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Trichotillomania Content Supplied by NHS Choices
Introduction

Trichotillomania is a condition where a person feels compelled to pull their hair out.

They may pull out the hair on their head or in other places, such as their eyebrows or eyelashes.

Trichotillomania is an impulse-control disorder, a psychological condition where the person is unable to stop themselves carrying out a particular action.

They will experience an intense urge to pull their hair out and growing tension until they do. After pulling out hair, they'll feel a sense of relief. Pulling out hair on the head leaves bald patches.

Trichotillomania can cause negative feelings, such as guilt. The person may also feel embarrassed or ashamed about pulling their hair out, and may try to deny it or cover it up. Sometimes trichotillomania can make the person feel unattractive and can lead to low self-esteem.

Impulse-control disorders are more common among teenagers and young adults. Trichotillomania tends to affect girls more than boys.

Read more about the symptoms of trichotillomania.

What causes trichotillomania

It's not known what causes trichotillomania, but there are several theories.

Some experts think hair pulling is a type of addiction. The more you pull your hair out, the more you want to keep doing it.

Trichotillomania may be a reflection of a mental health problem. Psychological and behavioural theories suggest that hair pulling may be a way of relieving stress or anxiety.

In some cases, trichotillomania may be a form of self-harm, where the person deliberately injures themselves as a way of seeking temporary relief from emotional distress.

Read more about the causes of trichotillomania.

Seeing your GP

See your GP if you're pulling your hair out or if you notice that your child is.

Your GP may examine areas where the hair is missing to check nothing else is causing the hair to come out, such as a skin infection.

In trichotillomania, bald patches are an unusual shape and may affect one side more than the other.

Read more about how trichotillomania is diagnosed.

Treating trichotillomania

Little medical research has been conducted into treatments for trichotillomania.

The most effective treatment is therapy to change the hair-pulling behaviour, combined with a network of emotional support.

Psychotherapy is a type of talking therapy that can be used to treat emotional problems and mental health conditions. It involves discussing emotional issues with a trained therapist.

In particular, cognitive behavioural therapy (CBT) is a type of psychotherapy that may be recommended. It helps you manage your problems by changing how you think and act.

CBT often involves behavioural therapy, also known as habit-reversal therapy, which aims to help you change the way you behave - for example, by reducing your hair-pulling behaviour.

Read more about treating trichotillomania.

Complications of trichotillomania

Trichotillomania can have a significant impact on the person's quality of life, and can also cause medical problems.

It can often cause feelings of guilt, shame, isolation or embarrassment, which can affect their social life and have an adverse impact on their performance at school or work.

Read more about the complications of trichotillomania.

Support

If you have trichotillomania, it's important you receive emotional help and support. This can be from family, friends or self-help groups.

Organisations such as Trichotillomania Support are good places to start if you're looking for support.

Symptoms of trichotillomania

Most people with trichotillomania pull out hair from their scalp, but some pull out hair from other areas.

These include:

  • eyebrows
  • eyelashes
  • genital area
  • underarm area
  • arms
  • legs
  • chest or tummy
  • face, such as a beard or moustache

People with trichotillomania feel an intense urge to pull their hair out and growing tension until they do. After pulling their hair out, they feel a sense of relief.

A person may sometimes pull their hair out in response to a stressful situation, or it may be done without really thinking about it.

Psychological symptoms

Trichotillomania can cause negative feelings, such as guilt. You may feel embarrassed or ashamed about pulling your hair out, and may try to deny it or cover it up. It can also make you feel unattractive and may lead to low self-esteem.

Trichotillomania may be a reflection of emotional or psychological distress, although the person with the condition may not always be aware of this.

For example, hair pulling may be a way of dealing with feelings of stress or self-loathing. In this way, it may be seen as a type of self-harm, where a person injures themself on purpose as a way of coping with emotional distress or anxiety.

Swallowing hair

Some people with trichotillomania chew and swallow the hair they pull out. This is known as trichophagia. Eating hair causes hair balls called trichobezoars to form in the stomach or bowel.

The hair balls can cause other symptoms, including:

  • feeling sick
  • vomiting
  • stomach pain
  • bleeding in your stomach, which can cause anaemia

Read more about the complications of trichotillomania.

Related conditions

Sometimes people with trichotillomania will have other related mental disorders, such as:

If the hair pulling takes place in response to a delusion (when you believe things that aren't true) or a hallucination (when you see or hear things that aren't there), you may have a different condition and should seek advice immediately from your GP.

