Trichotillomania (Hair-Pulling Disorder): Guidelines for Youth and Adults
Overview and Definition
by Dr Tiongko
Trichotillomania, also known as hair-pulling disorder, is a mental health condition characterized by recurrent, irresistible urges to pull out one’s own hair, leading to noticeable hair loss .It is classified in the DSM-5 as an Obsessive-Compulsive and Related Disorder, alongside conditions like skin-picking (excoriation) and OCD
Individuals with trichotillomania commonly pull hair from the scalp, eyebrows, eyelashes, or other body areas, often experiencing a rising tension or anxiety before pulling and a sense of relief or gratification afterward. The behavior is not just a bad habit; those affected typically struggle to stop despite wanting to, and the repeated pulling can result in patchy bald spots or thinning hair that they may try to conceal with hairstyles, hats, or makeup
This disorder often causes significant emotional distress – people may feel shame, guilt, or embarrassment about the hair loss – and it can impair daily functioning, social life, and self-esteem. Importantly, trichotillomania is not caused by a dermatologic condition or another medical illness; it is a psychological condition in which hair loss is self-inflicted by pulling, and sufferers usually make repeated attempts to reduce or stop the behavior without success
Epidemiology and Prevalence (Age-Related Focus)
Trichotillomania occurs in both children and adults, and research suggests it is relatively common. Epidemiological studies estimate that roughly 1%–2% of the general population meet criteria for hair-pulling disorder. A recent large survey of over 10,000 U.S. adults found about 1.7% had current trichotillomania, indicating that hair-pulling disorder affects nearly 1 in 60 individuals Interestingly, that study noted no significant gender difference in prevalence (approximately 1.8% of males and 1.7% of females) although earlier clinical reports often suggested a female predominance (possibly because females may be more likely to seek treatment). When including people who engage in some hair-pulling behaviors (even if they don’t meet the full disorder criteria), the numbers are higher.
Age of onset is typically in childhood or adolescence. Trichotillomania often begins around early puberty; the mean age of onset is around 12–17 years old in many cases. Many patients recall starting to pull their hair in middle school or high school. There is also a less common pediatric presentation in very young children (toddlers or preschool-age) who may pull hair; in some of these early-childhood cases the behavior can be transient and resolve on its own. However, when hair-pulling persists into adolescence, it often becomes a chronic condition with a waxing-and-waning course that can continue into adulthood if not effectively treated Indeed, without intervention, trichotillomania may follow a lifelong pattern of periods of increased pulling and periods of relative remission.
Trichotillomania can affect children, teens, and young adults across all backgrounds – including high-achieving students and young professionals – and it often co-occurs with other mental health conditions. In fact, comorbidity is the rule rather than the exception: up to 80% of individuals with trichotillomania have at least one other psychiatric diagnosis Common co-occurring disorders include anxiety disorders, depression, obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), post-traumatic stress disorder, and others.For example, one survey found 80% of people with trichotillomania had an anxiety or depressive disorder or another comorbidity. This high rate of co-morbid conditions is important, as it may influence treatment planning (for instance, treating an underlying anxiety disorder can sometimes help alleviate the hair-pulling urges).
Diagnostic Criteria (DSM-5)
The DSM-5 diagnostic criteria for trichotillomania (hair-pulling disorder) can be summarized as follows:
A. Recurrent hair pulling resulting in hair loss: The person repeatedly pulls out their hair, leading to noticeable hair loss. The hair may be pulled from any region of the body (commonly the scalp, eyebrows, eyelashes, but also arms, legs, etc.), and hair loss may be patchy or diffuse Often, affected areas show hairs of different lengths due to breakage and regrowth, rather than a completely smooth bald area as seen in alopecia areata.
B. Attempts to stop: The person has made repeated attempts to decrease or stop the hair pulling. Despite these efforts, they feel unable to control the urge and continue to pull hair.
C. Distress or impairment: The hair pulling causes clinically significant distress (for example, feelings of embarrassment, shame, or loss of control) or it impairs important areas of functioning such as social, academic, or occupational lifencbi.nlm.nih.gov. (For instance, the individual might avoid social activities for fear that others will notice their hair loss, or spend so much time pulling hair that it interferes with studying or work.)
