Trichotillomania (Hair Pulling Disorder): Causes, Symptoms, Treatment

Trichotillomania is psychiatrically classified as subtype of obsessive compulsive disorder characterized chiefly by the urge to pull out one’s own hair.  The condition, also known as “hair pulling disorder,” affects upwards of 2.5 million individuals in the United States at some point during their lives.  Onset of trichotillomania occurs most frequently between 9 and 13 years of age, affecting females to a significantly greater extent than males.

While it is most common for individuals with trichotillomania to pull or pluck hair from atop their scalps, pulling of eyelashes and eyebrows is also typical.  In some cases, those diagnosed with trichotillomania may go as far as to pull hair from arms, legs, and/or genital regions.  The inability to resist the compulsive pulling of hair follicles generally results in premature balding and compromised hair regrowth – unsightly features in a world highly-driven by external appearance.

The embarrassment associated with bald spots and/or disheveled scalp hair among those with trichotillomania may lead to the loss of friendships and/or potential mates.  It may also contribute heavily to feelings of depression, anxiety, and low self-esteem, stemming from compromised self-image.  In addition to compromised self-image, individuals with this condition may become so preoccupied with the pulling of hair, that it interferes with their ability to engage in normative societal functions such as: educational, occupational, or social pursuits.

Trichotillomania (“Hair Pulling Disorder”) Diagnosis

The DSM-IV (Diagnostic Statistical Manual of Mental Disorders) included trichotillomania classified as an “impulse control disorder” characterized by the inability to resist urges to pull hair.  Within the DSM-5, experts shifted its classification from an impulse control disorder to an obsessive compulsive disorder.  Furthermore, some of its specific diagnostic criteria were changed to more accurately diagnose the condition.

Criterion A: Recurrent pulling out of one’s hair, resulting in hair loss.

Someone who frequently pulls out their hair as a result of trichotillomania will generally end up losing some hair.  Whether the hair loss is “noticeable” is often a matter of trichotillomania severity, as well as how well the individual covers it up.  It is up to medical professionals to pinpoint the specific region in which the hair is lost; scalp is most common.

Some individuals with this condition may deliberately pull hair from a variety of sites – rather than a localized area.  This may make it more difficult to pinpoint bald spots or hair loss.  Therefore, it is necessary to realize that although hair will be lost, it may be difficult to notice.

Criterion B: Repeated attempts to decrease or stop hair pulling.

Even though individuals with trichotillomania want to stop pulling out their hair, they cannot resist the compulsive urge.  The individual may wear hats or wigs in effort to not only cover up existing hair loss, but to prevent the pulling of their own hair.  Despite these attempts to break the cycle of hair pulling or decrease its frequency, those with hair pulling disorders still relapse.

Criterion C: Hair pulling causes clinically significant distress or impairment in social, occupational, or important areas of functioning.

The pulling of hair may become so extreme, that it causes emotional distress for the person with trichotillomania.  Social distress may stem from the fact that friends are treating the individual differently upon noticing the bald spots.  Occupational distress may result from the fact that the person is so preoccupied with hair pulling that productivity suffers.

Criterion D: Hair pulling or hair loss cannot be attributed to another medical issue (e.g. dermatological conditions).

Individuals with medical conditions and/or taking certain medications may experience hair loss as a result.  Diagnosis of trichotillomania will necessitate the ruling out of medical conditions and medicines as the principal cause of hair loss.  For example, someone taking levothyroxine, a synthetic hormone replacement used to treat hypothyroidism – may experience hair loss during the first few months of treatment.

That said, in extremely rare cases, it could be that a person with legitimate trichotillomania is losing hair from a comorbid medical condition; in this case, both are contributing.  Examples of some conditions that may contribute to hair loss include: alopecia, hypothyroidism, iron deficiency, etc.

Criterion E: Hair pulling is not better explained by as a symptom of another medical disorder (e.g. body dysmorphic disorder).

If a person is diagnosed with body dysmorphic disorder, he/she may pull hair from specific regions in attempt to improve his/her physical appearance.  A skilled psychiatrist and/or psychologist should be able to distinguish trichotillomania from conditions such as body dysmorphic disorder that could (theoretically) involve some hair pulling.

More specifics on the diagnosis…

In the DSM-IV, trichotillomania incorporated criteria stating that a person must: “feel tension before the pulling” and “experience relief or gratification after pulling.”  The criteria have since been eliminated due to the fact that not all individuals feel tension prior to their pulling and/or report satisfaction/pleasure after the pulling.  In some cases, even with the above criteria, it is difficult to identify a person with trichotillomania.

Many individuals with the condition wear wigs and/or hats to cover up their hair loss or bald spots.  Additionally, patients with the condition may not seek help and could be ashamed of their hair pulling, making it difficult for them to admit that they suffer from trichotillomania.  Diagnosing the condition is generally easier if the patient reports directly pulling his/her hair.

Unfortunately, a subset of patients with the condition may deny their hair pulling.  Denial of hair pulling leads professionals to issue testing for other conditions such as low thyroid, low iron, etc.  Assuming all medical testing comes back negative, a biopsy may be necessary to confirm whether an individual legitimately has trichotillomania.

Biopsies reveal traumatized hair follicles, fragmented hair in the skin, empty follicles, and other hair deformities.  In the growth cycle of hair follicles, those with trichotillomania tend to exhibit many hairs in the catagen phase – signifying that a follicle is just 1 to 2 weeks old.  Those without trichotillomania tend to have hairs in the anagen phase – signifying the follicle is 2 to 6 years old.

Besides a biopsy, an alternative testing modality for hair pulling disorder involves shaving a subsection of a person’s scalp.  Thereafter, regrowth patterns of hair follicles are observed, and if abnormalities appear, it increases the likelihood that an individual has trichotillomania.  Usually a coupling of DSM-5 diagnostic criteria with a biopsy or hair analysis will yield the most accurate diagnosis for those unwilling to admit hair pulling.

