Hair-Pulling Disorder (Trichotillomania)

What is Trichotillomania?

Trichotillomania is a hair-pulling disorder that results in noticeable hair loss. Hair is most commonly pulled from the sides and crown of the scalp, usually one strand at a time. The pulled hair may sometimes be discarded, played with, or placed in the mouth and swallowed. In some cases, eyebrow or eyelash pulling may also occur. More rarely, hair may be pulled from the beard, arms, legs, groin, or underarm areas. While it was previously considered an impulse control disorder, it is now classified within the obsessive-compulsive spectrum.

In some cases, the pulled hair is swallowed, a condition known as trichophagia. The ingested hair can accumulate in the stomach and intestines, forming masses called trichobezoars. These masses may cause blockages and sometimes require surgical removal. The intestinal condition caused by trichophagia is known as Rapunzel syndrome, named after the fairy tale character Rapunzel, known for her long hair.

It usually begins in childhood or adolescence (ages 5–17) and may continue into adulthood. The prevalence among adolescents is approximately 1%.

Symptoms:

1. The individual pulls out hair, creating patchy areas of hair loss on the scalp. Eyebrow and eyelash pulling may also accompany this behavior.
2. The person appears to have lost control over the hair-pulling behavior and repeatedly attempts to stop but is unable to do so.
3. There is a sense of psychological tension before pulling, followed by relief during the act, often accompanied by feelings of guilt afterward.
4. The behavior impairs daily functioning. Due to visible hair loss, the person may avoid social situations, neglect responsibilities, and use wigs, hats, or caps to conceal the patches.

There are two subtypes:

1. Automatic type: Hair pulling occurs automatically while the person is engaged in another activity, such as reading, talking on the phone, or watching television—when attention is focused elsewhere.
2. Focused type: Hair pulling occurs as a response to negative emotional states such as stress, tension, or urges to pull, and serves as a way to regulate emotions.

The majority of cases are of the automatic type. However, depending on the situation, both types may occur in the same individual at different times.

Causes:

Childhood psychological trauma plays a role in the development of this disorder. Hair pulling is often used as a coping mechanism to reduce stress, but over time it becomes a source of stress itself. Individuals with trichotillomania tend to have greater difficulty regulating their emotions compared to others. From a psychoanalytic perspective, hair pulling may be seen as a manifestation of unconscious conflicts.

Scientific studies investigating whether there is a structural abnormality in the brain in trichotillomania have not yielded conclusive evidence.

Comorbid Conditions:

The most common psychiatric conditions associated with trichotillomania are anxiety disorders (especially generalized anxiety disorder). In addition, depression, attention deficit hyperactivity disorder (ADHD), eating disorders, and substance use disorders may also co-occur. Body-focused repetitive behaviors such as nail biting and skin picking are also frequently observed.

How is it treated?

1. Psychotherapy: Includes psychoeducation, habit reversal therapy, cognitive behavioral therapy, and psychodynamic therapy. Psychoeducation for both the patient and family is essential—understanding what the disorder is, when it occurs, what triggers it, and what needs to be done in treatment. In preschool children, symptoms tend to be milder and respond better to treatment, often with behavioral therapy alone. In school-age children and adolescents, medication may be added, and combining psychotherapy with medication increases treatment success.
2. Pharmacological treatment: Based on evidence suggesting dysregulation in serotonin and dopamine systems, medications targeting these systems may be used in treatment.

Psychiatrist Dr. Arzu Dalmış