Shawn Faust, DNP, PMHNP-BC
Published on 6/22/2026
What Is Trichotillomania?
Trichotillomania — also known as Hair Pulling Disorder — is a type of obsessive-compulsive related disorder characterized by recurrent, compulsive pulling out of one’s own hair, resulting in noticeable hair loss.¹ It is classified alongside conditions like Excoriation (Skin Picking) Disorder and Obsessive-Compulsive Disorder (OCD).¹
Trichotillomania affects approximately 1–2% of the population.¹˒² It can begin at any age, though onset most commonly occurs in adolescence, with a mean age of onset of approximately 17–18 years.³ Women are more frequently affected than men in clinical samples, though community surveys suggest the gender ratio may be closer to equal.¹˒²˒³ Trichotillomania is associated with significant distress, low self-esteem, and social impairment.⁴ Despite being relatively common, it is underrecognized and undertreated — many people suffer in silence for years before learning that their condition has a name. Effective treatments exist, including behavioral therapy and targeted medications.⁵˒⁶
What Trichotillomania Feels Like
Hair pulling often begins without a clear trigger — a hand drifts to the scalp, eyebrows, or eyelashes, and before the person fully realizes what is happening, they have pulled out several hairs. For some, the pulling is almost entirely automatic — it happens while reading, watching television, or lying in bed, and the person may not become aware of it until they notice a pile of hair or a bald patch.
For others, the pulling is more deliberate. There may be a building sense of tension or an urge that feels impossible to ignore. Pulling provides a brief moment of relief or satisfaction — a sense of release. Some people describe searching for a hair that feels “just right” — a particular texture, thickness, or root sensation. The act of pulling can become almost trance-like, with time passing unnoticed.
The aftermath is where the pain lies. Discovering a new bald patch, seeing hair on the pillow, or realizing that eyebrows or eyelashes are visibly thinned brings a wave of shame, frustration, and self-blame. Many people with Trichotillomania go to great lengths to conceal their hair loss — wearing hats, scarves, wigs, or heavy makeup. They may avoid swimming, windy weather, or any situation where their hair loss might be noticed. The secrecy and shame can be isolating, and many people suffer for years before seeking help.
Signs and Symptoms of Trichotillomania
Trichotillomania involves compulsive hair pulling that results in hair loss.
DSM-5 Diagnostic Criteria
To be diagnosed with Trichotillomania, a person must meet the following criteria:¹
- Recurrent pulling out of one’s own hair, resulting in hair loss
- Repeated attempts to decrease or stop the pulling
- The pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The hair pulling or hair loss is not attributable to another medical condition
- The hair pulling is not better explained by the symptoms of another mental disorder
Most common pulling sites are the scalp, eyebrows, and eyelashes; less common sites include facial, pubic, and body hair. Pulling sites may change over time.¹
Two styles of pulling are recognized:¹˒⁴
- Automatic (unfocused): Pulling occurs outside of awareness, often during sedentary activities like reading, watching TV, or driving
- Focused: Pulling is deliberate, preceded by an urge or tension, and may involve searching for a specific type of hair
Many people experience a mix of both styles.
Additional & Associated Features
Beyond the formal diagnostic criteria, many people with Trichotillomania also experience:¹˒⁴
- Post-pulling rituals — examining the hair, running it across the lips, or ingesting the hair (trichophagia), which in rare cases can lead to gastrointestinal complications (trichobezoar)
- Significant time spent pulling or resisting the urge to pull
- Avoidance of activities that might reveal hair loss (swimming, wind, intimacy)
- Emotional distress including shame, embarrassment, and frustration
- Co-occurring depression, anxiety, Excoriation Disorder, and OCD⁴
How Trichotillomania Affects Daily Life
Trichotillomania can significantly affect emotional well-being, social functioning, and self-image. The visible hair loss — bald patches on the scalp, thinned or absent eyebrows and eyelashes — can be a source of profound embarrassment. Many people organize their daily lives around concealment: choosing hairstyles carefully, applying makeup to fill in brows, wearing hats or scarves, and avoiding situations where hair loss might be noticed.
Social life often narrows. Intimacy can feel threatening because it risks exposing the hair loss. Activities like swimming, sports, or being outdoors in wind are avoided. Some people become increasingly isolated, declining invitations and withdrawing from relationships.
Work and school performance may be affected by the time consumed by pulling episodes and by the emotional toll of managing the condition. The shame and secrecy can contribute to depression and anxiety, creating a cycle that reinforces the pulling behavior.
Answers. Clarity. A Path Forward.
