What Is Trichotillomania?

Trichotillomania (TTM) is characterized by the repetitive action of pulling out one’s own hair from various locations on the body. Common hair pulling sites include the scalp, eyelashes, eyebrows and pubic area. Some individuals will report a strong urge to pull hair and feel a sense of relief or gratification after the hair is pulled.

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Who Suffers from Trichotillomania?

TTM has been found to occur across all age groups with an average age of onset typically between nine and thirteen years old. The lifetime prevalence rate is between 0.6% and 3.4% and more frequently occurs in females than males. Adults with TTM may also experience anxiety, obsessive – compulsive disorder, post traumatic stress disorder, depression, and eating disorders. It is not entirely understood how TTM develops, but it is believed both biological and environmental elements contribute to this condition.

What Are Causes of Trichotillomania?

Hair pulling can generally be characterized in two ways.  First, hair pulling can be described as a focused behavior in response to an internal or external event. Some individuals may pull in response to emotions such as anxiety, sadness, shame, or anger. Second, hair pulling can occur automatically.  Some individuals may pull and not even notice it happening until midway through or long after the episode of pulling has stopped. Boredom or having one’s hand close to hair (e.g., brushing hair, applying make-up in a mirror, reading, or lying in bed) can initiate a pulling episode.

What Are the Diagnostic Criteria of Trichotillomania?

TTM is identified as an impulse control disorder; though experts believe it ought to be considered on the spectrum of obsessive-compulsive conditions.  The current diagnostic criteria of TTM include the following five areas:

  • Recurrent pulling out of one’s hair resulting in noticeable hair loss.
  • Increased sense of tension immediately before pulling out the hair or when attempting to resist the behavior.
  • Pleasure, gratification, or relief when pulling out the hair.
  • Disturbance not better accounted for by another mental disorder and not due to a general medical condition (e.g., a dermatological condition).
  • Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
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What are Common Symptoms and Medical Issues of Trichotillomania?

Common symptoms of TTM include:

  • Bald spots on scalp or other areas of body
  • Sparse eyebrows or eyelashes
  • Playing with pulled hair by rolling it between fingers or brushing the hair follicle across lips or face region
  • Chewing or swallowing pulled hair
  • Hair pulling occurring in private
  • Wearing wigs or hats, penciling in eyebrows, and/or wearing false lashes to cover up bald areas
  • Low self-esteem, shame, embarrassment, anxiety, or depression
  • Limited social interaction or fear of intimacy

Some possible medical issues related to TTM include:

  • Carpel tunnel syndrome
  • Permanent hair loss
  • Infections
  • Trichophagia (eating one’s own hair)
  • Trichobezoar (intestinal hair ball)

Additional CBT Approaches

Some preliminary research suggests that augmenting treatment with additional CBT approaches may be beneficial.  These additional approaches include:

Acceptance and Commitment Therapy (ACT).  This treatment includes HRT and focuses on the individual’s commitment to treatment, personal values, learning to experience negative emotions, accepting urges, and strengthening their mindfulness capabilities.

Dialectical Behavior Therapy (DBT).  Some research findings suggest that individuals benefit from learning how to tolerate uncomfortable emotions and urges as they relate to pulling. This aspect of DBT tends to be most beneficial when introduced during the maintenance phase of treatment.

How Do We Treat Trichotillomania?

Cognitive behavior therapy (CBT) is problem-focused, goal-oriented and proactive treatment approach, with particular emphasis on the present and future, as opposed to the past (although learned behaviors from past experiences may also be relevant). CBT is a form of psychotherapy based on the premise that thoughts, emotions and behaviors are interconnected. Treatment emphasizes identifying, evaluating and modifying dysfunctional thinking patterns and problematic behaviors to improve overall quality of life. An advantage of CBT is that it teaches strategies to effectively cope even as difficult situations change and evolve. Collaboration and psychoeducation are key elements in guiding individuals to improved emotional well-being. CBT for TTM also includes the following:

Habit Reversal Training (HRT).  HRT is a four phase, multi-component treatment for habit behaviors and is considered the gold-standard treatment. While varying components of this treatment can be helpful to the individual, the following three components are considered the most critical:

  • Awareness Training.  Helps the individual develop full awareness of circumstances surrounding urges and actions of pulling hair.
  • Competing Response Training.  Individuals learn alternative responses for the pulling behavior that is incompatible with the undesired behavior.
  • Social Support.  Involving supportive family members and friends into the treatment process by allowing them to provide positive reinforcement (e.g., encouragement and/or tangible rewards) and gentle reminders of optimal times to use strategies to cope effectively.

Comprehensive Behavioral Treatment (ComB).  ComB combines HRT and other cognitive behavioral interventions. This therapeutic approach considers the nervous system’s need for sensory input while eliminating the hair pulling behavior.

What to Expect?

During your initial appointment, a comprehensive assessment and functional behavior analysis will be conducted. It is not uncommon for the assessment process to span a few sessions and it is an important phase of treatment to ensure your individual needs are addressed throughout the course of treatment. Our skilled psychologists will work closely with you to help you better understand TTM and learn various effective management techniques.

For additional questions or to schedule a consultation, please call 212-308-2440 or email

To learn more about trichotillomania, read A Comprehensive Model for Behavioral Treatment of Trichotillomania by Charles S. Mansueto, Ruth Goldfinger Golomb, Amanda McCombs Thomas and Ruth M. Townsley Stemberger.
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Trichotillomania is a disorder characterized by repetitive pulling out of one’s hair. In this paper, we explore the essential elements for effective treatment and propose a comprehensive model for behavioral intervention. Individualized, focused treatment proceeds through four phases: First, a functional analysis is conducted that garners information about critical antecedents, behaviors, and consequences of hair pulling. Next, this information is organized into cognitive, affective, motoric, sensory, and environmental modalities. Then, specific treatment strategies are selected and implemented to target critical maintaining factors through relevant modalities. Finally, evaluation and modifications are made as necessary. The potential advantages of this approach are discussed, as are its limitations.

Recommended Readings:

Anxiety Free: Unravel Your Fears Before They Unravel You by Robert L. Leahy
The Worry Cure: Seven Steps to Stop Worry from Stopping You by Robert L. Leahy

Clinicians may find the following books on cognitive behavioral therapy to be helpful in treating anxiety:

Leahy, R. L., Holland, S. J., & McGinn, L. K. – Treatment Plans and Interventions  for Depression and Anxiety Disorders (2nd ed.)
Leahy, R. L. – Cognitive Therapy Techniques
Sookman, D. and Leahy, R. L. – Treatment Resistant Anxiety Disorders: Resolving Impasses to Symptom Remission

Cognitive Therapy
Substance Abuse Miniseries by
Dr. Graham Reynolds