Pulling Your Hair Out – Not Just an Expression: Understanding Trichotillomania

Written by Jacob Silverman

Reviewed by Victoria Xu, Katie Kugler and Ethan Bendayan

Introduction

In 1889, Dr Francois Henry Hallopeau coined a new term for an age-old habit already described by Aristotle–trichotillomania–a compound of the Greek words for hair (trich), plucking (tillein), and madness (mania). Trichotillomania is primarily a mental health condition, but with notable dermatological involvement as hair is repetitively and compulsively pulled out. This can lead to irritation of hair follicles, hair follicle scarring and infections. Clear diagnostic criteria are outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the standard classification of mental health disorders:

1. Recurrent pulling of one’s hair, resulting in hair loss.

2. Repeated attempts to decrease or stop hair pulling.

3. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

4. The hair pulling or hair loss cannot be attributed to another medical condition (e.g., a dermatological condition).

5. The hair pulling cannot be better explained by another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance, such as may be observed in body dysmorphic disorder.

The hair pulling most commonly begins during early adolescence, around the onset of puberty. Approximately 1-2% of the population is affected at any time, though this number may be an underestimate due to underreporting, and it affects females at rates up to eight or nine times higher than males. Most people affected will continue to experience symptoms chronically, with periodic fluctuations.

Moreover, trichotillomania is associated with neurological and psychological differences. In fact, research shows that those with trichotillomania have differences in the parts of the brain that manage habits and self-control, when compared to those without trichotillomania. Additionally, it has been associated with environmental risk factors, especially stressful situations, and other mental health conditions like anxiety and depression. As with any health condition, trichotillomania is experienced differently by each affected individual. Some people will pull their hair automatically, while others are completely aware throughout the act. Additionally, some people will feel a sense of relief after the pulling, while others will be faced with guilt or shame.

Signs and Symptoms

Considering the symptoms previously mentioned and variable individual experiences, below are some ways that trichotillomania can show up in daily life:

1. Pulling hair from anywhere on the body (i.e. not only the scalp) repeatedly.

2. Feeling of rising tension before pulling, or when resisting the temptation to do so.

3. A wave of relief or pleasure after pulling the hair.

4. Visible hair loss, bald patches, or thinning.

5. Developing a hair-pulling ritual, such as needing to pull the “right” hair, or a need to pull hair in a specific setting.

6. Handling, biting, chewing, or eating the hair (trichophagia), which could lead to ingestion of hairballs that could obstruct the digestive tract and cause gastrointestinal issues.

7. Unsuccessful attempts at curbing or stopping the behaviour.

8. Distress, problems in daily functioning (school, work) or in social situations.

Treatments

Before delving into the treatments for trichotillomania, it is important to quote the words of The American Academy of Child and Adolescent Psychiatry: “Treatment is most effective when it covers the symptoms unique to each person and individualized to the needs of the child and family.” And so, the specific goals of treatment are left to the patient, ranging from complete abstinence of pulling to reduction of pulling to hair regrowth.

Regarding pharmacological treatments, while there are many medications indicated for trichotillomania, a review on the effects of various medications could not prove, or disprove, the efficacy of any agent or class of medication in the treatment of trichotillomania. However, certain medications may be beneficial in adults, such as N-acetylcysteine, clomipramine, and olanzapine. So far, there isn’t a medication that’s officially approved by the U.S. Food and Drug Administration (FDA) to treat trichotillomania.

Despite this, treatments for trichotillomania exist and are mainly in the form of therapy. The main treatment is a type of behavioural therapy called “habit reversal training.” It entails recognizing situations where one may be prone to engage in hair-pulling and substituting other behaviours in its place. Included in this interventional approach is a strategy called decoupling, where one quickly redirects their hand from their hair to another location. Additionally, other types of therapy like cognitive behavioural therapy may provide benefits.

Management in Children

Since onset of trichotillomania often occurs during childhood, management can be even more difficult. The Davis MIND Institute of the University of California has a useful Questions and Answers (Q&As) page on this exact topic, which offers practical, realistic, and family-centered management strategies for parents of children with trichotillomania. This page can be easily accessed with this link: https://health.ucdavis.edu/news/headlines/hair-pulling-and-skin-picking-how-to-help-your-child-stop-repetitive-behaviors/2023/02.

For example, one way to implement habit reversal training is to place a basket of fidget toys near the couch if TV time was high-risk for plucking. The child would be encouraged to start playing with a fidget toy before starting to watch television, so their hands are busy when the urge comes (so the need is satisfied by the ongoing fidgeting).

Another strategy that is suggested is stimulus control, such as wearing a hat during at-risk moments, thereby blocking the stimulus. Another simple trick is to wear non-prescription glasses, which can act as a barrier to stop eyelash picking.

The important role of parents during this process cannot be minimized. Positive reinforcement of management strategies can go a long way, and avoiding negative focus on the plan is important.

Finally, forums, such as the Canadian BFRB Support Network, offer anonymous online peer support services for those in need, no matter the age. These forums can be used by those with trichotillomania, but can also offer support and counseling to friends, family and loved ones of those affected. This network can be easily accessed using the following link: https://www.canadianbfrb.org/support/peer-support-online/.

Mental Health Impact

As explained throughout the article, there are several factors that contribute to the onset, progression and severity of this illness. More awareness and education are needed to ensure that affected individuals are cared for.

Of course, there is a cosmetic effect of a lack of hair on certain parts of the body. Hence, shame and low self-esteem are very common feelings reported in those experiencing trichotillomania. Research describes that individuals with trichotillomania are sometimes able to avoid pulling in public to avoid stigma, and instead pull at home, while in private. This pattern, along with the condition’s emotional toll, contributes to a vicious cycle of social withdrawal, stress, and anxiety.

