Symptoms

Trichotillomania

The urge to pull out one’s own hair is called trichotillomania. Literally, trichotillomania means “hair-plucking madness.”

Trichotillomania is characterized by the repeated pulling out of one’s own hair, for example, from the head, pubic area, eyebrows, and/or eyelashes. Some individuals pull out their hair more or less automatically, that is, without consciously realizing they are doing so. Others perform the action intentionally or to relieve tension. Repeated hair pulling often leads to visible hair loss.

For advice on what you can do about trichotillomania, see Helpful Things, Self-Help Techniques, and Videos. Self-Help Books as well as reports and blogs from affected people may also provide support. If you experience other problems such as feeling down or depressed, try the free COGITO app for iOS and Android. The app contains numerous tips on how to raise your self-esteem and mood.

Diagnosis

In the current classification system for psychological disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013), trichotillomania is recognized as a separate diagnosis. It is described in the chapter “Obsessive-Compulsive and Related Disorders” of the manual under the heading of body-focused repetitive behaviors. However, there is controversy over the classification of trichotillomania as an obsessive-compulsive spectrum disorder because not every BFRB is obsessive-compulsive in nature and few of those affected suffer from true compulsions such as control or washing compulsions.

Current DSM-5 (APA, 2013) diagnostic criteria for trichotillomania are as follows:

  • Recurrent pulling of the hair, resulting in hair loss
  • Repeated attempts to reduce or stop the behavior
  • Clinically significant distress or impairment in social, occupational, or other areas of functioning
  • Is not due to substance abuse or a medical condition (e.g., a dermatologic condition)
  • Cannot be better explained by another psychiatric disorder

Age of onset

The most common age of onset for trichotillomania is late childhood or early adolescence, between the ages of 6 and 18 (Christensen et al., 2023: Flessner et al., 2010; Grant et al., 2020; Moritz et al., 2024). For most affected people, the onset lies between the ages of 12 and 14 (Lochner et al., 2010; Moritz et al., 2024; Odlaug et al., 2010; Ricketts et al., 2019; Tay et al., 2004).

Prevalence

General population

During their lifetime, approximately 1 to 3 percent of the general population will be affected by trichotillomania (Grant et al., 2020; Grant & Chamberlain, 2016; Hayes et al., 2019; Moritz et al., 2024; Solley & Turner, 2018; Thomson et al., 2022). Milder cases of trichotillomania that do not result in highly visible consequences, such as significant hair loss, are found in up to 19.2 percent of the general population (lifetime prevalence).

Adolescence and young adulthood

Hair pulling, which results in visible hair loss, has been identified in approximately 1.5 percent of men and 3.4 percent of young women (Christenson et al., 1991; Grant et al., 2020; Grzesiak et al., 2017).

Adulthood

Approximately 1.7 percent (between 0.5 and 2 percent) of adults aged 18 to 69 years are affected by trichotillomania according to studies, but the actual number is probably a lot higher (Grant et al., 2020; Melo et al., 2022).

Gender differences

It is often assumed that females are more commonly affected than males. In adulthood, approximately 80 to 90 percent of clinical cases are women (Bezerra et al., 2020; King et al., 2014; Hautmann et al., 2002). Current research, however, is increasingly questioning these reported gender differences (Christensen et al., 2023; Grant et al., 2020; Moritz et al., 2024). In childhood the disorder occurs with about equal frequency in boys and girls (Cohen et al., 1995; Grzesiak et al., 2017).

Manifestation

Individuals with trichotillomania recurrently pull out their hair and cannot stop the behavior, despite the distress and consequences. The amount of hair pulled out, the time spent pulling hair, and the affected areas on the body vary from person to person. Most commonly, hair is pulled from the scalp, eyebrows, and eyelashes. Some people use their fingers to pull their hair, whereas others use tools such as tweezers.

Consequences

Many individuals have noticeable hair loss or even completely bald patches as a result of trichotillomania. Without treatment, trichotillomania can develop into a chronic, recurring disorder.

Thinning or bald patches on the head are often concealed with hairstyles, scarves, wigs, or makeup. Affected individuals often cover missing eyelashes, eyebrows, or body hair by using make-up or other means.

Many of those affected feel ashamed of their appearance and behavior. Emotions of shame and guilt affect their self-esteem. Social activities and physical intimacy are therefore often avoided.

Some individuals swallow their hair after pulling it out, which is called trichophagia (see also the section “Other impulse-control disorders”). If too much hair accumulates in the stomach, this can lead to severe gastric problems.

