Trichotillomania (Hair-Pulling Disorder) (F63.3)

Trichotillomania, also known as trich, is a poorly understood disorder characterized by the recurrent pulling out of one’s own hair that results in noticeable hair loss (Chamberlain, Menzies, Sahakian & Fineberg, 2007). A person with trichotillomania may pull out hair from any part of his or her body. The most common locations pulled are the scalp, eyebrows, and eyelashes. For people who suffer from this impulse-control disorder, pulling decreases stress and tension and causes pleasure (Bayer, 2000). The pulling may occur during periods of relaxation. However, stressful events tend to increase the amount of time a person may spend pulling his or her hair (Bayer, 2000). The act of pulling may take place in brief episodes throughout the day or during less-frequent periods that can last for hours (Bayer, 2000).

Trichotillomania causes considerable social and occupational problems. Sufferers do not typically pull their hair in front of others unless they are close family members, so they may tend to avoid social situations (Bayer, 2000). Some people with trichotillomania may deny the behavior and attempt to conceal bald spots (Bayer, 2000).

Some researchers suggest that trich is a compulsive behavior. Although people who seek treatment for trich may do so for reasons similar to people with OCD, trich is different from OCD in several ways. Unlike OCD, the behavior is not performed in response to an obsessional thought or to prevent some unwanted event or situation (Bayer, 2000). Furthermore, individuals with trich only pull hair, whereas people with OCD may perform multiple types of rituals (Bayer, 2000). Also, while OCD is equally evident in males and females, trich is a predominately a female disorder (Bayer, 2000).

Trichotillomania usually begins in childhood, but short term episodes of hair pulling in childhood may be a benign habit that does not persist later in life (Bayer, 2000). Some individuals experience continuous symptoms for several years while others can go into remission for weeks, months, or years (Bayer, 2000). High amounts stress may cause the behavior to reappear (Bayer, 2000). Those who suffer from trichotillomania are more likely than the general population to have mood, anxiety, and substance-related disorders (Bayer, 2000). According to DSM-IV, 1-2% of college students have a current or past history of the illness.

Fictional Character Case Study: “Jordan Kimura”

Demographic and Background

• Name: Jordan Kimura

• Age: 24

• Gender: Nonbinary (they/them)

• Occupation: Graduate student in Biomedical Engineering

• Living Situation: Shares a small apartment with a roommate; family lives in another state

• Cultural / Social Context: First-generation American of Japanese descent; strong expectation from family around academic performance and professional success

Symptom Onset & Development

Jordan first noticed hair pulling around age 16, soon after beginning high school. It started during late night study sessions: they would rub or pick hair on the crown of their scalp when stressed about exams. Over the years, the behavior increased in frequency and severity, especially during times of high academic or emotional stress (e.g. undergrad finals, advisor pressures in graduate school, interpersonal conflict).

Current Presentation (Past 6-12 Months)

Criterion A: Recurrent hair pulling resulting in hair loss

• Jordan recurrently pulls hair from multiple sites: the scalp (crown and part line), eyebrows, and occasionally eyelashes.

• Hair loss is noticeable: patches of thinning hair on scalp; eyebrows are sparse; eyelashes have gaps. They also trim or clip hair that is breaking or weak, but mostly pulling is by hand.

Criterion B: Repeated attempts to decrease or stop

• Jordan has attempted multiple times to reduce or stop: wearing gloves during study hours, trying to keep hair short, using hats or headbands, setting alarms as reminders not to touch scalp.

• Has tried coping strategies: mindfulness apps, stress journaling. Some minor periods (1-2 weeks) of reduced pulling, but always returns to baseline or worse during stress.

Criterion C: Significant distress or impairment

• Distress: They experience intense shame and self-consciousness. Avoids public speaking and attending seminars where they may be under bright lights or be photographed; hides hair with caps, scarves, styling; avoids physical intimacy with partner because of concern partner will notice eyebrow/eyelash gaps.

• Impairment: Their academic work suffers—difficulty concentrating, takes extra time to prepare (e.g. makeup, grooming) before leaving apartment. Social withdrawal: declines social invitations, isolates themselves. Sometimes late to class or lab so they can fix appearance in private.

