Trichotillomania in Adults

Individuals with trichotillomania may pull hair from any place on the body.  However, the most common sites are the scalp, eyebrows, and eyelashes.  Often individuals with trichotillomania will manipulate the pulled hair in some way, for example, by rolling it between their fingers, biting it, and/or swallowing it.

The hair loss may be very noticeable; for example, the person may have a bald patch (often on the crown or sides of the head) or complete hair loss on the scalp, eyelashes, or eyebrows.  However, in other cases hair pulling may be distributed and the hair loss may be less noticeable.  The person may also disguise the hair loss with makeup, scarves, or wigs.

A person with trichotillomania may pull in response to an urge or an itch-like sensation that is relieved by pulling.  Other times, pulling may occur without the person being fully aware of it.  People with trichotillomania sometimes report experiencing a sense of relief or satisfaction after pulling.

For trichotillomania to be diagnosed, the hair pulling or its consequences also needs to be distressing (upsetting) or impairing (getting in the way of the person’s life).

Most people with trichotillomania also have other psychiatric conditions, most commonly depression and other body-focused repetitive disorders (such as skin picking or nail biting).

The neurobiology of trichotillomania is not well understood, but there is some evidence that abnormalities in brain functioning, particularly in regions related to reward (e.g., nucleus accumbens) and the generation of motor habits (e.g., putamen) may contribute to the disorder.  Hair pulling behavior may be maintained by positive reinforcement, or a sense of gratification or satisfaction that occurs after the individual pulls a hair. The disorder appears to have a genetic component, although having a genetic predisposition to trichotillomania does not necessarily mean that someone will develop the disorder.

First Line Treatments

• Cognitive-behavioral therapy (CBT) is the treatment of choice for trichotillomania.  CBT for hair pulling primarily includes awareness training (increasing the person’s awareness of their pulling behaviors), stimulus control (using barriers like gloves to create “speed bumps” to reduce the likelihood of pulling), and competing response training (practicing using an incompatible behavior, like balling one’s hand into a fist, when the urge to pull arises).  Together, these interventions are sometimes called habit reversal training.  

Other Treatments to Consider

There are no published guidelines on second- and third-line treatments for trichotillomania.  However, clinical research suggests that the following interventions may be effective:

• Augmenting CBT with acceptance and commitment therapy (ACT) or dialectical behavior therapy (DBT)
• Monotherapy with N-acetylcysteine, naltrexone, olanzapine, or clomipramine
• Augmenting CBT with sertraline
• Note: Despite its efficacy for treating obsessive-compulsive disorder, monotherapy with SSRIs has not shown good efficacy for reducing hair pulling.  However, SSRIs may reduce associated symptoms of anxiety and depression.