Moreover, it is necessary to consider that a subset of those afflicted with trichotillomania may also engage in compulsive pulling of: carpet fibers, furs from toys, fur from pets, and/or hairs from family/friends.  While it isn’t as common to find individuals that pull hair from others, it has been documented in clinical reports that parents with trichotillomania pull the hair of their family members to satisfy their compulsive urges.  For this reason, medical professionals should beware of the fact that deleterious implications of trichotillomania may extend to unconsenting children.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/19270849

2 Types of Trichotillomania

Literature implies that there are two primary types of trichotillomania including: “automatic” and “focused.”  Distinguishing these two subtypes is relatively easy due to the fact that the automatic hair pullers are generally unaware of their hair pulling, while the focused hair pullers are extremely aware of their hair pulling – often to the extent that it is premeditated.  The importance of identifying a particular trichotillomania subtype may be significant in regards to predicting optimal therapeutic interventions.

Automatic:  The automatic subtype of trichotillomania essentially occurs on autopilot without conscious awareness of the pulling.  Those with the automatic subtype of trichotillomania are more likely to be children who may not even recall the fact that they pulled out a section of their scalp hairs.  They often end up pulling hairs as a result of an unconscious, reflexive habit.

When questioned about the possibility of hair pulling, individuals classified as “automatic” hair pullers may be unable to recollect hair pulling.  It’s almost as if they’re in a trance-like state with altered neuroelectrical (brain wave) activity (e.g. excessive theta waves and deficient beta waves).  An estimated 75% of individuals with trichotillomania are “automatic” pullers.

Focused: The “focused” subtype of trichotillomania involves individuals are consciously aware of the fact that they’re pulling their hair.  Those with the focused subtype may mentally map out the hairs that they’re going to pull prior to doing so.  In other words, the hair pulling of those with the focused subtype is often premeditated and sometimes carefully planned.

Some of the individuals with the focused subtype may pull hair in a ritualistic manner and/or derive some sort of pleasure from the act of hair pulling.  These rituals may incorporate the pulling of specific hairs before others (e.g. scalp before eyebrows), pulling hair at a specific time of day, and/or pulling hair until they reach a certain threshold of tactile feedback/satisfaction.

What causes trichotillomania (hair pulling disorder)?

The etiology of trichotillomania isn’t fully elucidated nor understood by researchers.  Rather than assuming there’s one definitive cause, it should be speculated that a combination of factors could lead to the onset of trichotillomania.  Furthermore, the specific causative factor(s) for trichotillomania in one person may differ from those in another.

Hypothetically, in one individual, trichotillomania may occur after a childhood trauma.  In another, it may emerge solely as a result of neurological changes associated with a neurodegenerative disease (e.g. vascular dementia).  Yet for third individual, a complex interplay between the environment and gene expression may explain its etiology.

Genetic variants: The genes you inherit may increase or decrease your propensity to develop trichotillomania.  A study published in 2006 noted that trichotillomania may be caused by dysfunctional serotonergic (5-HT) and dopaminergic (DA) pathways.  Since these pathways are mediated by genes, researchers collected genetic data from 39 individuals with trichotillomania and compared genetic variation to 250 individuals with OCD and 152 healthy controls.

Researchers discovered notable variations in 5-HT2A T102C variant gene among those with trichotillomania compared to healthy controls, and a slight (albeit non-significant) difference between those with trichotillomania and OCD.  Specifically, it appears as though the T102T-genotype is indicative of increased susceptibility to trichotillomania.  Although further research is warranted to confirm preliminary genetic correlates to trichotillomania, it is likely that 5-HT2A variants play a role in modulation of impulses.

Other studies have documented mutations in the SLITRK1 gene among patients with trichotillomania; these mutations appear to be absent among healthy controls.  The SLITRK1 gene modulates cortex development and neuronal growth, but mutations of the gene can cause neuropsychiatric conditions such as Tourette’s syndrome.  It is plausible that SLITRK1 mutations may lead to trichotillomania.

Animal research has suggested that mutation of HOXB8, a gene implicated in neural development, can lead to excessive grooming.  This excessive grooming often leads mice to pull hair – perhaps an animal model of trichotillomania.  While humans have this gene, research hasn’t yet unveiled whether mutations may cause trichotillomania.

The occurrence of trichotillomania is unlikely to be attributed to a single genetic variant.  There may be multiple genes that play a role in its development.  While genes may not cause the development of trichotillomania in every case, they are a likely influential in many cases – as evidenced by increased susceptibility among first-degree relatives to those with the condition.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/16910371
• Source: http://www.ncbi.nlm.nih.gov/pubmed/17003809
• Source: http://www.ncbi.nlm.nih.gov/pubmed/11779477

Neural abnormalities: Those with trichotillomania tend to exhibit abnormal neural activation compared to those without the condition.  Although many individuals with trichotillomania may present similar symptoms to those with obsessive compulsive disorders (OCD), there appear to be notable distinctions between the two conditions based on neural activation.  Evidence indicates that among individuals with trichotillomania, neural abnormalities are exhibited predominantly within the basal ganglia (specifically the left putamen), frontal lobe, and cerebellum.

This differs from OCD which is associated with abnormal functionality in the anterior cingulate cortex, caudate nucleus, and orbitofrontal cortex.  Among those with trichotillomania, there also appear to be differences in regional metabolism, white matter, and grey matter.  That said, it is unclear as to whether these neural abnormalities are a direct cause of the condition or a byproduct of its genetic underpinnings.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/17403968/
• Source: http://www.ncbi.nlm.nih.gov/pubmed/9255863/

Left putamen: The putamen is a round structure within the basal ganglia that is connected to the globus pallidus and substantia nigra.  It serves (primarily) to modulate movement and affects our ability to learn with the neurotransmission of GABA, acetylcholine, and encephalin.  Individuals with trichotillomania appear to have lower volumes of their left putamen, suggestive of dysfunctional fronto-striatal circuitry.

A study published in 1997 collected neuroimaging data via fMRI scans from 10 females with trichotillomania and compared those scans to 10 healthy individuals.  There was significant evidence indicating that (on average), the left putamen was significantly smaller than normal controls.  Another study published in 2002 noted deficits left putamen volume, as well as fronto-cortical / fronto-striatal circuitry.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/9193740
• Source: http://www.ncbi.nlm.nih.gov/pubmed/12369261

Cerebellum: The cerebellum is understood to influence a person’s motor control, specifically coordination, timing, and precision of movement.  To a lesser extent, it contributes to attentional/language processes and fear/pleasure modulation.  Some research has documented abnormalities in the cerebellum among individuals with trichotillomania.