Additionally, trichotillomania often seems to begin as a coping strategy in people with anxiety. As hair loss can be isolating, this can ultimately worsen anxiety and further perpetuate the cycle of hair pulling.

Many may be surprised that research indicates that people with trichotillomania may experience functional deficits leading to mild to moderate life impairment in various domains. More specifically, it has been found that affected individuals can experience interference with their job, at least once a month. Those still in school may suffer from frequent absences, difficulty maintaining responsibilities, and challenges with studying. Furthermore, not everyone has access to adequate therapy for treatment, and may turn to unhealthy coping mechanisms like alcohol and substance abuse.

An additional source of stress specifically experienced by children is the frustration their parents may feel due to a lack of comprehension of their child’s engagement in these behaviours. Some children are punished for hair-pulling, but this approach is not effective and can worsen self-esteem issues. To avoid this outcome and potential embarrassment, children may hide or deny their habit, further delaying therapy which may truly help them.

Finally, it doesn’t help the situation that many healthcare professionals are insufficiently trained regarding this condition, and thus patients don’t always receive the optimal care they need, further solidifying the importance of raising awareness.

Clearly, these consequences do nothing to help the situation, further contributing to the vicious cycle of distress and impairment that leaves affected individuals feeling stuck and overwhelmed.

Key Takeaways

Repetitive and compulsive hair pulling with an inability to stop, officially diagnosed as trichotillomania, is a mental health but also dermatological condition. Those who are affected are at risk for emotional and psychological effects that can lead to further difficulties and impairment in many areas of their daily functioning. It is crucial to raise awareness about this condition, reduce the stigma surrounding it, and encourage those suffering to seek support so they can live their lives to the fullest, in a healthy way. If you, or someone you know struggles with hair pulling, know that support and interventions exist!

Works Cited

1.        American Academy of Child and Adolescent Psychiatry. (2025). Hair Pulling (Trichotillomania). American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Hair-Pulling-_Trichotillomania_-096.aspx

2.        American Psychiatric Association. (2013). Trichotillomania (Hair-Pulling Disorder). In Diagnostic and Statistical Manual of Mental Disorders (5th ed.).

3.        Flessner, C. A., Woods, D. W., Franklin, M. E., Keuthen, N. J., Piacentini, J., Cashin, S. E., & Moore, P. S. (2007). The Milwaukee Inventory for Styles of Trichotillomania-Child Version (MIST-C): initial development and psy

chometric properties. Behav Modif, 31(6), 896-918. https://doi.org/10.1177/0145445507302521

4.        Find a peer support group. Canadian BFRB Support Network. (2022). https://www.canadianbfrb.org/support/find-a-support-group/  

5.        Grant, J. E., Redden, S. A., Leppink, E. W., & Chamberlain, S. R. (2017). Trichotillomania and co-occurring anxiety. Comprehensive psychiatry, 72, 1–5. https://doi.org/10.1016/j.comppsych.2016.09.005

6.        Hoffman, J., Williams, T., Rothbart, R., Ipser, J. C., Fineberg, N., Chamberlain, S. R., & Stein, D. J. (2021). Pharmacotherapy for trichotillomania. Cochrane Database of Systematic Reviews, 2021, CD007662. https://doi.org/10.1002/14651858.CD007662.pub3

7.        Hullett, A. (2024). Trichotillomania: Symptoms, Causes, and Treatment. Healthline Media. Retrieved June 1 from https://www.healthline.com/health/anxiety/trichotillomania

8.        Marcks, B. A., Wetterneck, C. T., & Woods, D. W. (2006). Investigating healthcare providers' knowledge of trichotillomania and its treatment. Cogn Behav Ther, 35(1), 19-27. https://doi.org/10.1080/16506070510010657

9.        Mayo Clinic Staff. (2023). Trichotillomania (hair-pulling disorder). Mayo Clinic. Retrieved June 1 from https://www.mayoclinic.org/diseases-conditions/trichotillomania/symptoms-causes/syc-20355188

10.  Pereyra, A. D., & Saadabadi, A. (2025). Trichotillomania. In StatPearls.https://www.ncbi.nlm.nih.gov/pubmed/29630238

11.  Phillips, K. A., & Stein, D. J. (2023). Trichotillomania. Merck & Co., Inc. Retrieved June 1 from https://www.merckmanuals.com/en-ca/professional/psychiatric-disorders/obsessive-compulsive-and-related-disorders/trichotillomania

12.  Sharp, M. R. (2023). Hair pulling and skin picking: How to help your child stop repetitive behaviors. UC Davis Health. Retrieved June 1 from https://health.ucdavis.edu/news/headlines/hair-pulling-and-skin-picking-how-to-help-your-child-stop-repetitive-behaviors/2023/02

13.  Waas, R. L., & Yesudian, P. D. (2018). Plucking, Picking, and Pulling: The Hair-Raising History of Trichotillomania. Int J Trichology, 10(6), 289-290. https://doi.org/10.4103/ijt.ijt_69_18

14.  Woods, D. W., Flessner, C. A., Franklin, M. E., Keuthen, N. J., Goodwin, R. D., Stein, D. J., Walther, M. R., & Trichotillomania Learning Center-Scientific Advisory, B. (2006). The Trichotillomania Impact Project (TIP): exploring phenomenology, functional impairment, and treatment utilization. J Clin Psychiatry, 67(12), 1877-1888. https://doi.org/10.4088/jcp.v67n1207

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