Trichotillomania (hair-pulling disorder)

What is trichotillomania?

Trichotillomania is recurrent hair pulling that is difficult to limit or stop. Hair is most often pulled from the scalp, eyebrows or eyelashes, but pulling can also involve other areas of the body. Even small, concealed areas of thinning may lead to sore skin, shame and considerable effort to hide the hair loss.

The condition is also called hair-pulling disorder. Together with skin-picking disorder, it is grouped among the body-focused repetitive behaviours, often abbreviated to BFRBs. These involve recurrent actions directed at areas such as the skin and hair.

Severity is not determined by a fixed number of hairs. What matters is that the pulling recurs, causes hair loss, is difficult to stop and affects daily life. Some people feel a clear urge or tension before pulling and brief relief afterwards. For others, the movement is so automatic that they barely notice it beginning.

Automatic and focused hair pulling

Hair pulling may be automatic, focused or a mixture of both.

Automatic hair pulling occurs with limited awareness. The hand moves towards the hair while the person reads, uses a screen, talks on the phone or is falling asleep. They may notice the action only when their fingers are holding a hair or the skin becomes sore.

Focused hair pulling is more deliberate. The person searches for a particular thickness, colour or texture and continues until the hair has been found and removed. The longer they feel and compare hairs, the more absorbing the search for a short, coarse or uneven one can become.

The same episode can begin automatically and become focused. At first, the fingers move through the hair without much awareness. When they find a particular texture, the search becomes more deliberate and the person may lose track of time.

What keeps hair pulling going?

Pulling does not always begin for the same reason. Sensory experiences, thoughts, emotions, movements and situations can each set it in motion.

Sensory experiences. It may begin with a coarse, bent or short hair, a tingling sensation on the scalp or the resistance felt during the pull. Some people examine the root afterwards or immediately search for another hair with the same texture.

Thoughts and emotions. The thought may be brief: I’ll only take this one hair. Some people pull mainly when they feel stressed, frustrated or restless; others do so when they are bored, tired or concentrating.

Posture and surroundings. During automatic pulling, an elbow may rest on the table, a hand may be close to the temple or one hand may be free in front of a screen. A particular chair, the bathroom mirror or the time just before sleep can become closely linked to pulling.

The pull ends the search and may provide relief, sensory satisfaction or a short break from discomfort. Because this effect is immediate, the action is easily repeated even though soreness and shame follow later.

Hair loss, the skin and swallowing hair

An episode may involve more than pulling. The person may search through the hair, wind it around a finger, examine the root, bite the hair, sort it or keep it. Recognising this full sequence makes it easier to notice an episode earlier.

Repeated pulling can cause soreness, small wounds and inflammation around the hair follicles. Hair often grows back when pulling is reduced, but prolonged pulling may affect the follicles. Regrowth may be slow, uneven or incomplete. Wounds, infection, pain or hair loss that may have another cause should be assessed by a doctor or dermatologist.

Swallowing pulled hair is called trichophagia. Hair is not broken down in the digestive system and can, in rare cases, collect into a hairball known as a trichobezoar. Anyone who swallows hair should tell a doctor. Persistent abdominal pain, vomiting, feeling full unusually quickly, a swollen abdomen or unexplained weight loss require medical attention.

Shame, concealment and everyday life

Trichotillomania can affect far more than the time spent pulling. Hairstyles, make-up, hats, wigs or false eyelashes may help conceal the hair loss, but managing them can become a time-consuming daily task. Bright light, wind, swimming, visits to the hairdresser, intimacy and photographs may all feel risky because the affected areas could become visible.

Shame can grow when other people treat the behaviour as something the person should simply stop doing. Reprimands may lead to greater concealment and delay seeking help from a doctor or psychologist. It is more helpful to ask with curiosity when and how the pulling occurs than to demand an explanation for why the person has not already stopped.

Hair pulling in different clinical patterns

Hair may be pulled for different reasons. What happens before, during and after the action helps distinguish between the patterns.

OCD. Hair may be removed to follow a rule, neutralise an obsession or prevent a feared consequence. In trichotillomania, urges, sensory experiences, movement habits and emotional regulation are more often central. The two conditions can occur together.

Body dysmorphic disorder (BDD). The person may remove hair to correct a perceived flaw in their appearance. In trichotillomania, the repeated searching and pulling are central, although the resulting hair loss can cause considerable concern about appearance.

Skin-picking disorder. Here, the skin is examined and worked on. The automatic and focused patterns can resemble those in hair pulling, and a person may have both conditions.

Self-harm. Pain, injury or punishment is part of what the action is intended to achieve. In trichotillomania, pulling is generally driven by an urge, a sensory experience or habit, even though it may cause physical harm.

Hair loss may also be caused by a skin condition, inflammation, medication or hormonal factors. If hair falls out without known pulling, or the pattern changes rapidly, medical assessment is relevant.

Treatment for trichotillomania

Behaviour therapy with habit reversal training (HRT) has the strongest evidence base. It helps the person identify the rapid sequence that leads to pulling and practise a different response before the hair is pulled.

Awareness training focuses on the early signs: the hand lifting, the fingers starting to search or the thought of a particular hair. A simple record focuses on what happens before and at the beginning of an episode rather than counting every hair.

A competing response is an agreed movement that cannot be performed at the same time as hair pulling. It is used briefly when an urge or early hand movement is noticed. The action needs to fit the situation and be simple enough for everyday use.

Changes to the environment can make the automatic sequence easier to notice and harder to continue without awareness. The changes are selected according to the places and activities in which pulling occurs.

Comprehensive Behavioral Treatment (ComB) is used to tailor treatment. The model considers sensory experiences, thoughts, emotions, movements and places. A plan for someone who searches for coarse hairs in front of a mirror will look different from one for someone whose hand automatically moves towards the hair during concentration.

Some people also need help with shame, avoidance and emotional regulation. Medication and supplements have been studied, but the evidence varies by preparation and age group. Decisions are made with a doctor or psychiatrist who can consider the expected effects, possible side effects and any other medication.

How can family and friends help?

Family and friends often notice the movement before the person does. Support works best when a neutral signal has been agreed in advance and the person knows what action to take next. Repeated commands, physically stopping the hand and comments in front of others can easily increase shame.

For children, parents and other adults can help identify situations, postures and sensory signals without punishment or constant monitoring. Siblings can be given a simple explanation but should not be made responsible for watching the child.

When is it relevant to seek help?

It is relevant to seek help when hair pulling returns despite attempts to stop, causes hair loss or skin damage, takes up a great deal of time or leads to concealment and avoidance. Even small areas of hair loss can have a substantial impact. A clinical assessment considers both automatic and focused episodes, the areas of the body involved, actions involving the hair, physical damage and any swallowing of hair.