A study published in 2007 attempted to elucidate the neurobiological correlates of trichotillomania and noted abnormal volumes within the cerebellum.  Researchers in this study collected MRI scans to determine neural activation in 14 women diagnosed with trichotillomania and compared the activation to 12 controls.  Thereafter, they utilized parcellation techniques to pinpoint subregional volumes within the cerebellum.

Results documented significant differences in cerebellum volume between the two groups.  Those with trichotillomania exhibited reduced volumes within the cerebellum compared to the controls.  Interestingly, the subregion of the left primary sensorimotor cluster was most associated with symptomatic severity of hair pulling.

The greater the severity of hair pulling, the more substantial the volume reduction in the left primary sensorimotor cluster.  Other information indicates that, in addition to reduced volume, there appears to be faster metabolism in the cerebellum among individuals with trichotillomania.  Based on this information, it is logical to speculate that dysfunction of the cerebellum and interconnected areas may directly cause the condition and affect its severity.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/16945351

Grey matter: A study published in 1991 assessed cerebral glucose metabolism among 10 women diagnosed with trichotillomania and compared it to 20 healthy women without TTM.  To assess the cerebral glucose metabolism, a tracer of 18-F-fluorodeoxyglucose was tracked via PET scans.  Results indicated that women with trichotillomania exhibited significantly increased global grey matter compared to the controls.

What’s more, treatment with the antidepressant clomipramine increased metabolism in the anterior cingulate and orbitofrontal cortex.  This information indicates that trichotillomania may be caused by a combination of increased global grey matter accompanied by metabolic differences in various regions such as the anterior cingulate and orbitofrontal cortex.

Research published in 2008 indicated that patients with trichotillomania exhibit increased grey matter densities within the left striatum, left amygdala-hippocampal areas, as well as bilateral cortical regions such as the: cingulate, frontal, and supplementary motor regions.  This shows distinct, localized grey matter abnormalities among those with trichotillomania compared to those without the condition.  Though grey matter may not play a standalone role in its pathophysiology, most individuals with the disorder have too much grey matter.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/1929773
• Source: http://www.ncbi.nlm.nih.gov/pubmed/18757980

White matter: White matter within the brain consists mostly of glial neurons and myelinated axons that signal from one region to another.  It plays an important role in modulating learning and other important neural functions.  A study published in 2010 documented white matter abnormalities among 18 individuals with trichotillomania compared to a group of 19 controls.

Researchers were able to pinpoint reductions in fractional anisotropy in various regions such as the anterior cingulate, presupplementary motor area, and temporal cortices – among those with trichotillomania.  They concluded that disorganized white matter tracts associated with the modulation (formation/suppression) of motor habits likely plays a role in the pathophysiology of trichotillomania.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/20819990

Parahippocampal gyrus: Psychiatric diagnostic criteria considers hair pulling disorder (trichotillomania) and skin picking disorder to be relatively similar conditions.  That said, few studies have been conducted comparing the neural correlates of the two conditions to determine differences.  A study published in 2015 examined the neural activation of 17 individuals with trichotillomania, 17 individuals with skin picking disorder, and 15 controls.

MRI imaging was collected from each of the participants and neural differences were documented.  Among those with trichotillomania, a region known as the right parahippocampal gyrus was significantly thinner than those with skin picking disorder and the control group.  The parahippocampal gyrus is understood to be a grey matter cortical region that encompasses the hippocampus and signals within the limbic system.

It is perhaps most involved in processes such as encoding of memories and their retrieval.  Researchers believe that a thin parahippocampal gyrus among those with trichotillomania may be cause dissociative symptoms that are often reported among those with the condition.  In other words, among individuals who are unable to recollect hair pulling or are “automatic” pullers, perhaps the lack of awareness is related to suboptimal activity within or thickness of this region.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/25435313

Neural underpinnings of dementia-induced trichotillomania

Perhaps we can learn more about the neural abnormalities associated with trichotillomania from a case report.  This particular case report involved a 79-year-old male of Indian descent who exhibited progressive neurocognitive decline along with behavioral changes that began 3 years prior to the neurocognitive dysfunction.  He was referred by his family doctor to the psychiatry department of a private clinic.

The psychiatry department used MRI neuroimaging to assess his brain function and discovered infarcts (dead tissue) in subcortical and cortical regions.  As a result, the patient was diagnosed with vascular dementia and administered pharmaceuticals along with multivitamins.  After 3 weeks of treatment with Donepezil (10 mg/day) and multivitamins, the man began pulling out his scalp hair without explanation.

Unlike many cases of trichotillomania which involve feelings of tension (leading up to the pulling) and satisfaction or pleasure thereafter, he denied these feelings.  The patient experienced no psychotic symptoms (e.g. hallucinations or delusions) and had no personal nor familial history of neuropsychiatric disorders such as OCD.  Psychiatrists diagnosed him with vascular dementia-induced trichotillomania.

The patient was given several SSRIs including: Lexapro, Luvox, Prozac, and Zoloft without relief.  He was even administered Remeron, an atypical antidepressant, and attained no symptomatic benefit in regards to the hair pulling.  Neuropsychiatric examinations documented substantial memory deficits, executive impairment, and motor dysfunction.

Thereafter, the psychiatric unit evaluated the metabolic activity in his brain for treatable causes of dementia; no abnormalities were discovered.  This patient clearly fit diagnostic criteria for dementia and trichotillomania, likely caused by the neurodegeneration.  Those reporting this case suspected that structural grey matter changes, particularly those involved in habit learning, cognition, and emotion – played a role in his development of trichotillomania.

It is also important to note that this individual had infarcts in his white matter, possibly also contributing to his trichotillomania.  Furthermore, this patient fit the “automatic” diagnostic subtype of trichotillomania, characterized by a lack of conscious awareness of hair pulling.  It could be speculated that his simultaneous frontal lobe dysfunction may have lead to the unconscious, automated pulling of scalp hairs and/or the inability to control hair pulling.

