> Table of Contents > Trichotillomania
Carol Hustedde, PhD
William G. Elder, PhD
image BASICS
  • Trichotillomania (TTM) is a hair-pulling disorder characterized by self-induced, repeated, and often noticeable hair loss. It can become severe and difficult to control.
  • TTM is currently conceptualized as a compulsive behavior related to obsessive-compulsive disorder (OCD). Tension or boredom typically play a significant role, and the individual may be conscious or unconscious that they are pulling hair.
  • TTM causes uncontrollable hair pulling from anywhere on the body, although the scalp is the most common area followed by the eyelashes, eyebrows, pubic/perirectal area, axilla, and face. It usually results in variable degrees of alopecia.
  • TTM usually presents in childhood or early adolescence.
  • Denial and hiding of hair pulling is common.
  • Recurrence or worsened hair pulling is associated with increased stress/anxiety, but TTM can also occur at times of relaxation and distraction, such as when reading.
  • The three subtypes of TTM: early onset, automatic, and focused
  • When TTM is associated with trichophagia, it may also result in GI complaints secondary to bezoars
  • TTM has frequent comorbidity with other psychiatric diagnoses
  • It is difficult to assess the exact number of individuals affected by TTM because of the social stigma associated with it. Small studies have estimated a range of 1-3.5% for late adolescents and young adults.
  • It is possible that up to 1 of 50 individuals are affected by TTM at least once in their lifetime.
  • The mean age of onset is at 13 years.
  • During childhood, males and females are equally affected by TTM. During adulthood, females are far more affected than males.
  • Serotonin deficiency
  • Tension relief
  • Habitual behavior
  • There is currently a significant flux in the conceptualizations of the mechanisms and causes of impulse control, behavior, anxiety, and OCDs. Brain imaging and biochemical and neuropsychological studies should help to resolve this issue. It can be expected that there will be increased differentiation as well as redefinitions of disorders that are based on neurophysiology and brain circuitry.
Genetics appears to contribute to the development of TTM as demonstrated by a higher rate of concordance in monozygotic twins (38.1%) versus dizygotic twins (0%). Genetic involvement is multifaceted and not clearly understood at this time.
  • Positive family history
  • Other psychiatric disorders: depression, OCD, anxiety, posttraumatic stress disorder (PTSD), eating disorders, nail biting, skin picking
  • Depression
  • Anxiety
  • OCD
  • Eating disorders
  • TTM may be difficult to diagnose because individuals may deny it because of the social stigma and embarrassment.
  • Several TTM-specific assessment tools have been developed that further understands about psychopathology of TTM.
  • Assessment should include multiple sources of information to provide understanding of TTM in context.
  • The most common manifestation of TTM is alopecia.
  • The severity of the alopecia is variable, from isolated areas of hair loss to complete baldness.
  • Hair loss can be from any part of the body.
  • The Friar Tuck sign may be seen, which consists of hair loss seen in a circular pattern with varying lengths of broken hairs.
  • There is also a lack of dermatologic abnormalities associated with the hair loss.
  • In addition to the hair loss, hair abnormalities consisting of damaged hair follicles, broken hairs of varying lengths
  • When TTM is associated with trichophagia and, consequently, trichobezoars, there may be symptoms of abdominal pain, nausea, vomiting, obstructive jaundice, bowel obstruction symptoms, and anemia.
  • Patients with TTM may also pull hairs from other people and pets, sometimes surreptitiously. They may also pull fibers from carpets and fabrics.
  • Alopecia areata
  • Tinea capitis
  • Traction alopecia
  • Loose anagen syndrome
  • OCD
  • Schizophrenia or other psychotic disorders
  • Stereotypic movement disorders
  • Factitious behaviors
US or CT scan for trichobezoar detection
Diagnostic Procedures/Other
  • Trichotillomania Scale for Children
  • Trichotillomania Diagnostic Interview
  • National Institute of Mental Health Trichotillomania Questionnaire
  • Premonitory Urge for Tics Scale

Test Interpretation
  • Punch biopsy: high frequency of telogen hairs; deformed, noninflamed catagen hairs; melanin pigment casts
  • Trichogram
  • Referrals
    • Some diagnostic procedures may require a dermatology referral. In the presence of missing hair follicles or other hair disorder, a dermatology consult will allow for visual and/or microscopic (trichogram) analysis to determine structure and cycle of the hair disorder.
