Trichotillomania (Hair Pulling Disorder) is a chronic psychiatric condition characterized by an inability to resist the recurrent urge to pull out one’s own hair, leading to noticeable hair loss. Classified under “Obsessive-Compulsive and Related Disorders” in DSM-5, trichotillomania often impairs daily functioning, disrupts social relationships and results in intense emotions such as shame, anxiety and guilt.

DSM-5 Criteria for Trichotillomania

According to the DSM-5 diagnostic guidelines, the criteria for trichotillomania include:

• Recurrent pulling out of one’s own hair, resulting in hair loss.
• Repeated attempts to decrease or stop hair pulling behavior. This behavior causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
• The hair pulling behavior is not attributable to another medical condition (for example, dermatological disorders) or better explained by another psychiatric condition (for example, body dysmorphic disorder).

Thus, hair pulling is not a simple habit but a compulsive, repetitive urge that the individual struggles to control.

Trichotillomania Symptoms

Trichotillomania often begins in childhood or adolescence. The most common symptoms include:

• Repetitive pulling of hair from the scalp, eyebrows, eyelashes, beard or other body areas,
• A cycle starting with tension, restlessness or increased arousal followed by hair pulling that provides temporary relief,
• Chewing or swallowing the pulled hair (trichophagia),
• Use of hats, wigs or makeup to conceal bald patches,
• Experiencing trance-like absorption or dissociation while pulling hair,
• Increased behavior when alone or under stress,
• Dermatological complications in affected areas such as infections, scarring or irritation.

Because trichotillomania is often perceived as embarrassing, individuals may conceal the behavior, delaying diagnosis.

Etiology of Trichotillomania

The exact cause of trichotillomania remains unclear, but the disorder is understood to have a multifactorial etiology involving genetic, neurobiological, psychological and environmental influences.

Genetic factors may play a role, as family studies show increased prevalence among first-degree relatives with trichotillomania or impulse-control disorders.

Neurobiological findings indicate dysfunction in the prefrontal cortex and basal ganglia. Neurochemical imbalances involving serotonin, dopamine and glutamate have been implicated in impaired impulse control.

Psychological factors include stress, anxiety, depression and low self-esteem. Hair pulling may serve as a maladaptive coping strategy to temporarily relieve negative emotions.

Environmental factors such as family conflict, childhood trauma and academic pressure may act as triggers.

Risk Factors

Risk factors that increase susceptibility to trichotillomania include:

• Family history of obsessive-compulsive disorder, tic disorders or trichotillomania,
• Female gender (cases beginning during adolescence are more common in females),
• Exposure to trauma or abuse,
• History of anxiety disorders or major depressive disorder,
• Loneliness and social isolation,
• Low self-esteem and negative body image.

These factors increase vulnerability but are not determinative on their own.

Diagnosis

Diagnosis involves a detailed psychiatric interview and clinical assessment. Clinicians evaluate the frequency of hair pulling, emotional states associated with the behavior and the degree of control the individual has over it.

Assessment tools such as the Massachusetts General Hospital Hairpulling Scale (MGH-HPS) can be used. Differential diagnosis should rule out body dysmorphic disorder, tic disorders and dermatological conditions.

Trichotillomania Treatment

Treatment is tailored to the severity of symptoms, comorbid psychiatric conditions and behavioral patterns. Psychotherapy is usually the first-line intervention, sometimes supported by pharmacotherapy.

1. Psychotherapy (Cognitive Behavioral Therapy – CBT)

CBT is the most evidence-based and widely used psychotherapeutic approach for trichotillomania. Key techniques include:

• Habit Reversal Training (HRT): Teaching individuals to recognize hair pulling urges and replace them with alternative behaviors.
• Stimulus Control: Modifying or avoiding environments that trigger pulling behavior.
• Emotion Regulation Techniques: Relaxation exercises and mindfulness to reduce anxiety and increase awareness.

Therapy typically lasts 8–16 sessions. Family involvement and homework assignments enhance treatment outcomes.

2. Pharmacotherapy

There is currently no medication specifically approved for the treatment of trichotillomania; however, pharmacological approaches may be considered as part of a comprehensive treatment plan, particularly when psychotherapy alone is insufficient or when comorbid psychiatric conditions are present.

Selective Serotonin Reuptake Inhibitors (SSRIs): These agents are commonly utilized to help reduce impulsive and compulsive behaviors as well as accompanying anxiety or depressive symptoms. Their effectiveness may vary among individuals and treatment response should be regularly evaluated.

Glutamate-Modulating Agents: Substances that regulate glutamatergic neurotransmission, such as N-acetylcysteine (NAC), have shown promise in clinical studies by reducing compulsive urges and improving self-control mechanisms.

Other Pharmacological Options: In treatment-resistant cases, adjunctive use of other psychotropic agents may be considered under close medical supervision.

Pharmacotherapy should always be personalized, used in combination with psychotherapy and monitored by a qualified psychiatrist to ensure optimal safety and efficacy.

3. Family Counseling and Psychoeducation

Because the disorder is often stigmatized, supportive and understanding family attitudes are crucial. Educating family members about the nature, course and treatment of trichotillomania improves communication and adherence.

4. Support Groups and Community-Based Interventions

Support groups, particularly for adolescents and young adults, can reduce isolation and increase adherence to treatment. In school settings, involvement of counseling services may also be beneficial.

Impact on Daily Life

Trichotillomania can significantly impair quality of life. Hair loss leads to cosmetic concerns, social anxiety, low self-esteem and academic or occupational difficulties. Visible hair loss, especially on the face, exacerbates social isolation and increases the risk of depression.

Trichophagia may result in severe gastrointestinal complications such as trichobezoar, sometimes requiring surgical intervention.

Trichotillomania is a serious disorder with both psychological and physical complications. Early diagnosis, structured psychotherapeutic methods such as CBT, and pharmacotherapy when needed, can lead to significant improvement. Individualized, holistic and multidisciplinary approaches enhance success, while raising public awareness and reducing stigma are vital for sustainable treatment outcomes.