Trichotillomania can be linked to other disorders, such as obsessive compulsive disorder (OCD). Visit your GP if you have repeated thoughts and urges you can't get out of your mind, or behaviours you have to repeat in a compulsive way.

Causes of trichotillomania

There's no single cause of trichotillomania (hair pulling), but there are a number of theories about why it may occur.

Mental health problem

Trichotillomania may be a reflection of a mental health problem. Psychological and behavioural theories suggest a person may pull their hair out as a way of relieving stress or anxiety.

As trichotillomania involves compulsive behaviour, some experts think it's closely related to obsessive compulsive disorder (OCD).

OCD tends to run in families. It's thought to be caused by both biological and environmental factors, which may lead to a chemical imbalance in the brain.

Neurotransmitters are chemicals that send messages from your brain to your nervous system.

If something goes wrong with the way neurotransmitters work, it can cause problems, such as compulsive and repetitive behaviours.

Self-harm

Trichotillomania may be a type of self-harm, where a person deliberately injures themselves to seek temporary relief from emotional distress.

The pain associated with self-harm makes the brain release endorphins (natural painkilling chemicals), which cause a short-lived sense of wellbeing.

Self-harm is often accompanied by feelings such as:

  • guilt
  • self-loathing
  • low self-esteem
  • low mood
  • anxiety

As well as pulling your hair out, you may also self-harm in other ways - for example, by cutting yourself.

Someone may start self-harming as a way to cope with a traumatic experience, such as sexual, physical or emotional abuse.

If you've been sexually abused, trichotillomania may be seen as a way of making yourself less attractive or less feminine (if you're female).

Making yourself less attractive confirms your negative view of yourself, and the cycle of self-loathing and self-harm continues.

Other theories

Some other theories about what causes trichotillomania include:

  • abnormalities in the brain - brain scans have revealed brain abnormalities in some people with trichotillomania
  • genetics - an alteration in a particular gene may lead to trichotillomania in some people, and a tendency to pull hair out may be inherited
  • a lack of serotonin (the "feel-good" chemical in the brain) - treatment with a selective serotonin reuptake inhibitor (SSRI), which boosts serotonin levels, has been effective in some people with trichotillomania
  • changes in hormone levels - trichotillomania is more common around ages when hormone levels frequently change, such as during puberty
Diagnosing trichotillomania

Visit your GP if you're pulling your hair out, or if you notice that your child is.

Your GP may ask about:

  • your symptoms
  • feelings you have before and after pulling your hair out
  • whether you've noticed anything that triggers your hair pulling

Your GP may also examine the areas where you've pulled your hair out. They'll need to check nothing else is causing your hair to come out, such as a skin infection.

In trichotillomania, the bald patches are an unusual shape and may affect one side more than the other.

Classifying trichotillomania

Trichotillomania is defined as a type of mental and behavioural disorder by both the International Classification of Diseases system and the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system.

Your GP may use some of the criteria below to diagnose your condition:

  • You repeatedly pull your hair out, causing noticeable hair loss.
  • You feel increasing tension before you pull your hair out.
  • You feel relief or pleasure when you've pulled your hair out.
  • There's no underlying medical condition causing you to pull your hair out, such as a skin condition.
  • Pulling your hair out causes you distress or affects your everyday life - for example, your relationships or work.

A person may sometimes be diagnosed with trichotillomania even if they don't meet all of the above criteria.

Treating trichotillomania

Therapy to change your hair-pulling behaviour is the most effective method of treating trichotillomania.

This should be combined with a network of emotional support.

Medications used to treat other psychological health conditions, such as depression and obsessive compulsive disorder (OCD), are sometimes also used in cases of trichotillomaina.

However, there's no evidence to suggest that any type of medication is effective in treating trichotillomania.

Psychotherapy

Psychotherapy is a talking therapy often used to treat emotional problems and mental health conditions. You or your child can discuss emotional issues with a specially trained therapist.

Cognitive behavioural therapy (CBT) is a type of psychotherapy that may be recommended. It can help you address your thoughts about yourself, your relationships with others, and how you relate to the world around you.