D. Not due to another medical condition: The hair loss cannot be attributed to another medical or dermatological condition This means conditions like alopecia areata, fungal infections of the scalp (tinea capitis), or other causes of hair loss must be ruled out. In trichotillomania, the hair loss is self-inflicted and not due to a physical illness.
E. Not better explained by another disorder: The hair-pulling behavior is not better accounted for by another mental disorder . For example, if hair pulling is done in response to a delusion or hallucination, or as part of body dysmorphic disorder (where the person pulls hair they perceive as flawed), those would not count as trichotillomania. Trichotillomania is considered a body-focused repetitive behavior rather than a compulsion driven by an obsession, and it exists as its own diagnosis.
In addition to these core criteria, clinicians assessing a patient will often note other associated features. Many individuals with trichotillomania feel a build-up of tension or anxiety before pulling and a sense of relief or satisfaction after pulling, although these features are not required for the diagnosis (they were emphasized in older definitions of the disorder). Patients may also have specific triggers or rituals around pulling (such as pulling only certain hairs or in certain ways). Some people are very aware of each pulling episode (focused pulling), while others may pull automatically without full awareness (for instance, pulling hair while reading or watching TV and only realizing when a pile of hair has accumulated). Because of shame or guilt, patients often try to hide the behavior – they may deny hair pulling initially or cover up bald spots. Clinicians therefore should maintain a high index of suspicion if they see unexplained patchy hair loss with irregular patterns. On examination, signs like hairs of varying lengths, broken-off hairs, and an absence of inflammation or scarring on the scalp support the diagnosis of trichotillomania over other causes
In some cases, people with trichotillomania also ingest the pulled hairs (a behavior called trichophagia); this can lead to gastrointestinal complications like hairballs (trichobezoars), though that occurs in only a subset of patients.
Evidence-Based Treatment Approaches
Trichotillomania can be challenging to treat, but there are evidence-based therapies that have been shown to help. The main treatment modalities are behavioral (non-medication) therapies and pharmacological (medication) treatments. Often a combination approach works best. It is important to note that, as of today, no medication has FDA approval specifically for trichotillomania and medication responses vary – so behavioral therapy is generally considered the first-line treatment, especially for children and adolescents
Behavioral Therapies
Habit Reversal Training (HRT) is the cornerstone of behavioral treatment for trichotillomania. HRT is a form of cognitive-behavioral therapy (CBT) that teaches the individual to become more aware of their hair-pulling urges and to replace the pulling with a different, incompatible action. Studies have shown that therapy programs using HRT techniques have the strongest track record of success in reducing hair-pulling symptoms.
How HRT works: In habit reversal training, a therapist works with the patient (and often the family, especially for children) on several componentsaacap.org. These typically include:
Awareness training: The individual learns to identify the situations, feelings, and sensations that precede hair pulling. This might involve keeping a diary to track pulling episodes and noting triggers such as boredom, stress, or specific times of day. Increased awareness helps the person catch themselves before or as they start pulling.
Competing response training: The patient then learns to perform a different behavior when they feel the urge to pull. This “competing response” is usually a physically incompatible action. For example, if someone gets an urge to pull hair, they might immediately clench their fists, squeeze a stress ball, or sit on their hands for a minute – any action that makes pulling impossible or less feasible in that momentaacap.org. The goal is to “rewire” the habitual response by consistently substituting a non-harmful behavior whenever the urge arises.
Stimulus control: This involves making changes to the environment to reduce opportunities for pulling. Simple strategies include wearing a hat or bandana to cover the hair, wearing gloves or fingertip bandages (especially at night or during trigger situations) so it’s harder to grasp hair, or keeping the hair trimmed short. For eyelashes or eyebrows, some individuals might wear glasses even if not needed, as a physical reminder. Removing tweezers or mirrors from easy reach if those are used in pulling can also help. These environmental tweaks serve to interrupt the habitual chain of behavior.
