What Is Trichotillomania?

Trichotillomania (TTM) may be funny word, but the disorder it describes — hair pulling — can be a serious problem for children and teenagers. Trichotillomania comes from the Greek words trich (hair) and tillein (to pull or pluck), and it is characterized by the purposeful pulling of one’s own hair from any part of the body.

TTM can be difficult to diagnose since those with the disorder are often secretive about their hair pulling and subsequent hair loss. And treatment is challenging because the hair pulling helps them manage negative emotions.

People with TTM may pull out hair from their head, eyebrows, eyelashes, arms, or pubic region. It impacts less than 2% of the population, and is evenly split amongst genders. One sign of the disorder is repeated attempts to reduce or stop hair pulling, without success. Another is that it causes significant distress or impairment, which can take the form of shame, embarrassment, and withdrawal from social and other activities.

TTM falls under the umbrella of body focused repetitive behaviors, along with excessive skin picking and nail biting. It also fits into the category of obsessive-compulsive and related disorders. Other diagnoses in this category include hoarding disorder, skin picking disorder (excoriation), and body dysmorphic disorder. There is some debate regarding just how related TTM and OCD are since the former is driven by an inability to resist the temptation to pull, whereas the latter is more of a ritualistic response to obsessive thoughts.

If left untreated, trichotillomania can lead to hair loss, bald spots, lack of eyebrows or eyelashes, and skin damage at the follicles. Kids may get teased or picked on for patchy hair. Then, when the hair does begin to grow back it is often itchy, which makes it more likely that the individual will pull it out again to ease the discomfort, thus creating a cycle.

And, for the more than 20 percent of people with trichotillomania who also engage in tricophagia (eating their own hair), this can also lead to something called trichobezoars, or gastrointestinal hairballs, which often need to be surgically removed.

Although all trichotillomania involves pulling out body hair, there are two types, explains Jerry Bubrick, PhD, director of the Intensive Pediatric OCD Program and a senior psychologist at the Child Mind Institute: automatic and focused pulling.

• In automatic hair pulling, the individual may not even realize they are doing it until after the fact. For example, they could be zoning out watching TV then look down and realize that the couch is full of hair they have pulled.

• In focused hair pulling, it is done very intentionally because it feels good. Often, focused hair pullers will wait until they are in private to engage in the behavior.

Determining which type of hair pulling a person is engaged in will help establish the treatment. “It’s not just looking at the behavior of hair pulling, it’s really understanding what the function is behind it,” explains Dr. Bubrick. This is done via interviews with the child and reports from parents and teachers.

In addition to the two types of hair pulling, another facet to the behavior is what people then do with the hair. “Sometimes the person will just pull the hair and flick it on the floor, or some people will save the hair in baggies,” explains Dr. Bubrick. “Other times people might pull the hair out and inspect whether they pulled what looks like the root, then they might play with the root or roll the hair in their fingers. They might put the strand of hair to their lips, they might bite it, and in some cases they might swallow it.”

And because eating the hair that they’ve pulled can result in medical complications, it’s crucial to find out not only how and when they are pulling their hair, but what they are then doing with the hair.

Often, parents may not realize their child has trichotillomania until they start to notice large patches of hair are missing. Dr. Bubrick says that you may see what’s called “infant pulling” starting at around 18 months of age and going until three or four years old, but that is hard to treat and very often goes away on its own. A simple intervention like having them wear mittens at night can often do the trick. Overall, he says, it’s not something to worry too much about.

Regular trichotillomania can impact anyone at any age, but the typical age of onset for boys is 17 or 18, while girls may start around age 14 or 15. “Red flags are if parents are finding hair where it shouldn’t be, like on the couch, a lot on the bed, or a pile of hair on the floor,” advises Dr. Bubrick. He says that for girls with long hair, for example, it might take a while to notice hair missing from their head. Also take note if they are spending much longer in the bathroom or looking in mirrors significantly more often.

Treatment for hair pulling can be tricky, Dr. Bubrick says, because it has a real function for kids who do it. “The hair pulling works in some way to alleviate stress,” he says. “So we’re essentially asking kids to take away a coping skill for stress and replace it with something that may not feel quite as good, so it’s a hard sell,” he explains.

Kids are often brought in for help by parents who — more than the child — are concerned about the hair loss. But sometimes it’s the child who is embarrassed by their appearance.

“I had a kid a couple of years ago, a really nice, smart guy who started pulling from the back of his head and created a bald spot,” Dr. Bubrick recalls. “He was being picked on for it, made fun of. The kids behind him in class were hitting his hand when he was going to pull or they would wonder out loud was he eating it or was he just putting it on his lips.”

In this case, the student took the initiative to get help. “It was his idea. He researched it online, he figured out what it was, and asked his parents to come in for treatment,” Dr. Bubrick adds, “Within two months he was quite a bit better.”

When approaching a child about getting treatment, he advises parents to open up a dialogue rather than asking point-blank if they are pulling out their hair. Instead, you can try talking about how it’s normal for people to play with their hair, and say that sometimes people don’t even notice they’re pulling it out, then ask if that’s something they’ve experienced. “It’s more about normalizing that this is a common thing that everyone does to some degree, but is it becoming an issue for you,” advises Dr. Bubrick.

The first step is to find a specialist with specific knowledge of trichotillomania, since many traditional therapists won’t be familiar with treatment. Traditionally, a cognitive behavioral approach called habit reversal therapy (HRT) has been the go-to treatment, in which the clinician and patient work together to identify triggers and develop alternative actions, or competing responses to the pulling. Increasingly, though, clinicians are employing comprehensive behavioral treatment (ComB), which is based on HRT but also incorporates elements of dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT), mindfulness training, and more.

The clinician will zero in on whether it’s automatic or focused pulling, and then try to understand when the pulling tends to happen. Is it when they’re bored? Stressed? Watching TV? In science class? Hiding in the bathroom? The child will also self-monitor and track the behavior to the best of their ability. Wearable technology, which collects data on where and when hair pulling happens, can be a big help for kids who have a hard time tracking on their own.

Once a professional has gotten to the root of the problem they can work together to physically stop the behavior by replacing it with less destructive alternatives —called a competing response. “We’ll try to find ways to put up barriers or slow down the pulling,” he says. This can include wearing a headband or hat, or putting Band-Aids on the fingers.

Possible alternatives to hair pulling can include something like a Koosh ball, where they can isolate and pull the individual strands, finger fidget toys, and sensory finger puppets with a spiny back the kids can play with and pull on. “Anything that the child can use and focus on that’s easier to do than the pulling,” says Dr. Bubrick.

For focused pulling in particular, Dr. Bubrick says, the treatment includes the cognitive work of changing the way the person responds to negative emotions. “The treatment has to focus on teaching the person better coping skills for the distress, the ability to tolerate negative emotions without pulling, so they can achieve the goal of having hair.”

Depending on the root causes, other strategies will come into play. If the TTM is a stress response, it may be helpful to teach the child mindfulness exercises. Elements of DBT could include a greater emphasis on learning to tolerate uncomfortable feelings and regulate emotions, while ACT may work to help the child develop a greater sense of self-acceptance.

One study found that 79% of people with trichotillomania also had another mental health condition, most often anxiety, depression, OCD, PTSD, or ADHD. Sometimes it is necessary to first focus on any coexisting conditions before targeting trichotillomania for treatment. While there is no medication that is directly effective for TTM, psychopharmacology may be indirectly helpful by treating any other disorders.