Although it is difficult to decipher whether the neural underpinnings of dementia-induced trichotillomania differ from those with standalone trichotillomania, there is likely some overlap.  This case supports preliminary findings that white matter integrity is compromised, and grey matter is abnormally high in cases of trichotillomania.  Researchers may want to further investigate the role of the frontal lobe function among those with the condition.

• Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3746227/

Environmental factors: A person’s environment may affect whether they’re likely to develop trichotillomania.  An individual raised in an environment with low stress and optimal parenting may never develop the condition – even with an underlying genetic susceptibility.  Conversely, someone in a high-stress environment with suboptimal parenting may develop trichotillomania, possibly without a genetic predisposition.

It is well-understood that environmental conditions can affect gene expression via epigenetics.  Since stress and certain parenting-styles may increase likelihood of trichotillomania, environmental influences should not be dismissed.  Particularly, many view trichotillomania as a way in which individuals learn to cope with chronic stress.

Parenting: In the early 1980s, psychologists speculated that trichotillomania may emerge as a result of an abnormal parent-child relationship.  Researchers hypothesized that the mother of the individual diagnosed with trichotillomania facilitates development of the condition by extending the child’s dependence upon her to satisfy his/her needs beyond childhood.  In other words, the mother continues to satisfy the child’s needs into adolescence and/or adulthood.

The ongoing satisfaction of the child’s needs into adolescence impairs the child’s ability to engage in new and/or complex learning experiences.  As a result, the child never gains a sense of self-mastery nor independence in terms of functioning in his/her environment.  Furthermore, the child isn’t exposed to environmental stimuli at proper times, leading to dysfunctional ego development.

Overall, the child is unable to become self-sufficient and the mother continues to take care of it.  From this lack of self-sufficiency and the continued unhealthy parent-child relationship, trichotillomania is thought to emerge.  The psychological theory is that individuals with trichotillomania are unable to develop “object constancy” or the ability to remember that people (e.g. mother) are consistent, trustworthy, reliable, etc. – even when they’re outside of the visual field (e.g. when they leave the child’s room).

Due to the lacking of object constancy, individuals are unable to attain visible evidence that their needs of security will be met in the future (by their mother).  Psychologists from the 1980s thought that the incessant pulling of hair served to symbolize the mother’s “need satisfying” during times she wasn’t available.  Whether this theory has any legitimacy is highly questionable.

Trichotillomania is unlikely to emerge solely from mother-child relationships, excessive need-satisfaction, and lack of object constancy.  However, just because the theory is old doesn’t mean it should be dismissed altogether.  There are likely critical neurodevelopmental periods, that when slightly dysfunctional, could cause trichotillomania in a subset of individuals.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/6201939

Stress: It is likely that stress can contribute to the development of trichotillomania.  Stress, especially during childhood and adolescence, can alter gene expression (epigentically) as well as affect brain development.  The combination of epigenetics and impaired neural development due to high-stress environments may make an individual more prone to hair pulling disorders.

Specifically, the act of hair pulling may be adopted by individuals as a way in which they can cope with the physiological tension associated with stress.  Many cases of trichotillomania report “tension” leading up to the act of the hair pulling and “soothing” sensations once the hairs are pulled.  This soothing sensation may serve as a possible strategy for the mitigation of tension and/or stressors.

Assuming a person’s hair pulling flares up when they are stressed, trichotillomania may have served as nothing more than a soothing mechanism.  However, when repeated (over long periods of time) as the predominant modality of coping with stress, the hair pulling behavior may have essentially been “wired” into the person’s brain as a nearly reflexive behavior.  This may lead the individual to pull his/her hair even without stress as a soothing mechanism.

• Source: http://www.trich.org/about/hair-causes.html
• Source: http://www.ncbi.nlm.nih.gov/pubmed/11360867

Trauma: Although some individuals may develop trichotillomania from early childhood/adolescent stress and/or as a way to cope with stress, others may develop the condition following a traumatic experience.  Research documents a significant overlap of trichotillomania with trauma and some experts believe that a traumatic experience may directly cause trichotillomania in certain cases.  To better understand the relationship between trauma and trichotillomania, researchers conducted a study.

The study recruited 42 individuals diagnosed with trichotillomania and assessed their life for the occurrence of a traumatic event or prior PTSD diagnosis.  Up to 76% of those with trichotillomania had experienced at least one traumatic event and 19% fit diagnostic criteria for PTSD.  Interestingly, there appeared to be an inverse relationship between the severity of PTSD symptoms compared to those associated with trichotillomania.

In other words, the more severe the PTSD, the less severe the trichotillomania; and vice-versa.  Researchers noted that the occurrence of PTSD among those with trichotillomania may be higher than in the general population.  Results suggested that the more diverse and numerous a person’s traumas, the longer the duration of hair pulling and more likely they are to pull hair from the scalp.

Trichotillomania that occurs among trauma victims may serve as a form of self-soothing in response to the trauma and/or a coping mechanism.  Though it has also been suggested that trichotillomania may be a form self-harm, most evidence suggests otherwise.  It should be noted that there is also a link between psychological trauma and a related condition to TTM known as skin picking disorder (SPD).

• Source: http://www.ncbi.nlm.nih.gov/pubmed/16897695
• Source: http://www.ncbi.nlm.nih.gov/pubmed/26028973

Self-stimulation: Some believe that trichotillomania or chronic hair pulling may represent a form of self-stimulation.  Many individuals with trichotillomania pull their hair compulsively during times of relaxation or scenarios devoid of stress.  Individuals lacking sufficient stimulation and/or experiencing some sort of sensory processing disorder may resort to hair pulling to compensate for suboptimal sensory stimulation.

Individuals with autism are perhaps a good model for investigating trichotillomania as a self-stimulatory, stereotypic behavior.  Professionals trained in sensory aspects of autism can usually pinpoint the sensory processing difficulties that may be contributing to a hair pulling compulsion.  The repeated self-stimulation via hair pulling eventually becomes a neurologically imprinted habit that’s difficult to overcome.