Cognitive techniques and stress management: Because stress and emotions can fuel hair-pulling, therapy often also teaches anxiety management, relaxation techniques, or mindfulness. Patients learn to handle urges and the uncomfortable feelings without giving in to pulling. Techniques from Cognitive Behavioral Therapy (CBT) may be used to address any irrational thoughts (for instance, “I must pull this hair to feel ‘just right’” can be challenged and re-framed). Some programs also incorporate elements of Acceptance and Commitment Therapy (ACT) to help individuals tolerate the urge without acting on it.
Often, HRT is delivered as part of a broader treatment program sometimes referred to as Comprehensive Behavioral Intervention for Trichotillomania (ComB). ComB is a personalized CBT approach that assesses various domains (sensory, cognitive, emotional, environmental factors driving the behavior) and targets interventions accordingly, with HRT at its core.
For children and adolescents, behavioral treatment is adapted to their developmental level. Parents may participate in sessions to learn how to support the child (for example, providing reminders in a constructive way, or helping set up reward systems for successful use of strategies). It’s important to create a positive, blame-free environment – kids should not be punished for pulling their hair, as punishment usually does not stop the behavior and can harm self-esteem aacap.org. Instead, emphasis is on encouragement and making the child an active partner in overcoming the habit.
Effectiveness: Behavioral therapy has the most robust evidence for trichotillomania. Many patients experience a significant reduction in hair-pulling severity with HRT-based therapy. However, motivation and adherence to techniques (like consistently using the competing responses) are key factors in success. In real-world practice, access to a therapist experienced in treating trichotillomania can be a challenge – surveys have found that fewer than one-third of patients were receiving evidence-based therapy, partly because many clinicians are not familiar with the disorder. For this reason, primary care and mental health professionals are encouraged to refer patients to therapists who have training in HRT or to resources (such as the TLC Foundation for BFRBs) that can help locate appropriate care. Some newer approaches, like online or app-based habit reversal programs and peer support groups, can also be useful adjuncts, especially if in-person therapy is delayed. In addition, other behavioral interventions (e.g. group therapy formats, or family therapy focusing on reducing conflict and stress at home) may help in certain cases. though these are considered supplementary to the core HRT approach.
Pharmacological Treatments
There is currently no universally effective medication for trichotillomania, but several medications have been tried off-label with some success in select patients. Medications are typically considered when behavioral therapy alone is not sufficient or when the person has significant comorbid conditions (like depression or severe anxiety) that might benefit from medication. It’s important for both clinicians and patients to have realistic expectations, as medication responses vary and the evidence for most drug treatments in trichotillomania is mixed or limited.
Below are the medication options that have been studied:
Selective Serotonin Reuptake Inhibitors (SSRIs): Despite being commonly used in practice, SSRIs (such as fluoxetine, sertraline, paroxetine, etc.) have not shown strong benefit for trichotillomania in controlled studies SSRIs are well-known treatments for OCD and anxiety disorders, so early on it was hoped they would help hair-pulling urges. However, multiple trials in both adults and youth failed to find SSRIs significantly more effective than placebo for reducing hair-pulling frequency or intensity. For example, patients often did not pull less hair on SSRIs compared to sugar pills in studies. That said, SSRIs may still be useful in cases with comorbid anxiety or OCD symptoms, and some individuals report partial improvement in urge intensity or mood when on an SSRI. They are generally well-tolerated in younger patients. In practice, a doctor might prescribe a trial of an SSRI if a patient has notable depression or anxiety alongside trichotillomania, but SSRIs are not considered first-line specifically for hair-pulling behavior.
Tricyclic Antidepressant (Clomipramine): Clomipramine is an older antidepressant (a tricyclic) with strong effects on serotonin. It has a long history in treating OCD. In trichotillomania, one small randomized trial found clomipramine more effective than a placebo (and more effective than another tricyclic, desipramine) in reducing hair-pulling symptoms. That study and subsequent analyses suggest clomipramine can decrease urges and pulling episodes to a moderate degre. In the 2020 meta-analysis, clomipramine was one of the few medications with a significant benefit over placebo (effect size in the moderate range) However, clomipramine’s use is limited by its side effect profile (it can cause sedation, dry mouth, dizziness, and in rare cases heart rhythm changes), and it requires careful dosing and monitoring. It is sometimes used in adults with trichotillomania, especially if they also have OCD symptoms, but is used with caution in pediatric patients. Newer SSRIs are generally safer, but as noted, they have not proven very effective for TTM itself. Overall, clomipramine offers a possible medication option for severe cases, but more research is needed and it’s not a first-choice due to side effects.