Literature

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. (2013). https://doi.org/10.1176/appi.books.9780890425596

Bezerra, A. P., Machado, M. O., Maes, M., Marazziti, D., Nunes-Neto, P. R., Solmi, M., Firth, J., Ishrat Husain, M., Brunoni, A.R., Kurdyak, P., Smith, L., Alavi, A., Piguet, V. & Carvalho, A. F. (2020). Trichotillomania—psychopathological correlates and associations with health-related quality of life in a large sample. CNS Spectrums, 1-8. https://doi.org/10.1017/s109285292000111x

Christensen, R. E., Tan, I. & Jafferany, M. (2023). Recent advances in trichotillomania: a narrative review. Acta Dermatovenerologica Alpina, Panonica Et Adriatica, 32(4). https://doi.org/10.15570/actaapa.2023.28

Christenson, G. A., Pyle, R. L., & Mitchell, J. E. (1991). Estimated lifetime prevalence of trichotillomania in college students. Journal of Cinical Psychiatry, 52(10), 415–417.

Cohen, L. J., Stein, D. J., Simeon, D., Spadaccini, E., Rosen, J., Aronowitz, B. & Hollander, E. (1995). Clinical profile, comorbidity, and treatment history in 123 hair pullers: a survey study. Journal of Clinical Psychiatry, 56(7), 319–326.

Flessner, C. A., Lochner, C., Stein, D. J., Woods, D. W., Franklin, M. E. & Keuthen, N. J. (2010). Age of onset of trichotillomania symptoms: investigating clinical correlates. The Journal of Nervous and Mental Disease,198(12), 896–900. https://doi.org/10.1097/nmd.0b013e3181fe7423

Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania. The American Journal of Psychiatry, 173(9), 868–874. https://doi.org/10.1176/appi.ajp.2016.15111432

Grant, J. E., Dougherty, D. D., & Chamberlain, S. R. (2020). Prevalence, gender correlates, and co-morbidity of trichotillomania. Psychiatry Research, 288, 112948. https://doi.org/10.1016/j.psychres.2020.112948

Grzesiak, M., Hadrys, T., Pacan, P., Reich, A., & Szepietowski, J. C. (2017). Trichotillomania among young adults: prevalence and comorbidity. Acta Dermato Venereologica, 97(4), 509–512. https://doi.org/10.2340/00015555-2565

Hautmann, G., Hercogova, J., & Lotti, T. (2002). Trichotillomania. Journal of the American Academy of Dermatology, 46(6), 807–826. https://doi.org/10.1067/mjd.2002.122749

Hayes, S. L., Storch, E. A., & Berlanga, L. (2009). Skin picking behaviors: An examination of the prevalence and severity in a community sample. Journal of Anxiety Disorders, 23(3), 314–319. https://doi.org/10.1016/j.janxdis.2009.01.008

King, R. A., Scahill, L., Vitulano, L. A., Schwab-Stone, M., Tercyak, K. P., Jr, & Riddle, M. A. (1995). Childhood trichotillomania: clinical phenomenology, comorbidity, and family genetics. Journal of the American Academy of Child and Adolescent Psychiatry, 34(11), 1451–1459. 

Lochner, C., Seedat, S. & Stein, D. J. (2010). Chronic hair-pulling: phenomenology-based subtypes. Journal of Anxiety Disorders, 24(2), 196–202. https://doi.org/10.1016/j.janxdis.2009.10.008

Melo, D. F., Lima, C., Piraccini, B. M., & Tosti, A. (2022). Trichotillomania: What do we know so far?. Skin Appendage Disorders, 8(1), 1–7. https://doi.org/10.1159/000518191

Moritz, S., Scheunemann, J., Jelinek, L., Penney, D., Schmotz, S., Hoyer, L., Grudzień, D. & Aleksandrowicz, A. (2024). Prevalence of body-focused repetitive behaviors in a diverse population sample – rates across age, gender, race and education. Psychological Medicine, 54(8), 1552–1558. https://doi.org/10.1017/S0033291723003392

Odlaug, B. L., Kim, S. W. & Grant, J. E. (2010). Quality of life and clinical severity in pathological skin picking and trichotillomania. Journal of Anxiety Disorders, 24(8), 823–829. https://doi.org/10.1016/j.janxdis.2010.06.004

Ricketts, E. J., Snorrason, I., Kircanski, K., Alexander, J. R., Stiede, J. T., Thamrin, H., Flessner, C. A., Franklin, M. E., Keuthen, N. J., Walther, M. R., Piacentini, J., Stein, D. & Woods, D. W. (2019). A latent profile analysis of age of onset in trichotillomania. Annals of Clinical Psychiatry, 31(3), 169–178.

Solley, K. & Turner, C. (2018). Prevalence and correlates of clinically significant body-focused repetitive behaviors in a non-clinical sample. Comprehensive Psychiatry, 86, 9–18. https://doi.org/10.1016/j.comppsych.2018.06.014

Tay, Y. K., Levy, M. L., & Metry, D. W. (2004). Trichotillomania in childhood: case series and review. Pediatrics, 113(5), e494–e498. https://doi.org/10.1542/peds.113.5.e494