Criterion D: Not due to another medical condition

• Dermatological evaluation ruled out alopecia areata, fungal infections, or other scalp disease. No thyroid issues; no nutritional deficiencies.

Criterion E: Not better explained by another mental disorder

• Jordan does also have worries about appearance, but they do not meet full criteria for Body Dysmorphic Disorder: in BDD the focus is on perceived defect/flaw; for Jordan the concern about appearance is secondary to shame from hair loss, rather than a delusional belief or overvalued idea about some “flaw” in the hair itself. Also, they do not engage in repetitive mirror checking or camouflaging in the same way. They do not pull hair in order to relieve intrusive thoughts like OCD rituals (though comorbid anxiety exists).

Other Features / Specifiers

• Style: both automatic and focused pulling. Many pulls occur without awareness (e.g. when reading, watching video), sometimes in response to emotional tension (before lab meetings, after criticism).

• Triggers: stress, boredom, feeling unsettled; sensory triggers (feeling of hair that is rough, or tickly); sometimes after a minor physical itch or irritation.

• Post-pulling behavior: after pulling, Jordan sometimes examines the hair, rolls it between fingers; occasionally bites the tip; sometimes swallows small hair fragments (trichophagia), though no large bezoars identified so far.

• Comorbidity: Diagnosed with generalized anxiety disorder (GAD) in past; occasional depressive symptoms, especially during periods of academic setback.

• Course: chronic; symptoms wax and wane. There were periods of lower severity (e.g. during summer breaks or after intense therapy) but resurgence during high stress (e.g. thesis deadline).

Differential Diagnoses & Exclusions

• Body Dysmorphic Disorder (BDD): Jordan does have concerns about appearance, but those are reactive—secondary to pulling; no persistent belief of defect.

• Obsessive-Compulsive Disorder (OCD): Their hair pulling is not a ritual in response to intrusive obsessions, but often a response to tension or sensory discomfort.

• Dermatological Conditions: Ruled out with medical evaluations.

• Other body‐focused repetitive behaviors (BFRBs): Jordan also picks at cuticles/nails, but these behaviors are less severe, less distressing. Those are comorbid, but do not account for full syndrome.

• Impulse control disorders / habit disorders: Important to consider that the behavior has habitual features; but in DSM-5, hair pulling is classified under Obsessive-Compulsive and Related Disorders, not under impulse control. NCBI+1

Severity & Functional Implications

• The behavior is chronic (8+ years), increasing severity during stress.

• Jordan spends a considerable amount of time (estimation: cumulative several hours/week) in pulling episodes or trying to manage skin/hair/cover hair loss.

• Socially: avoidance of events; psychological distress (shame, embarrassment); reduced self-esteem; possible mood dips.

• Academically: attention and concentration are affected; sometimes lab partner or advisor notice Jordan’s appearance; verbal comments (unintentional) increase anxiety.

Possible Medical Complications

• Trichophagia: occasional ingestion of hair fibers—no confirmed trichobezoar yet, but occasional gastrointestinal discomfort.

• Skin irritation / folliculitis in areas frequently pulled; mild scarring and reduced regrowth in some patches.

Treatment Considerations

• Behavioral therapy: Primary recommended approach is Habit Reversal Training (HRT), possibly augmented by stimulus control. Jordan might benefit from awareness training (e.g. recognizing urges, situations), competing responses, environmental modifications. MSD Manuals+2Medscape+2

• Cognitive strategies: Address shame, self-criticism, negative beliefs about self and appearance.

• Pharmacotherapy: Consider SSRIs or clomipramine in cases of comorbid depression/anxiety; agents such as N-acetylcysteine or other glutamate modulators have some evidence. MSD Manuals+2Psychopharmacology Institute+2

• Supportive interventions: Psychoeducation; peer support groups; dermatological care for managing damage; possibly counseling around appearance, coping with social stigma.

• Monitoring for complications: Especially if trichophagia escalates; regular GI evaluation if symptoms suggest.