Common Causes and Risk Factors for Trichotillomania
Trichotillomania develops through a combination of genetic, neurobiological, and environmental factors.
Genetics: Trichotillomania runs in families and shares genetic overlap with OCD and other body-focused repetitive behaviors. First-degree relatives of people with Trichotillomania have elevated rates of hair pulling and related conditions.¹˒⁴
Brain biology: Research suggests involvement of brain circuits related to habit formation, impulse control, and reward processing — particularly the cortico-striatal pathways. Dysfunction in the glutamate system has been implicated, which has informed the development of targeted pharmacological treatments.⁵˒⁶
Temperament and emotional regulation: Hair pulling often serves as a way to manage emotional states — reducing tension, alleviating boredom, or providing sensory stimulation. Stress, anxiety, fatigue, and boredom are common triggers for pulling episodes.¹˒⁴
Life experiences: Stressful life events can trigger the onset or worsening of hair pulling. Childhood onset is common, and early-onset cases may have a different course than those beginning in adulthood.¹
Other factors: Trichotillomania frequently co-occurs with Excoriation Disorder, OCD, depression, and anxiety disorders. Approximately 63–82% of individuals with Trichotillomania report co-occurring anxiety, and 34–50% report co-occurring depression.⁴˒⁷
How Trichotillomania Is Diagnosed
Trichotillomania is diagnosed through a clinical interview with a mental health professional — not through lab work or imaging. The clinician will ask about hair pulling behavior, the resulting hair loss, attempts to stop, and the impact on daily functioning and emotional well-being. Because shame is a major barrier to disclosure, direct and nonjudgmental questioning is essential — many people will not volunteer information about hair pulling unless specifically asked.
To meet diagnostic criteria, there must be recurrent hair pulling resulting in hair loss, repeated attempts to decrease or stop, and clinically significant distress or impairment. The pulling must not be attributable to another medical condition or better explained by another mental disorder.¹
The clinician will also consider whether symptoms are better explained by another condition. OCD can involve hair pulling as part of a compulsion driven by an obsession (e.g., pulling hair that feels “contaminated”) — in Trichotillomania, the pulling is driven by urges, tension, or habit rather than obsessive thoughts.¹ Body Dysmorphic Disorder (BDD) may involve hair removal to “fix” a perceived appearance flaw.¹ A dermatological evaluation may be helpful to rule out medical causes of hair loss such as alopecia areata or tinea capitis.
The evaluation is straightforward and conversational — the goal is to understand your experience so the right treatment can begin.
Treatment for Trichotillomania
Trichotillomania responds well to treatment, even in severe cases. The two main evidence-based approaches are behavioral therapy and medication, and they can be used alone or in combination. Most people improve significantly with evidence-based treatment.⁵˒⁶
Behavioral therapy: Habit Reversal Training (HRT) is the most established behavioral treatment for Trichotillomania, with the largest effect sizes of any intervention.⁵˒⁶ HRT involves three core components: awareness training (learning to recognize the urge and situations that trigger pulling), competing response training (substituting a different behavior when the urge arises), and social support. Comprehensive Behavioral Treatment (ComB) expands on HRT by incorporating additional strategies such as stimulus control (modifying the environment to reduce pulling opportunities). Acceptance and Commitment Therapy (ACT)-enhanced HRT has also demonstrated strong efficacy.⁶
Medication: There are no FDA-approved medications specifically for Trichotillomania, but several agents have shown benefit in clinical trials. Glutamatergic medications have the most targeted evidence:
- N-acetylcysteine (NAC) — demonstrated benefit in a randomized controlled trial at doses of 1200 mg twice daily⁵˒⁸
- Memantine (Namenda) — demonstrated significant benefit in a double-blind placebo-controlled trial (10–20 mg/day), with 60.5% of participants rated “much or very much improved” compared to 8.3% on placebo⁹
Serotonergic medications may also be considered:
- Clomipramine (Anafranil) — a tricyclic antidepressant with strong serotonin reuptake inhibitor properties, with preliminary evidence of benefit for pulling behavior⁵
- SSRIs such as sertraline (Zoloft), fluoxetine (Prozac), and escitalopram (Lexapro) — often used to treat co-occurring depression, anxiety, and OCD, though evidence for directly reducing pulling behavior is mixed⁵˒⁶
Combination treatment: Combining medication with behavioral therapy is often more effective than either alone. Medication can reduce urge intensity, making it easier to engage in and benefit from behavioral therapy — while HRT/ComB builds lasting awareness and competing response skills.