CBT may also involve behavioural therapy, which aims to help you change the way you behave - for example, reducing your hair-pulling behaviour. It's also known as habit-reversal therapy, and could include:

  • educating you about your condition and how it's treated
  • making you more aware of when and why you pull your hair out - for example, you may pull your hair out when you're stressed
  • learning a new response to carry out when you feel the urge to pull your hair out - for example, clenching your hand into a fist
  • creating barriers that prevent you from pulling your hair out - for example, wearing a hat if you usually pull hair from your scalp
  • involving your parents or partner in your treatment - for example, they could praise and encourage you when you don't pull your hair out

Emotional support

If you have trichotillomania, it's likely you're experiencing emotional distress, such as feelings of self-loathing and guilt.

It's important you receive emotional support to help you cope with these feelings. This may be from family, friends or a self-help group.

In the UK, there are a number of regional trichotillomania support groups you can contact.

Family therapy

Trichotillomania can be particularly distressing for families of children and young adults who pull their hair out.

Pulling your hair out may be a way of communicating distress to your family, but they may feel powerless to help you. In this situation, family therapy may be suggested.

A therapist will meet the whole family to explore their views and relationships, and understand any problems the family may be having. It helps family members communicate better with each other.

Family therapy can be particularly useful when a child or young person has a serious problem, such as trichotillomania, that's affecting the rest of the family.

The family can work together to address the issue that's causing you to pull your hair out, and seek support for any distress caused to other family members.

Medication

Several medications have been used to treat trichotillomania, although there haven't been many large-scale clinical trials on them.

If the healthcare professional treating you recommends a particular medication, they should discuss the possible risks and benefits with you, including any side effects.

Selective serotonin reuptake inhibitors (SSRIs)

In the past, selective serotonin reuptake inhibitors (SSRIs) have been used to treat trichotillomania, although there's some evidence to suggest they're not effective. SSRIs are often used to treat depression and anxiety disorders.

For children under the age of 18, the recommended SSRIs are sertraline and fluoxetine. These should only be used under the supervision of a mental health specialist, such as a specialist child and adolescent psychiatrist. This is a qualified medical doctor who's been trained in treating childhood mental health conditions.

Clomipramine

Clomipramine is another medicine that may be recommended for trichotillomania. It's often used to treat depression and obsessional states.

A child under 18 years of age being treated with clomipramine should be supervised by a specialist child and adolescent psychiatrist.

Clomipramine has been tested as a treatment for trichotillomania and has been found to be effective at reducing hair-pulling behaviours.

Other medicines

Small trials have been carried out for other medicines, but not enough is known about their effectiveness. In particular, there's a lack of research into medicines used to treat children with trichotillomania.

Wigs and appearance tips

If you're concerned about the bald patches on your head, you can buy wigs made from real hair or man-made fibres. Wigs made from real hair look more natural, but are more expensive and harder to look after.

Wigs are available from the NHS, but you'll usually have to pay for them unless you qualify for help with charges.

If you've pulled out your eyebrow hair, it may be possible to use an eyebrow pencil or have tattoos. You can use false eyelashes if you've pulled out your eyelashes, or you can use make-up to add more definition to your eyes.

Alopecia UK has some useful information about wigs, plus a section about appearance tips that you may also find helpful.

Complications of trichotillomania

Trichotillomania (hair pulling) can have a significant impact on your quality of life. It can also cause further medical problems.

Quality of life

Trichotillomania can be distressing for those with the condition because it can cause feelings of:

  • guilt
  • shame
  • isolation (feeling alone)
  • embarrassment

This can affect your social life - for example, you may have fewer friends or you may find intimate relationships difficult.

Trichotillomania may also affect how well you perform at school or work. For example, you may end up missing school because you're too embarrassed to go in, or you may find it difficult to concentrate at work, which could affect your career progression.

Some people also feel angry or frustrated about being unable to control their urges, and may use alcohol, smoking or drugs as a way of coping.

Alopecia

Alopecia is loss of hair. People with trichotillomania end up losing their hair because they pull it out.

This can cause bald patches or, in some cases, total baldness, which can affect your confidence and self-esteem.

You may avoid certain activities where the bald patches could be noticed, such as going to the hairdresser or going swimming.

Trichobezoars

Trichobezoars are hair balls that can form in your stomach or bowel if you eat the hair you pull out. The hair balls can cause serious symptoms such as:

  • blocking, or making a hole in, your digestive system
  • acute pancreatitis - painful inflammation of your pancreas
  • obstructive jaundice - where the hair ball blocks tubes that remove bile (a fluid that helps digest food), causing a build-up of a yellow substance called bilirubin, resulting in a yellowing of the skin and whites of the eyes

In severe cases, stomach or intestinal surgery may be needed to remove the hair ball.

 
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