Associated Features

• Individuals with trichotillomania are often seen by the public as having a habit of playing with their hair. People with trich will examine the hair root, twirl it off, pull the strand of hair between their teeth, or may eat their hair. Hair eating is known as trichophagia. They usually do not pull their hair out in the presence of anyone except family members. Some individuals suffering from this disorder will deny that they pull out their hair and will attempt to hide the resulting baldness. If the case is extreme, the individual may have urges to pull other people’s hair, but often can refrain. Dolls, pets, carpet, and sweaters are often pulled on like hair (Bayer, 2008). Nail biting, scratching, gnawing, and excoriation (tearing off skin or skin picking) are often associated with this disorder.
• Trichotillomania is linked to obsessive-compulsive disorder; often, both disorders are present in younger females. The pulling of the hair becomes a habit to obsess about. Many of the same attributes of OCD appear in patient with trichotillomania including the need for perfection and order. Hair pulling has appeared to be stress relief from the obsessions.

Child vs. Adult presentation

Trich usually begins in late childhood or early adolescence. The peak age of onset is 13 to 14 years old (Chamberlain et al., 2007). It is more common during the first 20 years of someone’s life. There is not a difference in presentation between children and adults, however. Children with trich may feel socially isolated because they often feel that no one else has this disorder (Anegundi, Shetty, Yavagal & Pandurangi, 2010)

Gender and cultural differences in presentation

• When presented in children, the rates between genders tend to be relatively equal. However, trichotillomania is more common in adult females than adult males. It has been found that approximately 70% of adults that have trich are female (Anegundi et al., 2010). This finding of an off-balance male-to-female ratio may be a result of the true gender ratio of the condition, or it could be due to treatment-seeking curve formed due to cultural or gender based attitudes regarding acceptance of the associated features of this disease (Anegundi, Shetty, Yavagal & Pandurangi, 2010).
• Women tend to pull from limited locations while men pull from many locations on the body (Anegundi et al., 2010)

Epidemiology

• Trichotillomania is now believed to be more common than it once was. Studies show that today the lifetime prevalence rate of this disorder is 0.6%, but it is difficult to determine. This rate is based on the psychological affect- the release of tension after pulling the hair out. However, when including those individuals who subconsciously pull hair, the rate is approximately 1.5% for males and 3.4% of females. A study of 2,500 college students found similar lifetime prevalence rates when using strict DSM-III-R criteria (Chamberlain et al., 2007).
• Trich is often comorbid with with mood and anxiety disorders, such as major depression, generalized anxiety disorder, and simple phobias (Chamberlain et al., 2007).

Etiology

• There is evidence of a genetic predisposition. Hair pulling and similar grooming phenomena often occur in family members of people with trich (Chamberlain et al., 2007). Mutations in a gene called SLITRK1 have been linked to trichotillomania as well as to Tourette syndrome, a neurological disorder that causes a person to make unusual movements and sounds.
• Trich also shows high overlap with PTSD, which suggests affective contributions (Chamberlain et al., 2007).
• Neurochemical problems can also play a role in trichotillomania. Some studies suggest that abnormalities in the natural brain chemicals serotonin and dopamine may play a role.
• There are two types of trichotillomania that have been described: focused pulling and non-focused pulling. The focused pulling is used to control negative emotions, such as anger. The non-focused pulling is a nonintentional type of pulling that occurs without the patients complete awareness.

Empirically supported treatments

• Treatment for trichotillomania may be through behavior therapy aimed at habit reversal (Chamberlain et al., 2007). Sufferers learn to identify when they have urges to pull out their hair and how to relax in order to reduce the tension caused by the urge. Therapy also helps them develop a competing response when their urge arises. For example, they may make a fist with their hands to stop from pulling out hair.
• Cognitive therapy may also be used to address distorted thinking.
• Medication such as an antidepressant called selective serotonin reuptake inhibitors (SSRIs) may be used as part of the treatment program as well.
• Given the limited amount of research available, no formal treatment algorithm can be created (Chamberlain et al., 2007)