Symptoms

Signs and symptoms of trichotillomania often include:

• Repeatedly pulling your hair out, typically from your scalp, eyebrows or eyelashes, but it can be from other body areas as well
• A strong urge to pull hair, followed by feelings of relief after the hair is pulled
• Patchy bald areas on the scalp or other areas of your body
• Sparse or missing eyelashes or eyebrows
• Chewing or eating pulled-out hair
• Playing with pulled-out hair
• Rubbing pulled-out hair across your lips or face

Most people with trichotillomania pull hair in private and generally try to hide the disorder from others.

For some people, hair pulling is intentional and focused. They're aware that they're pulling their hair out and may even develop elaborate rituals for doing so. Other people pull their hair unconsciously. The same person may also do both, depending on the situation and mood. For example, focused hair pulling may occur when you're frustrated in the car. Or you may unconsciously pull hair when you're bored. Certain positions or rituals may trigger hair pulling, such as resting your head on your hand or brushing your hair.

Causes

The cause of trichotillomania is unclear. But like many complex disorders, trichotillomania probably results from a combination of genetic and environmental factors. Also, abnormalities in the natural brain chemicals serotonin and dopamine may play a role in trichotillomania.

Risk factors

These factors tend to be associated with trichotillomania:

• Family history. Susceptibility to trichotillomania may be inherited.
• Age. Trichotillomania usually develops during adolescence — most often between the ages of 11 and 13 — and is often a lifelong problem. Children younger than age 5 also can be prone to hair pulling, but this is usually mild and goes away on its own without treatment.
• Sex. Although far more women than men are treated for trichotillomania, this may be because women are more likely to seek medical advice. In early childhood, boys and girls appear to be equally affected.
• Negative emotions. For many people with trichotillomania, hair pulling is a way of dealing with negative or uncomfortable feelings, such as stress, anxiety, tension, loneliness, fatigue or frustration.
• Positive reinforcement. People with trichotillomania often find that pulling out hair feels satisfying and provides a measure of relief. As a result, they continue to pull their hair to maintain these positive feelings.
• Other disorders. People who have trichotillomania may also have other disorders, including depression, anxiety, obsessive-compulsive disorder or eating disorders. Nail biting and skin picking have also been associated with trichotillomania.

Complications

Although it may not seem particularly serious, trichotillomania can have a great impact on your life. Complications include:

• Emotional distress. Many people with trichotillomania report feeling shame, humiliation and embarrassment and experience low self-esteem, depression and anxiety because of their condition.
• Social problems. Embarrassment because of hair loss may lead you to avoid swimming, haircuts and windy weather. People with trichotillomania may wear wigs, style their hair to disguise bald patches or wear false eyelashes. Some people may avoid intimacy for fear that their condition will be discovered.
• Skin damage. Constant hair pulling can cause abrasions and other damage, including infections, to the skin on your scalp or the specific area you're pulling hair from.
• Hairballs. Eating your hair may lead to a large, matted hairball (trichobezoar) in your digestive tract. Over a period of years, the hairball can cause weight loss, vomiting, intestinal obstruction and even death.

Preparing for your appointment

Seeking help is the first step in treating trichotillomania. At first you may see your primary care doctor or a dermatologist. He or she may then refer you to a mental health provider.

These suggestions may help make your appointment easier:

• Write down all the symptoms you're experiencing, even if they seem unrelated to hair pulling. Trichotillomania can cause both physical and psychological symptoms. Note which factors trigger your hair pulling, how you've tried to deal with the problem, and factors that make it better or worse.
• Write down key personal information, including any major stresses or recent life changes and whether hair pulling runs in your family.
• Make a list of all medications, as well as any vitamins or supplements, that you're taking. Include on your list the specific name and dose of these medications, and how long you've been taking them.

Create a list of questions ahead of your appointment so that you can make the most of your time with your doctor. For example:

• What might have caused me to develop this disorder?
• How do you diagnose this condition?
• Is this something that will go away on its own? Is there anything I can do on my own to improve my symptoms?
• What treatments do you recommend for this disorder?
• What if I can't afford therapy?
• If I decide to take medications, how long will it take for my symptoms to improve?
• What are the side effects of the medications you're recommending?
• How much improvement can I realistically expect if I follow your treatment plan?
• What if nothing helps?

In addition to your prepared questions, don't hesitate to ask questions during your appointment.

Tests and diagnosis

Your doctor will perform a thorough evaluation to determine if you have trichotillomania, which may include examining how much hair loss you have, having you fill out a questionnaire and eliminating other possible causes of hair pulling or hair loss. In some cases, your doctor may also take a biopsy of your hair or skin to try to pinpoint the problem.

To be diagnosed with trichotillomania, you must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association.

DSM criteria for the diagnosis of trichotillomania include:

• Repeatedly pulling out your hair, resulting in noticeable hair loss
• An increasing sense of tension before pulling, or when you try to resist pulling
• Pleasure or relief when pulling
• Your hair loss isn't attributed to another medical or dermatologic condition
• Hair pulling causes you significant distress

There is some debate among mental health providers — and people with trichotillomania — about these criteria, and they may change in the future.

Treatment and drugs

Research on treatment of trichotillomania is limited. Current approaches focus on:

• Psychotherapy. A form of psychotherapy called habit reversal training may be an effective treatment for trichotillomania. This type of therapy helps you learn how to recognize situations where you're likely to pull and how to substitute other behaviors instead, such as clenching your fists for a period to "freeze" the urge, or redirecting your hand from your hair to your ear. Sometimes elements of other therapies may be blended with habit reversal training. For instance, your care provider may use cognitive therapy to help you challenge and examine distorted beliefs you may have in relation to hair pulling. Another treatment, acceptance and commitment therapy (ACT), helps people learn to accept their hair-pulling urges while at the same time teaching them how to avoid acting on their impulses.
• Medications. Your doctor may also recommend that you take an antidepressant, such as clomipramine (Anafranil).

Alternative medicine

Some complementary therapies to psychotherapy and medications that may help trichotillomania include:

• Hypnosis. Hypnosis may be a successful treatment for trichotillomania.
• Relaxation techniques. Learning relaxation techniques, such as progressive muscle relaxation, may help divert the urge to pull hair.

Coping and support

Many people with trichotillomania report feeling alone in their experience of hair pulling. It may help to join a support group for people with trichotillomania so that you can meet others with similar experiences and who can relate to your feelings. You might ask your doctor for a recommendation or visit the Trichotillomania Learning Center's website to find a support group.

Family and friends of people with trichotillomania also may benefit from group therapy.