N-acetylcysteine (NAC): N-acetylcysteine is a glutamate-modulating agent (available as a dietary supplement) that has shown promise in trichotillomania. A well-known placebo-controlled trial in adults found that NAC significantly reduced hair-pulling symptoms in about 56% of participants after 9–12 weeks, versus 16% on placebo.This study sparked interest because NAC is relatively safe and easy to obtain. NAC is thought to help regulate glutamate in the brain, which may reduce addictive or compulsive behavior urges. For adults, a dose of around 1,200–2,400 mg per day has been used. In practice some psychiatrists or dermatologists recommend NAC off-label for adult patients due to its benign side effect profile. In children/adolescents, however, the evidence is less encouraging. A recent randomized controlled trial in youth (ages 8–17) Both groups improved somewhat over time (perhaps due to placebo effect or concurrent therapy), but NAC did not outperform the sugar pill in that pediatric study. This suggests that NAC’s effectiveness might not generalize to younger patients, or that more research is needed. (It’s possible that the developing brains of children respond differently, or that higher doses / longer treatment might be needed.)
Atypical Antipsychotics: Certain second-generation antipsychotic medications have been tested for trichotillomania, especially in severe or refractory cases. The most studied is olanzapine. In a controlled trial with adults, olanzapine (an atypical antipsychotic) showed better outcomes than placebo – patients on olanzapine had greater reduction in hair-pulling urges and behaviors. The 2020 meta-analysis also found olanzapine to have a significant benefit (moderate-to-large effect size) for trichotillomania symptoms compared to placebo. Another antipsychotic, quetiapine, did not show clear benefit in limited studies, and there are some case reports of aripiprazole helping a few patients but robust data are lacking.
Use of antipsychotics is generally reserved for adults with severe TTM that hasn’t responded to other treatments, due to the side effect considerations. Olanzapine, for instance, can cause weight gain, metabolic changes, sedation, and other effects, which make it less desirable, especially for children or young adults unless absolutely necessary. In practice, a psychiatrist might consider a low dose antipsychotic trial if someone’s hair-pulling is extremely severe or accompanied by other symptoms that these medications can help (like severe anxiety or impulse control issues). Given the low certainty evidence and potential side effects, these are not first-line, but rather third-line or adjunct optionsAny patient on these medications needs monitoring for side effects.
Medications play a secondary role and should ideally be used to complement therapy, or to address co-occurring conditions. In children and adolescents, experts emphasize starting with therapy and using medications sparingly.
In adults, an individualized approach is taken: some may benefit from an SSRI or N-acetylcysteine trial, or possibly clomipramine or olanzapine in refractory cases, but these decisions are made on a case-by-case basis weighing potential benefits and risks. It’s also important to monitor any medical treatment closely.
For example, if a patient is started on NAC, the clinician will want to see if hair-pulling frequency actually decreases over 8–12 weeks; if not, the NAC can be discontinued. Likewise, if an SSRI is prescribed for anxiety, they will track mood and any change in pulling urges. Since no medication is a sure cure, patients should be counseled that pharmacotherapy is often an adjunct – something to reduce symptoms enough so that therapy and self-management become easier.
