Trichotillomania (TTM), otherwise known as Hair-Pulling Disorder, can be a severe and debilitating disorder with many individuals living with this disorder in secrecy and shame.
However many people who do have this disorder, do not know its name or what can be done about it (Woods & Twohig, 2008). According to the Diagnostic and Statistical Manual, Fifth Edition (DSM-5; American Psychological Association (APA), 2013) the estimated prevalence for TTM in the general population (please note that these are not South African stats but American stats) is between 1% and 2%. With females seemingly more affected than males by a ration of 10:1. However, among children, males and females appear to be represented more equally.
With the above in mind, there have been advances in the treatment approach to TTM (Tolin & Morrison, 2010), and individuals suffering from this disorder do not need to live with an unknown condition and/or in shame and secrecy. The first step however is to be able to identify TTM.
According to the DSM-5 (APA, 2013, p. 251) the criteria for TTM is:
Hair pulling may occur in all areas where there may be hair growth and many sites around the body may be affected. It is also possible that the hair-pulling sites may vary over time. The most common hair pulling sites are the scalp, eyebrows and eyelashes with less common areas being the trunk, face, armpits, pubic region and peri-rectal regions (Sadock & Sadock, 2007). Hair pulling can occur in short brief periods throughout the day or it may occur less frequently but for a much more sustained period (e.g. hours). It is important to note that the individual most commonly pulls with his/her hands however some individuals do use tools to pull such as tweezers (DSM-5, APA, 2013).
According to Tolin and Morrison (2010) hair-pulling can lead to hair loss, which is part of the criteria for TTM, however this may not be easily recognisable as many individuals will not pick hair from one site but will scatter their picking and pick hair from multiple sites around the body. This leads to more evenly or widely distributed hair pulling and less hair loss in one area. It is also common that due to the shame and secrecy involved with this disorder, the individual may take measures to hide or mask possible hair loss by using wigs, make-up, scarves, long sleeve clothes, etc. Having said this, TTM can be significantly severe and may be difficult to hide due to patches of baldness and/or complete baldness in certain areas of the body.
It is also common for hair pulling to be associated with other routines or habits involving the hair. These routines seem to be associated with visual, tactile and oral manipulation of the hairs (Tolin & Morrison, 2010). For example, the individual may search for the hair to pick by colour or texture; may bite on or chew the hair both prior to or after pulling the hair; roll the hair between his/her fingers or rub the hair on his/her face; or the individual may have a precise way of pulling the hair out (DSM-5; APA, 2013).
It appears as if TTM has a genetic component as according to DSM-5 (APA, 2013, p. 253) “ there is evidence for a genetic vulnerability to Trichotillomania. The disorder is more common in individuals with Obsessive-Compulsive Disorder (OCD) and their first-degree relatives than in the general population”. Hair pulling can be seen in infants and young children but this behaviour usually resolves as the child ages. The onset of TTM is more commonly during puberty, which would then have a higher possibility of not resolving without some form of treatment, regardless of whether the course of the TTM is chronic or has a waxing and waning path (Sadock & Sadock, 2007).
Research from Mansueto, Townsley-Stemberger, Thomas, and Golomb (1997) and Wetterneck, Woods, Flessner, Norberg, and Begotka (2005) state that hair pulling is often preceded and/or maintained by various emotional states. The hair pulling may be triggered by anxiety or boredom. Individuals with TTM often describe that prior to pulling they experience bodily sensations such as tension. This tension may be general or localized to a certain area of the body. The individual may also experience a sense of discomfort prior to pulling, which could explain as vague urges, not feeling “just right”, and/or inner pressure. The hair pulling may then lead to immediate and short-term relief, gratification, and/or pleasure. However in the long-term the individual may experience guilt, anger and frustration, leading to even longer-term fatigue and loneliness (DSM-5, APA, 2013; Woods & Twohig, 2008).
