impact on the prevalence of trichotillomania in this research. 

While lifetime prevalence of trichotillomania is similar among men and women, that’s not the case for the 30-49 age group. Males were more likely to have this condition. Gender differences vary from one age group to another. For example, the disorder was more prevalent in females in the 50-69 age group than their male counterparts. The average age of onset of trichotillomania was 17.7. 

Interestingly, 24% or 42 out of 175 persons with trichotillomania also had a current comorbid skin picking disorder. The most common comorbidities were anxiety (53%), depression (45%), OCD (29%), PTSD (29%), and ADHD (29%).

How does Trichotillomania relate to emotions?

Trichotillomania relates to emotions because it serves as an outlet for an affected person to exhibit both negative and positive feelings. 

For many individuals with this disorder, hair-pulling is an escape from uncomfortable feelings. A person may start pulling their hair as a way to deal with symptoms of anxiety, and depression, or to overcome tension, boredom, fatigue, frustration, and loneliness. 

For a number of people, trichotillomania is also associated with trauma. In other words, trichotillomania may serve as an outlet to cope with negative emotions.

At the same time, others may pull their hair out due to positive feelings. Sometimes, the act of pulling hair produces feelings of satisfaction and pleasure. In turn, a person may be inclined to do it over and over again just to feel that same pleasure.

While trichotillomania is strongly associated with emotions in most cases, sometimes it doesn’t relate to the emotional aspect. A study by Lochner et al., published in the 2021 issue of Frontiers in Psychology found other factors besides emotion dysregulation that are involved in this disorder, such as habit-forming, cognitive disinhibition, and dissociation . 

Are there any celebrities who suffer from trichotillomania?

Yes, there are celebrities who suffer from trichotillomania, including Olivia Munn, Sara Sampaio, and Samantha Faiers. 

Olivia Munn, known for her roles in The Newsroom, X-Men, and The Predator, is open about her struggle with trichotillomania. In a cover story written by Ann Oldenburg for the October 2014 issue of Self magazine, the actress confessed she started with obsessive eyelash pulling at the age of 26. 

Munn explained her condition was associated with anxiety that resulted from a tumultuous and hectic life since her childhood. Fortunately, she managed to overcome her condition successfully and she credits hypnotherapy for making it happen.

Portuguese model, Sara Sampaio, took to Instagram in 2018 to talk about her experience with the hair-pulling disorder. According to the 2018 news article written by Temi Adebowale for Harper’s Bazaar, the Victoria’s Secret angel revealed she started pulling out eyelashes when she was 15. Eventually, she started pulling out her eyebrows too. The condition was worse when she was under a lot of stress. As a result, she has gaps in her eyebrows that she covers with an eyebrow pencil.

English TV personality and model, Samantha Faiers, revealed that she has been struggling with trichotillomania for 20 years. She compulsively pulls out her eyelashes and admits she’s finding it difficult to control her condition because she does it even when she sleeps, according to a 2021 news article written by Kate Dennett for Mail Online. 

While numerous trichotillomania websites claim Megan Fox has this disorder and was hospitalized three times because of it, there is no evidence to confirm that. At this point, it’s unclear whether The Transformers star really has trichotillomania or that’s just a rumor. Also, Charlize Theron, Kate Beckinsale,Colin Farrell, and Justin Timberlake are believed to have trichotillomania. Charlize Theron did play a character with this disorder in her movie Young Adult.

How long does it take for trichotillomania hair to regrow?

It may take two to four years for trichotillomania hair to regrow. The compulsive need to frequently pull out hair may induce damage to hair follicles and slow down hair growth. 

In cases when trichotillomania goes untreated for years, hair follicles could be damaged permanently. That means hair in those areas may never grow back, a 2021 article written by James Roland for Healthline explains.

Generally speaking, the timeline for hair re-growth is unpredictable. When hair pulling doesn’t damage the follicle, standard hair growth is possible. The standard growth phase of eyelashes and eyebrows is one to six months. Scalp hair grows around six inches a year and continues to grow for up to eight years. However, these rules may not apply to persons with trichotillomania. 

The hair-pulling disorder can damage follicles and thereby impair their function and hair growth cycle. A hair follicle pulled out means it’s difficult or almost impossible to grow hair in that specific spot.

What are the complications of trichotillomania?

Complications of trichotillomania include emotional distress, hairballs, skin and hair damage such as permanent hair loss, and problems with social and work functioning. 

According to a 2022 article on trichotillomania (hair-pulling disorder) from Mayo Clinic, emotional distress occurs because many persons with trichotillomania feel humiliated, ashamed, and embarrassed due to their disorder. They also tend to struggle with low self-esteem, depression, and anxiety and may start consuming alcohol or street drugs to overcome their emotions.

In addition to pulling out hair, patients may also develop trichophagia i.e. they eat the hair they pull out. People who eat their hair risk developing hairballs in the digestive tract. The presence of hairballs inside the body can cause serious health problems, including intestinal obstruction and even death.

The compulsive need to pull out hair can damage skin and hair. Some problems include scarring, infections, and permanent hair loss.

Since patients with trichotillomania feel shame and embarrassment for their condition, they may avoid socializing with other people or pass up a great job opportunity. Intimacy problems are also common for persons with this disorder.

How can you prevent trichotillomania?

There is no known method to prevent trichotillomania. That being said, prompt and adequate treatment can prevent complications of this disorder and improve a patient’s quality of life, an article on trichotillomania published in Cleveland Clinic confirms. 

Since stress is a major trigger of hair-pulling behavior, stress management techniques could help patients with trichotillomania. 

A major problem is that many patients with this condition are reluctant to seek help and talk about their symptoms. A 2016 review by Gawłowska-Sawosz et al., from Psychiatria Polska confirms it’s necessary to increase awareness of this disorder. As a result, trichotillomania might be diagnosed earlier, therapy would be more effective, and potentially life-threatening side effects could be avoided. 

In a nutshell, although there’s no specific prevention method at this point, early treatment (when symptoms first appear) and stress management can help prevent complications, improve relationships, and decrease the impact of this condition on quality of life.