In many cases, targeting the specific underpinnings of sensory processing dysfunction will alleviate the urge to pull hair.  However, further therapy may be necessary to introduce competing “responses” or alternative modalities of self-stimulation besides hair pulling.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/17075554
• Source: http://www.ncbi.nlm.nih.gov/pubmed/8005911
• Source: http://www.ncbi.nlm.nih.gov/pubmed/10513028

Psychostimulants:  There is evidence that ingestion of certain drugs, particularly psychostimulants, may provoke transient forms of trichotillomania.  There are several reports in the literature of stimulant-induced trichotillomania, involving the pharmaceutical drug Adderall and the illicit substance cocaine.  Those that experience psychostimulant-induced trichotillomania tend to recover spontaneously upon discontinuation of the causative agent.

Adderall: A case-report published in 2013 documented the occurrence of Adderall-induced trichotillomania in a 12-year-old girl who had been taking the medication to treat ADHD.  She was prescribed Adderall XR at a dosage of 10 mg/day.  Upon initiation of treatment, the girl’s parents reported that she began pulling her hair.

Medical inquiry revealed that the girl felt anxious while taking Adderall, and the anxiety prompted her engagement in hair pulling.  The girl mentioned that pulling her hair helped alleviate underlying anxiety.  Her family doctor noticed that most of her hair pulling was from the scalp, particularly in the frontal area.

The family doctor then made a referral for the patient to see a psychiatrist for further neuropsychiatric evaluation.  The psychiatrist diagnosed her with ADHD (combined inattentive-hyperactive) and other possible conditions such as: OCD, PTSD, GAD, depression, and bipolar disorder – were ruled out.  After pinpointing that the girl solely suffered from ADHD, the psychiatrist suspected that hair pulling was induced by the Adderall.

He transitioned the girl off of Adderall to guanfacine for ADHD symptoms.  A 2-week follow up indicated that her anxiety subsided along with the compulsion to pull her hair (as a coping mechanism).  An additional 4-week follow-up appointment suggested that she had stabilized on the guanfacine and that hair pulling behaviors had completely abated.

As a result, her hair regrew in the frontal region of the scalp and no further hair loss was ever reported.  This suggests that psychostimulatory medications such as Adderall may induce hair pulling behaviors along with anxiety.  Patients who engage in hair pulling upon commencement of psychostimulant treatment may necessitate an alternative, non-stimulant intervention.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/24062968

Cocaine: The illicit psychostimulant cocaine may provoke trichotillomania in a subset of users, particularly when abused. A report published in 2005 noted a 24-year-old woman suffering from trichotillomania-related behaviors, attributed to her cocaine abuse.  The case documented constant hair pulling from various regions including: the scalp, eyebrows, arms, axilla, and pubic region.

Significant hair loss was apparent in all of these bodily regions.  Extensive questioning indicated that the woman experienced hair pulling urges only while under the influence of cocaine.  Her cocaine abuse, along with the incessant hair pulling had occurred for an estimated duration of 1 year.

Fortunately, the hair pulling behavior induced by cocaine is not permanent and appears to resolve upon cessation of usage.  There is some evidence to suggest that temporary treatment with an antipsychotic such as Zyprexa (Olanzapine) may be useful for attenuating the stimulant-induced trichotillomania.  Moreover, while transient trichotillomania can occur as a result of cocaine abuse – it is not considered common.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/20391272
• Source: http://www.ncbi.nlm.nih.gov/pubmed/15679755

Trichotillomania Symptoms & Signs (List)

Trichotillomania is not always easy to identify because individuals may successfully hide and/or mask their hair pulling from others.  Understand that the signs and symptoms of trichotillomania predominantly involve hair loss and/or pulling, other symptoms may be evident.  Keep in mind that number of symptoms experienced, as well as their severities, may be subject to interindividual variation; not all individuals with trichotillomania will exhibit the same symptoms.

Moreover, it is necessary to emphasize that diagnosis of the condition cannot be made based solely upon specific symptoms.  Diagnosis must be made by a medical professional, preferably a specialist.  That said, if you know someone experiencing many of the symptoms listed below, you may want to tactfully suggest that they seek medical attention.