Treatment duration: Long-term or maintenance treatment is often necessary, as hair pulling symptoms frequently recur when treatment is discontinued. Ongoing use of behavioral strategies — and in many cases continued medication — helps maintain improvement.
When to Seek Professional Help for Trichotillomania
Consider reaching out to a mental health professional if:
- Hair pulling is causing noticeable hair loss
- Repeated attempts to stop have been unsuccessful
- The behavior is consuming significant time or causing emotional distress
- Social activities, relationships, or work are being affected
- Sleep is being regularly disrupted by pulling urges or distress about the behavior
- There is reliance on alcohol or other substances to manage distress
- Hair is being ingested (trichophagia), which can cause gastrointestinal complications
Seek immediate help if experiencing thoughts of self-harm or suicide. Contact the 988 Suicide and Crisis Lifeline by calling or texting 988, available 24/7.
Conditions That Can Look Similar to Trichotillomania
Obsessive-Compulsive Disorder (OCD): Some people with OCD pull hair as part of a compulsion driven by an obsession (e.g., pulling hair that feels “contaminated”). In Trichotillomania, the pulling is driven by urges, tension, or habit rather than obsessive thoughts.¹
Body Dysmorphic Disorder (BDD): BDD may involve hair removal to “fix” a perceived appearance flaw. In Trichotillomania, the pulling is driven by urges, tension, or sensory gratification rather than appearance concerns.¹
Excoriation (Skin Picking) Disorder: A closely related condition involving compulsive skin picking rather than hair pulling. The two conditions frequently co-occur and share similar treatment approaches.¹
Frequently Asked Questions About Trichotillomania
Is Trichotillomania just a bad habit?
No. Trichotillomania is a recognized psychiatric condition involving disruptions in brain circuits related to impulse control and habit formation. The inability to stop is not a matter of willpower.¹
Will the hair grow back?
In most cases, yes — hair will regrow once pulling stops. However, prolonged pulling over many years can damage hair follicles and lead to permanent hair loss in some areas.
Why don’t SSRIs work as well for Trichotillomania as they do for OCD?
Despite being classified alongside OCD, Trichotillomania appears to involve different neurobiological mechanisms — particularly the glutamate system rather than the serotonin system. This is why glutamatergic medications such as NAC and memantine (Namenda) have shown more promise than SSRIs for directly reducing pulling behavior.⁵˒⁶˒⁹
Can children have Trichotillomania?
Yes. Hair pulling can begin in early childhood (sometimes as young as age 1–2), though childhood-onset cases sometimes resolve spontaneously. When pulling persists or causes distress, evaluation and treatment are recommended.¹
Do I need to tell my mental health professional about my hair pulling?
Yes. Many people feel ashamed and avoid disclosing hair pulling, but mental health professionals are familiar with Trichotillomania and can provide effective, nonjudgmental treatment. Disclosure is the first step toward getting help.
References
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Publishing; 2022.
- Thomson HA, Farhat LC, Olfson E, Levine JLS, Bloch MH. Prevalence and Gender Distribution of Trichotillomania: A Systematic Review and Meta-Analysis. J Psychiatr Res. 2022;153:1-7.
- Grant JE, Dougherty DD, Chamberlain SR. Prevalence, Gender Correlates, and Co-Morbidity of Trichotillomania. Psychiatry Res. 2020;288:112948.
- Grant JE. Obsessive-Compulsive Disorder. N Engl J Med. 2014;371(7):646-653.
- Hoffman J, Williams T, Rothbart R, et al. Pharmacotherapy for Trichotillomania. Cochrane Database Syst Rev. 2021;(9):CD007662.
- Farhat LC, Olfson E, Nasir M, et al. Pharmacological and Behavioral Treatment for Trichotillomania: An Updated Systematic Review With Meta-Analysis. Depress Anxiety. 2020;37(8):715-727.
- Lin A, Farhat LC, Flores JM, et al. Characteristics of Trichotillomania and Excoriation Disorder Across the Lifespan. Psychiatry Res. 2023;322:115121.
- Lee DK, Lipner SR. The Potential of N-Acetylcysteine for Treatment of Trichotillomania, Excoriation Disorder, Onychophagia, and Onychotillomania: An Updated Literature Review. Int J Environ Res Public Health. 2022;19(11):6370.
- Grant JE, Chesivoir E, Valle S, Ehsan D, Chamberlain SR. Double-Blind Placebo-Controlled Study of Memantine in Trichotillomania and Skin-Picking Disorder. Am J Psychiatry. 2023;180(5):348-356.
6/22/2026