According to Woods and Twohig (2008) evidence suggests that at least two processes underlie hair pulling. The first process is called focused pulling, which suggests that the individual pulls as a specific behaviour intended to reduce or escape from the urges, bodily sensations such as itching or burning, emotions such as anxiety, and/or unhelpful cognitions. The pulling usually provides short-term pleasure or relief. The second process is called automatic pulling, which is pulling that occurs in situation in which the individual may be partaking in a sedentary activity. Sedentary activities may be watching a movie, reading, or driving. There are often no identifiable antecedent urges, bodily sensations, emotions, or cognitions and the individual will pull outside of their own awareness. It is more common that individuals with TTM will report a mix of both focused and automatic pulling.
TTM is rarely seen in isolation and is commonly accompanied by other mental disorders. The most common disorders that accompany TTM are Obsessive-Compulsive Disorder (OCD), Skin-Picking (Excoriation) Disorder, Major Depressive Disorder (MDD), Anxiety Disorders, Substance Use Disorders and Eating Disorders (DSM-5, APA, 2013; Woods & Twohig, 2008). These comorbid disorders can make treatment of the TTM tricky.
However, what appears to bring individuals to therapy is the distress and the functional impairment caused by the repeated pulling. The individual may have difficulty with their social and occupational functioning as they feel ashamed of the hair pulling and will often shy away from work and/or social events (even dating). The individual may have strained relationships with their family members as it can be frustrating for family members see a loved on pulling their hair out. The family member may continuously tell the individual with TTM to stop pulling and wonder why they cannot stop, while the individual with TTM may be trying to stop but is unable to (Sadock & Sadock, 2007).
Tolin and Morrison (2010) describe that the individual with TTM may also have physical difficulties such as irreversible hair damage, hair growth and/or hair quality due to the repeated hair pulling. The person with TTM may pull from difficult to reach areas and can develop back, shoulder and neck pains. It is common that individuals may play with their hair after pulling, e.g. chew on their hair, rub the hair between their fingers, and or rub the hair on their face, etc., which along with the actual pulling may lead to carpal tunnel syndrome. The biting of the hair may lead to damaged teeth. Sometimes the person will swallow the hair, which leads to trichobezoars (“conglomerates of hair and food that form in the gastrointestinal tract” (Woods & Twohig, 2008, p. 2)) that may cause many other physical ailments and require surgery to be removed.
As can be seen from the above, TTM can be severely debilitating and help is required. According to Tolin & Morrison (2010) pharmacotherapy is a common intervention for TTM however research is still limited in this field. Psychotherapy appears to be beneficial to individuals suffering from TTM. The type of psychotherapy that seems the most beneficial is Cognitive Behavioural Therapy (CBT) through the use of Habit Reversal Training (HRT), Stimulus Control (SC), and Acceptance and Commitment Therapy (ACT).
It is advisable to see a psychologist and/or psychiatrist if you feel you may be suffering from TTM, who can then explain the medications and procedures further and in detail. Consulting with a psychologist and/or psychiatrist is a step in getting this disorder under control.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
Mansueto, C. S., Townsley-Stemberger, R. M., Thomas, A., & Golomb, R. (1997). Trichotillomania: A Comprehensive Behavioral Model. Clinical Psychology Review, 17, 567-577.
Sadock, B. J., & Sadock, V. A. (2007). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th ed.). Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer Business.
Tolin, D. F., & Morrison, S. (2010). Impulse Control Disorders. In M. M. Antony & D. H. Barlow (Eds.), Handbook of Assessment and Treatment Planning for psychological Disorders (2nd ed., pp. 606-632). New York: Guilford Press.
Wetterneck, C. T., Woods, D. W., Flessner, C. A., Norberg, M., & Begotka, A. (2005). Antecedent Phenomena Associated with Trichotillomania: Research and Treatment Implications for an Online Study. Symposium presented at the Association for Behavior Analysis Conference, Chicago, Il.
Woods, D. W., & Twohig, M. P. (2008). Trichotillomania: An ACT-enhanced Behaviour Therapy Approach Therapists Guide. New York: Oxford University Press.