Trichotillomania (hair pulling disorder) is part of a cluster of diagnoses called the obsessive-compulsive and related disorders. Obsessive-compulsive and related disorders are a group of psychiatric conditions that include:
These disorders are characterized by the occurrence of repetitive behaviors, often called compulsions. Individuals with obsessive-compulsive disorder might engage in compulsive behaviors such as excessive washing, checking, arranging, or counting. Individuals with body dysmorphic disorder might engage in frequent checking of their appearance in the mirror, or excessive grooming-related behaviors. Individuals with hoarding disorder may engage in excessive acquiring of objects, combined with a strong need to save items. Individuals with trichotillomania engage in excessive hair pulling, and individuals with excoriation disorder engage in excessive skin picking.
In some cases, the obsessive-compulsive and related disorders are also characterized by intrusive, unwanted, or distressing thoughts, called obsessions, which come to mind again and again. People with obsessive-compulsive disorder might have obsessive thoughts about dirt or germs, thoughts of harming others, fears of making mistakes, or distress about things being out of order. People with body dysmorphic disorder have repetitive, negative thoughts about their own appearance. However, people with certain other obsessive-compulsive and related disorders (such as trichotillomania or excoriation disorder) often do not experience obsessive thoughts.
Trichotillomania is a psychiatric disorder that usually begins in late childhood/early puberty. Although trichotillomania was previously believed to rarely occur in children and adolescents, more recent estimates of the prevalence in older adolescents and young adults range between 1% and 3.5%.
The prevalence of trichotillomania among younger children remains largely unknown. It occurs about equally in boys and girls in childhood. Trichotillomania is characterized by two main symptoms:
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. Children in particular may deny engaging in hair pulling behavior due to embarrassment or fear of negative evaluation by others.
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).
Trichotillomania severity can range from mild to very severe. In severe cases, trichotillomania can lead to severe distress or embarrassment and/or health complications, such as damage to teeth from biting the hair or abdominal pain or injury from trichobezoars (masses of hair in the digestive system).
The negative psychosocial effects of trichotillomania for children and adolescents can be substantial, as peers typically have a negative view of hair pulling. Children with trichotillomania report disruption in their ability to maintain social relationships and may avoid social events. Children also report a similar impact on their academic performance, including missing school and having difficulty with academic responsibilities, such as studying. It is thought that psychosocial difficulties due to trichotillomania might increase in severity as children mature because hair pulling and its consequences might become less socially acceptable later in development. Approximately one third to two thirds of children and adolescents with trichotillomania meet criteria for at least one comorbid psychiatric condition, particularly anxiety and other internalizing disorders such as depression. Although trichotillomania that appears in early childhood (0-3 years of age) has often been considered a benign habit similar to thumb sucking, there are some cases in this age range that are clinically significant and warrant attention.
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.
Trichotillomania is treatable. The Trichotillomania Learning Center (TLC) and the Society of Clinical Child and Adolescent Psychology has published guidelines on the treatment of trichotillomania.
First Line Treatments
Other Treatments to Consider
There are no published guidelines on second- and third-line treatments for trichotillomania in children and adolescents. However, clinical research suggests that the following intervention may be effective:
First Line Treatments
Other Treatments to Consider
There are no published guidelines on second- and third-line treatments for trichotillomania in children and adolescents. However, clinical research suggests that the following intervention may be effective: