Behavioral Health Update
BHSI Newsletter Vol. 2, No. 2

Patricia Kraemer, MA, LP
Trichotillomania (TM) is a disorder of recurrent hair pulling. It is included in the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) (DSM-IV) under “impulse control disorders not elsewhere classified.” The condition has previously been considered rare, but recent studies indicate that it may be more common than once believed. Clinically relevant hair pulling may occur in approximately 2% of the population. Most patients with recurrent and/or chronic hair pulling are too embarrassed to volunteer the problem. TM is often not obvious.

Clinical Features

This condition appears to be more common among women. Any body hair may be targeted, although the scalp is the most common site followed by eyelashes and eyebrows. Hair pulling commonly occurs during sedentary and contemplative activities such as reading or watching television. Most patients do not pay attention to what they are doing and do not report anxiety while engaged in hair pulling (one of several characteristics that seem to distinguish TM from obsessive-compulsive disorder). The onset of TM is typically in childhood or adolescence. The mean age at onset is 13 years. Some research suggests that if, at the time of presentation in children, hair pulling has been present less than 6 months, the prognosis for recovery with minimal intervention is good; otherwise a chronic pattern of hair pulling is typical.

Associated Features

By definition, TM results in noticeable hair thinning or bald spots of the involved area. At times patients adapt hairstyles or wear scarves, hats, and wigs. Attempts to hide hair loss may lead to avoidance of situations in which the scalp would be visible. Hair pulling from any site may lead to avoidance of intimate relationships. Oral manipulation of hair is reported in 48% of TM cases. This may involve chewing the end of the hair, rubbing hair along the mouth, or complete ingestion of hair. For this reason, it is important to inquire about hair ingestion or gastrointestinal pain in the assessment so as not to miss a connected hair mass in the stomach or bowel (i.e., trichobezoar). This is a serious and life-threatening condition that needs immediate medical attention. TM is frequently associated with psychiatric comorbidity such as mood (65%), anxiety (57%), chemical use (22%), and eating disorders (20%).


Hair pulling onset has been associated with loss or perceived loss or trauma, such as divorce of parents, family move, change of schools, or physical abuse. More recently, it has been speculated that TM belongs to a spectrum of disorders related to obsessive-compulsive disorder (OCD). Supporting such an assertion are observed similarities between TM and OCD regarding phenomenology, neuropsychological test performance, response to serotonin reuptake blockers, and familial association. Another theory is that TM is the human equivalent of displacement activities, a well-known phenomenon in the ethnological literature. In such a model, TM is viewed as abnormal grooming behavior elicited in response to stress and limited options for motoric behavior and tension release; hair pulling typically occurs in the context of sedentary activities with the patient engaged in heightened concentration. These patterns have a strong genetic basis, only needing the appropriate stimulus to be released. Grooming is one fixed-action pattern that has much in common with compulsive behavior. This behavior might be evoked by defects in communication between the frontal lobes and the basal ganglia.


The literature on treatment options for TM remains scant. Most accounts are single-case reports that represent a wide range of techniques beyond a comprehensive review. The interested reader is referred to an excellent review on this subject by Friman and associates, l984. The habit-reversal method of behavioral therapy has been demonstrated to be effective in the motivated patient. Habit-reversal is a multicomponent approach of behavioral therapy. Subjects are instructed in behavioral monitoring, including recording hair-pulling behavior in a chart and observing hair pulling in a mirror to enhance their awareness of the behavior. They are also instructed to note preliminary behaviors and negative consequences resulting from TM and to enter previously avoided situations. A competing response is taught and substituted for hair pulling when encountering high-risk situations or after hair pulling. Finally, relaxation training targets anxiety and tension that might initiate or exacerbate hair pulling. With special populations (e.g., young children and developmentally delayed individuals), other behavioral techniques may be necessary such as a token economy system. Serotonin reuptake inhibitors also appear promising in the treatment of TM. Regardless of which intervention is selected, however, the therapist must provide empathy and support, emphasize understanding, expect lapses (versus relapses), and help the patient cope with setbacks that often follow successful interventions.