Patient Education Tips and Resources
Managing trichotillomania is not only about what happens in the therapist’s office – what patients do in their daily life matters greatly. Here are some practical tips and resources for patients (and families) that can aid in coping with hair-pulling urges and support the treatment process:
Identify and manage triggers: Pay attention to the situations or feelings that tend to precede hair pulling. Common triggers include periods of inactivity or boredom (for example, watching TV, reading, driving in a car, or using the phone) as well as stress or strong emotions. Once you know your high-risk times, you can plan for them. For instance, if you often pull hair while studying or watching shows, try to keep your hands busy during those activities – squeeze a stress ball, doodle, knit, or even sit on your hands for short intervals. If stress or anxiety triggers you, consider stress-reduction techniques like taking a short walk, deep breathing exercises, or listening to calming music when the urge hits instead of pulling. By reducing stress overall (through regular exercise, adequate sleep, meditation, etc.), you may also reduce the frequency of urges
Use habit reversal strategies on your own: The same strategies from therapy can be practiced in everyday life. When you feel the urge to pull coming on, immediately engage in a “competing response” – do something that makes it hard to pull hair. Examples: make a tight fist or stretch your fingers, play with a fidget toy (there are fidget cubes, textured rolls, worry stones, etc.), chew gum or suck on a mint (if you tend to pull with your mouth, like chewing hair), or even clap your hands. The action can be subtle if you’re in public – e.g., pressing your palms against your knees. The idea is to let the urge pass without giving in, essentially “surfing” the urge like a wave. Urges are like cravings that will peak and then subside if you don’t act on them. With practice, this gets easier. Keep a journal or use a tracking app to mark down each time you successfully resisted an urge – seeing progress over time (like more urge resistance or fewer hairs pulled) can be very motivating.
Modify your environment to make pulling harder: Especially in the early stages of breaking the habit, small environmental changes can be very helpful. Some ideas: wear a hat, bandana, or head covering at home during times you typically pull – this serves as a barrier and a reminder. If you tend to pull hair at night or while asleep, consider wearing soft gloves or even adhesive bandages on your fingertips at night. Keep your hair short or tied back tightly, if you’re comfortable with that style, so there’s less length to grab (some people find a new haircut can interrupt the habitual gesture). Identify any tools you use to pull (tweezers, mirrors for eyelashes, etc.) and store them out of reach or get rid of them if possible. Creating a “low temptation” environment sets you up for success.
Practice self-compassion and avoid blame: It’s important to remember that trichotillomania is a medical condition, not a character flaw. Feeling guilt or anger at yourself can actually increase stress and make urges stronger. Instead, adopt a compassionate mindset: recognize that you are working to change a behavior that has been serving as a coping mechanism. Celebrate small victories (like a day with fewer pulling episodes) and don’t despair over setbacks. If you’re a parent of a child with trichotillomania, avoid punishing or scolding the child for pulling Instead, use positive reinforcement when they use a strategy or when they manage not to pull for a period. Create a reward system for younger kids (for example, stickers or points for each pull-free day, earning a fun activity). The entire family should aim to create a supportive environment – one that reduces stress and does not revolve entirely around the pulling behavior.
Utilize support networks: Consider joining a support group or connecting with others who have hair-pulling disorder. Knowing others share this struggle can reduce feelings of isolation and shame. The TLC Foundation for Body-Focused Repetitive Behaviors (BFRBs) is an excellent resource. They offer information, forums, and can help you find local or online peer support groups. Sometimes just talking to someone who “gets it” – perhaps an online community of people with trichotillomania – can provide emotional relief and tips. If you’re a young adult or professional worried about your appearance at work or school, a support group might offer practical advice on camouflage (like cosmetic solutions for eyebrows, or use of wigs/extensions) and how to handle questions or comments from others.
Educational materials and professional resources: High-quality information can empower you. The National Institute of Mental Health (NIMH) and the American Academy of Child & Adolescent Psychiatry (AACAP) have readable materials on trichotillomania and OCD-related disorders. AACAP’s Facts for Families guide on hair pulling is a good starting brochure for parents and older kids to read together.
For literature, there are a few self-help books based on habit reversal techniques that some find helpful (for example, “The Hair-Pulling Problem: A Complete Guide to Trichotillomania” by Fred Penzel) or “Overcoming Body-focused Repetitive Behaviors” by Charles Mansueto. While these are not a substitute for professional therapy, they can complement it.
Keep your healthcare providers in the loop: Stay connected with your doctors and therapists about your progress. If you find a certain strategy is or isn’t working, let them know – they can adjust your treatment plan. If you are taking any medications or supplements (like NAC), report any changes (good or bad) to your prescribing doctor. Never be afraid to reach out to your provider if you’re struggling – sometimes a “booster” therapy session or a check-in can be scheduled to help get you back on track. Remember that overcoming trichotillomania is often a gradual process; it’s okay to ask for help along the way.