• Anxiety: Individuals with trichotillomania often feel anxiety for numerous reasons. They may have a comorbid anxiety disorder, chronic anxiety from a past trauma, and/or anxiety stemming from their inability to control hair pulling.  The inability to control hair pulling eventually contributes to hair loss and makes individuals anxious over their public appearance.
• Avoidance of wind: It is common for individuals with trichotillomania to avoid the wind. The wind is avoided due to the fact that, on an especially windy day, a wig/hat may blow off the person’s head – exposing their trichotillomania-induced bald spots or uneven hair.  Another reason an individual with this condition may avoid the wind is for fear that weakly rooted hairs may essentially fall out as a result of excessive movement via wind.
• Bald spots: Those with trichotillomania may pick hairs from a specific, isolated location on the scalp or other region of the body. Continued picking from a particular region tends to leave bald spots that can sometimes be identified by friends/family.  That said, many individuals with trichotillomania wear hats and/or wigs to cover the balding – making it difficult for others to detect.
• Constantly adjusting hair: Many individuals with trichotillomania will constantly adjust their hair in public to avoid others detecting bald spots and/or uneven hairs. Some persons will make frequent trips to the bathroom to make sure their hair is properly “adjusted” or carry a mirror with them to examine and correct an unwanted look.  Others may perceive the behavior as extreme and/or obsessive, but may not know about the underlying trichotillomania.
• Depression: It is common for individuals with trichotillomania to experience depression. The depression may occur as a result of poor self-image associated with uneven, disheveled hair resulting from hair pulling.  Additionally, preoccupation with hair pulling may interfere with social relationships and/or occupational performance – leading the individual to become depressed as a result.  It should also be mentioned that subset of individuals could have comorbid depression that emerged prior to the onset of trichotillomania.
• Excessive makeup: To take attention away from the scalp hair, eyelashes, and eyebrows – those with trichotillomania may apply excessive makeup and/or eyeliner. In some cases, the excessive makeup may be applied as a compensatory mechanism for the lack of hair.  As a standalone symptom, excessive application of makeup isn’t too revealing.  However, in the event that someone is attempting to take attention away from their hair via makeup application – it could indicate trichotillomania.
• Functional impairment: Those with trichotillomania may struggle to maintain friendships or jobs due to the fact that they are preoccupied with hair pulling. Individuals with the condition who are still in school may notice a significant decline in grades because they are too caught up with hair pulling to focus on academics.  The emotional baggage of depression and/or anxiety associated with trichotillomania may further impair one’s functionality.
• Hair eating: While not everyone with trichotillomania will resort to eating the hairs that are pulled, a subset of those diagnosed will ingest them. The eating of hair is classified as “tricophagia” and can lead to numerous medical complications including gastrointestinal distress.  Excessive hair eating could lead to the development of a hair ball (trichobezoar) which may interfere with bowel functions.
• Hair loss: Examination of a patient with trichotillomania will reveal hair loss in some area(s) of the body. A majority of those diagnosed with trichotillomania commonly pull hair from one or two sites, but some patients may pull from other areas.  The most common area to detect hair loss from pulling is atop the scalp.  Eyebrows, eyelashes, face, arms, and legs – are most common secondary sites.  Other areas that are less commonly targeted include: armpits, beard, chest, and pubic area.
• Hair pulling: Trichotillomania involves compulsive pulling of hairs from parts of the body. Although hair pulling behaviors of the individual diagnosed with trichotillomania are not always obvious to family/friends/acquaintances, they sometimes are.  Those with the “automatic” subtype of trichotillomania may unconsciously pull hair follicles while watching TV, talking on the phone, reading a book, writing a paper, surfing the internet, etc.  On the other hand, a “focused” puller my engage in covert pulling – doing his/her best to hide it from others.
• Low self-esteem: The self-esteem of a person with trichotillomania may be extremely low. This low self-esteem often stems from the fact that they are unable to control their hair pulling behavior and it’s affecting their self-image.  Others may treat them differently during social interactions due to their disheveled hairstyle and/or they may perceive themselves as being less physically attractive than before the pulling.  They may even face bullying from others as a result of their hair loss.
• Medical complications: There are many adverse medical effects that may stem from recurrent, chronic hair pulling. Failure to treat trichotillomania may cause: permanent hair loss, repetitive stress injuries, carpal tunnel syndrome, scalp infections, and/or gastrointestinal distress (in the event that a person also ingests the hair).  In rare cases, the ingestion of hair after pulling may severely obstruct the bowel and could be fatal.
• Refusal to swim: In addition to avoidance of windy conditions, a person with trichotillomania may also refuse to swim. If they swim, especially in public, they may run the risk that others will detect their condition or see bald spots (which could hurt their self-esteem).  Those who avoid to swim may also go as far as to avoid any wet conditions (e.g. rain) as it may interfere with the appearance they’re trying to maintain.
• Shame: Many individuals with the condition are ashamed of themselves for being unable to stop the hair pulling. What’s more, those who are discovered to be hair pullers by friends and/or family members may be picked on or viewed as weak for being unable to stop.  They may also not realize that it’s a legitimate psychiatric condition, and as a result, may not seek treatment and feel ashamed of their hair pulling compulsion.
• Social isolation: An unfortunate sign that a person is suffering from trichotillomania is social isolation. It is unclear exactly what leads to the isolation, but a combination of factors may contribute.  Friends may detect the hair loss and may begin treating the person differently.  Another possibility is that the person with trichotillomania is so preoccupied with hair pulling that he/she begins avoiding social events.  Furthermore, the emotional distress associated with trichotillomania may lead to isolation from others.
• Uneven hair: Those with trichotillomania are not guaranteed to exhibit overt bald spots. Some may pick hairs in a scattered manner, leading to an uneven appearance.  Even in cases in which hair is systematically picked in a premeditated manner, professionals can often spot sections of uneven hairs among those diagnosed.  Hairs may appear to be of uneven shape, follicles may differ in lengths, and ends of follicles may appear blunted or tapered.
• Wearing hats or wigs: In effort to cover up the hair loss, bald spots, and uneven/misshapen hair following recurrent pulling, many individuals invest in a supply of hats or wigs. The hats and/or wigs allow the individual to maintain a normative appearance without others detecting hair abnormalities or speculating possible trichotillomania.  Wearing of hats/wigs may also be accompanied by noticeable stylistic alterations such as excessive makeup, fake eyelashes, and pencil-drawn eyebrows.

Trichotillomania Treatment & Cure (Hair Pulling Disorder)

Due to the fact that the neural underpinnings of trichotillomania are distinct from OCD and other psychiatric disorders, it is often difficult to treat with psychiatric medications.  Treatment for trichotillomania often consists of psychotherapeutic interventions and/or pharmacological agents.  The efficacy of a specific treatment or regimen for hair pulling disorder is likely subject to interindividual variation based on a person’s age and hypothesized causative underpinnings.

Psychotherapeutic interventions: When it comes to treating trichotillomania, evidence supports the usage of psychotherapeutic interventions far more than pharmacology.  Evidence from robustly designed randomized controlled trials indicates that pharmacological agents are unlikely to provide benefit to those with hair pulling disorder.  Moreover, there may be deleterious implications associated with utilization of pharmacology among pediatric populations (e.g. side effects, abnormal neural development, etc.).

On the other hand, psychotherapy appears to significantly reduce hair pulling tendencies without side effects – hence, it should be considered a first-line intervention for all populations with the condition.  There are various forms of psychotherapy that may provide therapeutic benefit to patients with trichotillomania, but the modality with the most scientific support is cognitive behavioral therapy (CBT).

CBT: Cognitive behavioral therapy is a form of psychotherapy that was originally engineered to treat depressive disorders, but is effective as a treatment for numerous psychiatric conditions – including trichotillomania.  It aims to acknowledge a patient’s problematic hair pulling tendencies and then provide that individual with specific cognitive/behavioral strategies to reduce likelihood of future hair pulling behaviors.  There are various subtypes of CBT that may be useful for individuals with trichotillomania including HRT (habit reversal training) and DBT (dialectical behavior therapy).

HRT: The form of CBT regarded as most effective for the treatment of trichotillomania is habit reversal training (HRT).  Habit reversal training involves awareness training, stimulus control, and competing response training.  Many trials have documented the efficacy of HRT, especially among children and adolescents with the condition.