    • A referral to a psychiatrist, psychologist, or psychopharmacologist who specializes in impulse control and OCD may be helpful. He or she will have access to the specialized symptoms scales described above and also is likely to have professional relationships with psychotherapists who can provide specific therapies, such as habit reversal training. Such referral may also allow for stepped treatment including aggressive use of SSRIs and other antidepressants with combinations of second-line pharmacologic options sometimes tried for impulse control and OCD disorders.
  • Treatment of TTM involves both psychological methods that include specific psychotherapies, pharmacologic treatment, and combined approaches.
  • Psychological treatment of TTM may be the primary treatment and is almost always needed in addition to medications.
    • Habit reversal training (HRT) has the strongest empirical support in adults (1)[B]:
      • HRT is a behavioral therapy that is effective in reducing troublesome behaviors associated with TTM. It consists of four main components: awareness training, development of a competing response, building motivation, and generalization of skills.
    • Principles of cognitive-behavior therapy (CBT) can be adjusted to developmental age to treat young children (2)[B].
    • Relaxation training (when stress is high)
    • Support groups to deal with stigma and denial
    • Treatment of comorbid psychiatric condition
    • Unlikely to be helpful
      • Undifferentiated, nonspecific psychotherapy
      • Hypnosis
      • Acupuncture
    • A nutritional supplement, N-acetylcysteine (1,200 to 2,400 mg/day), shows some benefit for adults but not for children and adolescents.
  • Previous RCT studies evaluate pharmacotherapy across various classes of medications had small sample sizes and did not indicate benefit (3).
  • SSRIs have not demonstrated efficacy and most studies reported findings on subjects with little comorbidity. These medications may be options in concert with CBT.
    • Fluoxetine (Prozac): 20 to 80 mg/day
    • Sertraline (Zoloft): 50 to 200 mg/day
    • Paroxetine (Paxil): 10 to 50 mg/day
    • Citalopram (Celexa): 20 to 40 mg/day
    • Escitalopram (Lexapro): 10 to 20 mg/day
  • Glutamate modulators (e.g., N-acetylcysteine) may reduce TTM in adults; however, benefit has not been demonstrated for children (4).
Surgery is only warranted for removal of trichobezoars.
Inpatient admission is usually not due to TTM itself but either treatment of comorbid psychiatric conditions or a bowel obstruction secondary to trichobezoar.
No special diet required for TTM
  • TTM is a multifactorial condition. Not only do medications aid in the treatment of TTM, but also psychological therapies may have a significant benefit as well.
  • Online resources: www.trich.org; www.stoppulling.com
TTM tends to be a chronic disorder; however, it can be transient in childhood.
1. Morris SH, Zickgraf HF, Dingfelder HE, et al. Habit reversal training in trichotillomania: guide for the clinician. Expert Rev Neurother. 2013;13(9): 1069-1077.
2. Tompkins M. Cognitive-behavior therapy for pediatric trichotillomania. J Rat-Emo Cognitive-Behav Ther. 2014;32:98-109.
3. Rothbart R, Stein DJ. Pharmacotherapy of trichotillomania (hair pulling disorder): an updated systematic review. Expert Opin Pharmacother. 2014;15(18):2709-2719.
4. Grant JE, Odlaug BL, Kim SW. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry. 2009;66(7):756-763.
Additional Reading
  • Chattopadhyay K. The genetic factors influencing the development of trichotillomania. J Genet. 2012;91(2):259-262.
  • Duke DC, Keeley ML, Geffken GR, et al. Trichotillomania: a current review. Clin Psychol Rev. 2010;30(2):181-193.
  • Franklin ME, Zagrabbe K, Benavides KL. Trichotillomania and its treatment: a review and recommendations. Expert Rev Neurother. 2011;11(8):1165-1174.
  • Harrison JP, Franklin ME. Pediatric trichotillomania. Curr Psychiatry Rep. 2012;14(3):188-196.
  • Trichotillomania Learning Center. Expert consensus guidelines on treatment of trichotillomania, skin picking and other body-focused repetitive behaviors. www.trich.org/dnld/ExpertGuidelines_000.pdf. Accessed 2014.
F63.3 Trichotillomania
Clinical Pearls
  • Etiology of TTM is multifactorial and differs among individuals. It is important to distinguish between different etiologies.
  • TTM may occur in the presence of comorbid conditions.
  • Patients may benefit from psychotherapy and selected medications.
  • It is important to realize that TTM is underreported and underdiagnosed because of the social stigma.
  • TTM can have a significant impact on psychological, social, academic, and occupational functions.