What are the other Names for this Condition? (Also known as/Synonyms)

• Compulsive Hair-Pulling Disorder
• Hair-Pulling Disorder
• TTM (Trichotillomania)

What is Trichotillomania? (Definition/Background Information)

• Trichotillomania (TTM) is a psychiatric disorder in which individuals pull out hair from their own head or body, leading to serious cosmetic issues. It is also known as Compulsive Hair-Pulling Disorder
• In other words, Trichotillomania may be described as an impulse control disorder in which one has a recurrent, irresistible urge to pull out his/her hair from any part of the body, despite wanting to stop. Pulling out hair gives such individuals a feeling of relief, and this begins a vicious cycle, where individuals continue the repetitive behavior, despite it affecting their performance (at school or job) and cosmetic appearance
• Trichotillomania is mostly observed during childhood and adolescence, and more cases are reported in females. Having a family history of the condition and constantly harboring negative emotions (such as anxiety and depression) are some risk factors for developing this disorder. However, the exact cause of TTM is unknown. Several theories, such as stress, imbalance in neurotransmitters in the brain, and hormonal fluxes during puberty, have been proposed to explain the condition
• The signs and symptoms of Trichotillomania include compulsive pulling of hair from the scalp, eyelashes, eyebrows, arms and legs, swallowing pulled hair, and gastrointestinal issues due to hair ingestion. It can lead to considerable hair loss, baldness and distress, affecting one’s social life and overall functioning
• Individuals experience tension and anxiety before pulling hair from their body, but are unable to resist the urge. Once the urge of wanting to pull out hair is fulfilled, the individuals enjoy a feeling of relief and gratification. This component also forms a criterion to diagnose the disorder. TTM is often associated with other psychiatric disorders such as depression and self-inflicted behavior
• In many cases, the treatment of Trichotillomania is difficult. Often, a combination of behavioral therapy and antidepressant medications is employed to treat the disorder. Usually, children with TTM recover completely. The prognosis for adolescents and adults is determined on a case-by-case basis, as the disorder may continue for the remainder of their lives, requiring continual treatment

Who gets Trichotillomania? (Age and Sex Distribution)

• Trichotillomania affects an estimated 1-2% of the population. One study estimates that 0.6% of all college students may have this disorder
• The condition occurs more commonly in children between 9 to 13 years of age; it can continue for the individual’s entire life
• Whereas both genders are affected, females are more susceptible to TTM than males, particularly post-childhood
• In childhood, it is equally common in both boys and girls. However, in adults, women are more commonly affected
• No racial and ethnic group preference has been noted

What are the Risk Factors for Trichotillomania? (Predisposing Factors)

The risk factors associated with Trichotillomania may include:

• Family history of the condition
• Females are generally known to have a higher risk, since more number of cases are observed among them
• Negative emotions: TTM is considered to be an outlet for negative feelings, like distress, anxiety, tension, and loneliness. Some studies have reported high levels of anxiety and depression in those with the condition
• Post-traumatic stress disorder (PTSD)
• Positive reinforcement: Many affected individuals report a sense of relief after pulling their hair. This strengthens the habit and causes repetitive behavior
• A few studies indicate that childhood trauma and abuse may be risk factors for the condition

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Trichotillomania? (Etiology)

Currently, there are no specific causes outlined for Trichotillomania. However, some theories have been postulated in this regard and these include:

• Trichotillomania as a means of relieving stress and anxiety:
  • The behavior observed in TTM has also been associated with obsessive-compulsive disorders and other similar conditions
  • It has been suggested that the disorder is a type of self-harm, and individuals practice that to seek temporary relief from emotional distress. For example, pulling hair as a mechanism of coping with stress has been reported in individuals suffering from post-traumatic stress disorder (PTSD). Deliberately harming oneself inflicts pain, which causes the brain to release endorphins, leading to a short-lived sense of wellbeing
  • Individuals, who experienced sexual abuse have also been associated with self-harm, including pulling-out their hair as a means of appearing less attractive
• Changes in levels of neurotransmitters: It has been theorized that changes in the levels of dopamine and norepinephrine, and thus resulting in a chemical imbalance in the brain, may play a role in the development of this condition
• Hormonal changes during puberty may also account for the high prevalence rates seen in pubertal age groups
• A sense of pleasure with the pulling of hair, which becomes a repetitive habit and subsequently addictive

What are the Signs and Symptoms of Trichotillomania?