Some speculate that early intervention with HRT (in cases of childhood-onset trichotillomania) may essentially correct or “cure” the condition prior to adolescence and adulthood.  Ongoing HRT may rewire neural processes and thereby reduce hair pulling behaviors.  For those who fail to derive full benefit from HRT, it may be augmented with dialectical behavior therapy (DBT), psychoeducation, and/or pharmacology to improve treatment outcomes.

A case-report published in 2012 documented the efficacy of HRT as a treatment for trichotillomania in a 22-year-old woman referred to as Ms. JK.  This woman had exhibited hair loss since the age of 8 as a result of her chronic hair pulling behaviors.  An experienced psychotherapist implemented HRT (habit reversal training) along with Stimulus Control over a 12-week duration and the woman exhibited complete remission.

The patient agreed to receive 1 session of HRT per week and signed a contract to bolster her commitment.  Efficacy of the psychotherapeutic interventions were assessed with the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS).  It is important to highlight this case to get a better understanding of HRT in the management of trichotillomania.  Psychotherapy for Ms. JK entailed the following:

First session: Education + Preparation

The first session of HRT psychotherapy involved educating the patient about trichotillomania as well as the psychotherapy to be employed.  Additionally, the woman was given a self-monitoring form to be completed on a daily basis to track specific aspects of her trichotillomania.

• Education: In the first session, the woman was educated on trichotillomania. The therapist explained the diagnosis, causes, prevalence, etc.  The processes of habit reversal training (HRT) and Stimulus Control (SC) were also explained to the patient.  The woman admitted that her hair pulling behavior caused significant psychological distress throughout years.
• Preparation: Therapist gave Ms. JK a questionnaire to fill out regarding her hair pulling behaviors, triggers, and consequences. The patient committed to filling out a self-monitoring form on a daily basis for the entire duration of therapy.

Second session: Self-awareness + Relaxation Training

The second session involved giving Ms. JK feedback from the first session and assessment of her self-monitoring form.  The self-monitoring form indicated that she had pulled in several situations and specific settings – particularly when the woman was sedentary.  Usage of the self-monitoring form was helping her become more aware of the unwanted hair pulling habit and lead to some resistance in pulling.

Discussion of hair pulling triggers with the therapist revealed that hair stroking and/or management often lead to pulling.  Additionally, sensations throughout Ms. JK’s skin often triggered pulling behaviors.  In this second session, the therapist taught her progressive muscle relaxation (PMR) and diaphragmatic breathing technique.  She was instructed to implement both the PMR and diaphragmatic breathing into her routine on a daily basis.

Third session: Competing response

The third psychotherapy session involved teaching Ms. JK a “competing response.”  A competing response is a cognitive/behavioral activity that competes with the urge or compulsion to pull hair.  In this case, the client was taught to engage in a specific muscle tensing activity that entailed clenching the fist of the hand that she uses for hair pulling.

Upon clenching the fist, she was told to bend her elbow and press her clenched fist and entire arm against her side around her waist – holding it for at least 1 minute.  It should be noted that this competing response isn’t initiated immediately when she felt the urge to pull.  The therapist instructed that whenever an urge occurred – she should first relax with 1 minute of diaphragmatic breathing and then initiate the muscle tensing response for 1 minute.

Fourth session: Replacement behaviors

After learning how to consciously implement a competing response, the woman was taught various replacement behaviors such as cue-controlled relaxation and postural adjustments.  She was instructed to refrain from: holding her head in her hands (during work or driving), placing hands near her head while in bed, and watching television (as this increased likelihood of pulling).  The therapist also suggested to increase the distance between hands and head at all times, as well as to hold a pen in her idle hand during occupational work.

Additional sessions (6-12): Monitoring, Modifications, Review

The report indicated that for an additional 8 sessions, the psychotherapist monitored the efficacy of current treatment strategies and made modifications if deemed necessary.  The therapist also reviewed replacement behaviors and determined which were most effective.  Any cognitive symptoms associated with trichotillomania were addressed promptly in therapy.

Efficacy of HRT psychotherapy was assessed with the MGH-HPS score following 12-weeks of treatment.  During the first week, the patient’s trichotillomania was relatively severe – scoring a 22/28 on the MGH-HPS scale.  However, after just 6 sessions, the score had plummeted to a 0 – indicating complete symptomatic remission.

No hair was pulled from the 6^th to 12^th session and the patient become more confident.  Her hair had regrown and she no longer utilized a scarf cover-up atop her head.  After 12 weeks of therapy, she and her therapist agreed that therapy was no longer necessary – she had fully recovered.  Follow-up appointments were scheduled on an “as needed” basis thereafter.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/22628990
• Source: http://www.ncbi.nlm.nih.gov/pubmed/23964997

Stepped care: There are web-based self-help programs that have been devised to help individuals overcome and/or cope with trichotillomania.  These self-help programs follow step-by-step guidelines and incorporate online-educational training, followed by in-person psychotherapy.  The stepped care model involves Step 1 (10 weeks of online self-help via the website StopPulling.com) followed by an optional Step 2 (8 sessions of in-person HRT).

A study published in 2014 recruited 60 adults with trichotillomania to test the efficacy of stepped care for the treatment of trichotillomania.  Participants were assigned at random to be part of a waitlist control group or receive stepped care.  Efficacy of Step 1 (10 weeks of online self-help) was assessed compared to the control (waitlist) group and no significant differences were noted in efficacy.

That said, there was a slight advantage associated with Step 1 over the control.  There was also a correlation between frequency of website usage and symptomatic reduction.  Step 1 didn’t appear to decrease motivation to manage trichotillomania and lead over 75% of participants to partake in the optional Step 2 psychotherapy with HRT.

Researchers concluded that stepped care is highly acceptable and those who pursued Step 2 (HRT) experienced marked symptomatic reduction compared to the control.  While this doesn’t necessarily support a stepped-care model for the treatment of trichotillomania, it does highlight the efficacy of HRT.  Moreover, stepped care may be more likely to prompt certain individuals to pursue HRT therapy.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/24491078

HRT for children: In a report published in 1998, researchers documented the implementation of simple habit reversal training (HRT) for 3 adolescents (age 12) afflicted with chronic hair pulling.  The simplified HRT procedure involved: awareness training, competing response training, and social support.

