Trichotillomania (Hair-Pulling Disorder)

Trichotillomania is a body-focused repetitive behavior involving recurrent pulling out of one's own hair — most often from the scalp, eyebrows, or eyelashes — resulting in noticeable hair loss. Pulling can be 'automatic,' occurring largely outside conscious awareness during sedentary activities like reading or watching television, or 'focused,' a deliberate response to an urge or feeling of tension that is relieved by pulling. Most people make repeated, often unsuccessful, attempts to stop.

Trichotillomania is defined as recurrent pulling out of one's hair, resulting in hair loss, with repeated attempts to decrease or stop the behavior, causing clinically significant distress or impairment, and not attributable to another medical or dermatological condition or better explained by another mental disorder.

Trichotillomania has a genetic component and is classified alongside OCD as an obsessive-compulsive-related condition, though it is also strongly linked to habit-formation circuitry in the brain. It typically begins in adolescence and may be triggered or maintained by stress, boredom, or as an automatic behavior during sedentary, low-stimulation activities.

• Family history of trichotillomania or other body-focused repetitive behaviors
• Family history of OCD or obsessive-compulsive spectrum conditions
• High stress or anxiety
• Perfectionistic traits
• Boredom-prone states or frequent sedentary, low-stimulation activity
• Co-occurring anxiety or depressive disorders

Trichotillomania shares some overlap with the CSTC circuit dysfunction seen in OCD but is distinguished by stronger involvement of the basal ganglia's habit-formation pathways, reflecting its more automatic, habit-like quality in many individuals — as opposed to the fear-driven, obsession-focused quality typical of classic OCD.

• Recurrent pulling of hair from the scalp, eyebrows, eyelashes, or other body areas
• Noticeable hair loss or thinning in the affected area
• Repeated, often unsuccessful attempts to decrease or stop pulling
• 'Automatic' pulling occurring largely outside awareness during other activities
• 'Focused' pulling as a deliberate response to an urge or tension, often followed by relief or gratification
• Rituals accompanying pulling — examining the hair root, biting or chewing the hair, or, in some cases, eating pulled hair (trichophagia)
• Avoidance of situations that might reveal hair loss (swimming, windy weather, close inspection)

• Recurrent pulling out of one's hair, resulting in hair loss
• Repeated attempts to decrease or stop hair pulling
• Causes clinically significant distress or impairment
• Not attributable to another medical or dermatological condition (e.g., a skin condition)
• Not better explained by another mental disorder

Conditions a psychiatrist will consider and rule out before confirming this diagnosis:

Alopecia Areata

A dermatological autoimmune condition causing patchy hair loss without any pulling behavior; trichoscopy can distinguish broken hairs of varying length (pulling) from uniform loss.

Obsessive-Compulsive Disorder

OCD compulsions are usually performed to reduce a specific feared outcome, whereas hair pulling is often automatic or tension-driven without a specific feared consequence.

Excoriation (Skin-Picking) Disorder

A closely related and frequently co-occurring body-focused repetitive behavior involving skin rather than hair.

Normative hair twirling in young children

Common, usually self-limiting, and typically does not cause noticeable hair loss.

• Clinical interview covering pulling patterns, triggers, and impact
• Dermatological examination, sometimes including trichoscopy, to confirm pulling versus other causes of hair loss
• Massachusetts General Hospital Hairpulling Scale to assess severity
• Screening for co-occurring skin-picking, nail-biting, or other body-focused repetitive behaviors

Habit Reversal Training (HRT), a structured behavioral therapy, is the first-line and best-evidenced treatment. N-acetylcysteine, an over-the-counter glutamate-modulating supplement, has shown benefit in some studies. Medication evidence is less robust and consistent than for OCD, though SSRIs are sometimes tried, particularly with co-occurring anxiety or depression.

N-acetylcysteine (NAC)

A glutamate-modulating supplement with some evidence of reducing pulling urges; often tried given its favorable side-effect profile.

SSRIs

Evidence is less consistent than in OCD, but may help, particularly when anxiety or depression co-occurs.

Clomipramine

Some evidence supporting its use, similar to other body-focused repetitive behaviors.

Habit Reversal Training (HRT)

Combines awareness training (noticing pulling urges and triggers), competing response training (substituting a different action, like fist clenching), and stimulus control (modifying situations that trigger pulling).

Comprehensive Behavioral (ComB) model

An expanded approach addressing sensory, cognitive, affective, motor, and environmental triggers individually.

Acceptance and Commitment Therapy (ACT)

Helps build tolerance of the urge to pull without acting on it, alongside HRT.

• Identify specific triggers — boredom, sedentary activities, stress — and plan alternative behaviors in advance
• Use fidget objects, gloves, or hats during high-risk times or activities
• Keep nails short and trimmed to reduce the ease and satisfaction of pulling
• Keep an awareness journal to track patterns and progress
• Address underlying stress or anxiety through relaxation techniques

Trichotillomania tends to follow a chronic, waxing-and-waning course, but Habit Reversal Training produces meaningful, often substantial symptom reduction for most people. Without treatment, ongoing hair loss can significantly affect self-esteem, appearance, and social confidence.

• Early behavioral intervention for children who develop a hair-pulling habit, before it becomes deeply entrenched
• Stress management and building alternative coping strategies for boredom or tension
• Avoiding shame-based responses from family, which tend to increase secrecy and pulling in private

Avoid repeatedly pointing out pulling or expressing frustration, as this tends to increase shame and secretive pulling rather than reduce the behavior. Support engagement with Habit Reversal Training, help identify and reduce access to high-risk situations (excessive idle time, certain seating/lighting where pulling is easier), and be patient, since progress with HRT is typically gradual.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR).
2. TLC Foundation for Body-Focused Repetitive Behaviors.