The common signs and symptoms of Trichotillomania include:

• Continuously pulling out hair from the scalp, eyebrows, eyelashes, arms/hands
• Sense of tension before pulling hair, and relief after pulling hair
• Repeated attempts at stopping the habit does not result in a success
• Bald patches in the scalp (alopecia), which individuals try to camouflage or hide
• Little or no eyebrows or eyelashes
• Playing with pulled hair, rolling it between the fingers
• Biting or swallowing such removed (pulled) hair
• Digestive tract problems as a prolonged result of eating hair
• Low self-esteem
• Functional and social impairment, such as avoidance of social gatherings, intimacy, public places, etc., due to feelings of embarrassment, low self-esteem, shame and fear of being discovered
• Some individuals may pull their hair in sleep. They may or may not be aware of their habit

How is Trichotillomania Diagnosed?

The diagnosis of Trichotillomania is made by clinical assessment and may involve the following:

• Physical examination and an assessment of symptoms
• Evaluation of medical history
• A healthcare provider may also examine scalp and other areas, to assess hair loss. In some cases, the affected individual or their family may deny any ‘hair-pulling’, or the individual may be unaware of his/her habit of pulling hair in sleep. In such cases, a scalp biopsy may sometimes be warranted to rule out other skin diseases (such as alopecia areata)

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, provides guidelines to classify whether the patient meets all criteria to be diagnosed with Trichotillomania. The criteria include:

• Recurrent hair pulling resulting in noticeable hair loss
• Increasing sense of tension prior to the hair-pulling event
• Sense of gratification after pulling hair
• Clinically significant distress, or occupational, functional, and/or social impairment
• The symptoms are not due to any other medical disorder or substance abuse

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Trichotillomania?

The potential complications associated with Trichotillomania include:

• Emotional distress: Those with TTM experience a feeling of disgrace, loss of self-respect, low morale, confusion and worry. This may affect their occupation, relationships, and functioning
• Itching, infections, and injury to muscles and joints may occur due to excessive hair-pulling
• Ingesting hair that is pulled-out may cause gastrointestinal distress
• This may also rarely develop a trichobezoar (hairball in the intestines or stomach), which can cause intestinal blockage requiring surgical removal

How is Trichotillomania Treated?

Typically, Trichotillomania is a disorder that is difficult to treat. The following are some options for treatment:

• Psychotherapy
  • Habit reversal training: It helps by substituting other behaviors for the hair-pulling habit
  • Cognitive therapy: The therapy helps by challenging and examining “distorted” beliefs about hair-pulling
  • Acceptance and commitment therapy (ACT), in which the affected individuals learn to accept fault for the habit and avoid it
• Medications: The physicians may recommend medications such as antidepressants

A combination of medication and psychotherapy is often used for effective treatment.

How can Trichotillomania be Prevented?

• Presently, no guidelines or methods exist for the prevention of Trichotillomania
• However, identifying triggers and learning to control the urge to pull hair, may help avoid further such episodes

What is the Prognosis of Trichotillomania? (Outcomes/Resolutions)

The prognosis of Trichotillomania is generally dependent on the age of the affected individual:

• Young children, less than 6 years of age, recover from this habit without any treatment, usually within 12 months
• For older children/adolescents, young and older adults, TTM may become a lifelong medical condition, requiring sustained treatment. Nevertheless, most of the affected individuals, do report benefiting from psychotherapy

Additional and Relevant Useful Information for Trichotillomania:

Please visit our Behavioral & Mental Health Center for more physician-approved health information:

http://www.dovemed.com/healthy-living/emotional-well-being/