During the awareness aspect of training, participants were taught how to detect all hair pulling actions by describing the tactile sensations associated with hair on the fingers.  Next, participants were told to simulate the behavior by feeling their hair (between the fingertips) without actually pulling it.  Thereafter, participants were instructed to deliberately engage in hair pulling – but were restrained by a researcher.

This helped the participants understand which muscles were implicated in the hair pulling process.  After self-awareness was established, participants were trained in competing responses or behaviors that were incongruent with hair pulling.  Then the participant was told to engage in one of these incongruent behaviors (e.g. sitting on hands) each time they felt an urge to pull hair.

In the psychotherapy training, this competing response was practiced up to 15 times and maintained for a minute each time.  The final aspect of HRT involved social support of the children by instructing parents to remind their children about competing responses and to provide positive reinforcement (via praise) whenever these responses were overtly initiated.

Results indicated that hair pulling significantly decreased for all 3 participants during the study.  Some participants required maintenance 30-minute “booster” therapy sessions to manage the condition.  That said, with booster sessions on an “as needed” basis, trichotillomania can be effectively attenuated among children after initial CBT.

• Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1284118/pdf/9652106.pdf

HRT-behavioral therapy:  A study published in 2003 highlighted the superiority of behavioral therapy compared to pharmacological interventions (e.g. SSRIs) for trichotillomania.  This study recruited 43 patients that had been formally diagnosed with trichotillomania and randomly assigned them to one of several groups: behavioral therapy, Prozac (60 mg/day), or waiting list (control group).  The study was carried out over a 12-week term and measured the efficacy of interventions with the Massachusetts General Hair-pulling Scale.

Results indicated that patients receiving behavioral therapy experienced significant symptomatic reduction compared to those in the waiting list (control) and Prozac groups.  This reduction in trichotillomania symptoms was based upon the change in measures on the Massachusetts General Hospital Hair-pulling Scale.  Researchers concluded that behavioral therapy is efficacious in attenuating symptoms of trichotillomania over a short-term (12-weeks), whereas standard pharmacology is not.

Another study published in 2010 assessed the efficacy of behavioral therapy for those with pediatric trichotillomania.  Researchers in this study organized a randomized, placebo-controlled trial assigning 12 patients to receive behavioral therapy and the other 12 to a minimal attention control group.  To gauge efficacy, trichotillomania severity was evaluated with the NIMH-Trichotillomania Severity Scale at pre-treatment baseline and compared after treatment.

The behavioral therapy implemented a combination of: psychoeducation, awareness training, stimulus control, competing response training, relaxation strategies, and cognitive restructuring.  Analysis of the results indicates that children and adolescents respond equally well to behavioral therapy for trichotillomania as adults.  Most evidence suggests that behavioral therapy, or more specifically behavioral therapy incorporating HRT (habit reversal training) is effective for the treatment of trichotillomania.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/12742873
• Source: http://www.ncbi.nlm.nih.gov/pubmed/20584275

DBT: Another subtype of cognitive behavioral therapy is DBT (dialectical behavioral therapy).  DBT was originally developed to improve psychological states of suicidal individuals diagnosed with borderline personality disorder, but its implementation is effective for a variety of other psychiatric conditions.  DBT incorporates four sets of behavioral skills including: mindfulness, distress tolerance, interpersonal efficacy, and emotional regulation.

The mindfulness aspect aims to increase a patient’s momentary awareness.  The distress tolerance component teaches the patient how to tolerate pain in various situations rather than changing it.  Interpersonal efficacy involves helping the client ask for what they want and teaching them to say no without compromising self-worth or interpersonal relationships.  Finally, the emotional regulation aspect teaches clients to adjust emotions that they dislike.

Preliminary evidence suggests that DBT may effectively augment HRT (habit reversal training) for those with trichotillomania.  DBT involves 4 stages including: attaining behavioral control (Stage 1), learning to experience the full spectrum of human emotions (Stage 2), helping the client learn to live and find peace (Stage 3), and finding fulfillment with joy and freedom (Stage 4).  A study published in 2010 noted that not everyone with trichotillomania responds fully to treatment with CBT and/or is able to maintain the therapeutic benefits derived from CBT.

Researchers speculated that enhancement of CBT with DBT may improve treatment outcomes among individuals with trichotillomania.  For the study, researchers recruited 10 individuals that fit DSM-IV criteria for trichotillomania in an open-label design.  All participants received one DBT-enhanced CBT session per week for 11 weeks and an additional 4 maintenance sessions over a 3-month term.

To determine efficacy of the DBT-enhanced CBT, hair pulling was rated by self-reports and independent assessors.  Results indicated that hair pulling severity, emotional regulation, and hair pulling impairment significantly improved as a result of treatment.  The therapeutic improvements were maintained throughout follow-up sessions.

It appears as though DBT-enhanced CBT is an effective intervention for trichotillomania.  The DBT component specifically is thought to improve emotional regulation throughout treatment.  Those who appear to have comorbid emotional distress and/or are unable to derive full benefit from CBT may want to consider therapeutic enhancement with DBT.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/20721929

In summary, the most evidence-based treatment for trichotillomania is CBT – specifically CBT that incorporates HRT (habit reversal training). CBT with an HRT emphasis is more effective than a control “waitlist,” pharmacological interventions (clomipramine, fluoxetine, etc.), placebo pills, and other forms of psychotherapy. Furthermore, HRT appears to be effective for children, adolescents, and adults with trichotillomania.

That said, it is important to note that efficacy of HRT for pediatric populations may be slightly lesser than in adult populations due to the fact that young children often lack self-awareness necessary for proper HRT.  Additionally, children may require “follow-up” booster sessions more frequently than adults to maintain symptomatic remission. A systematic review published in 2007 indicates that HRT is the single most effective treatment for trichotillomania.

It is more effective than other alternative interventions including punishment (for hair pulling behaviors) and hypnotherapy.  While the efficacy of pharmacological options cannot be dismissed in a subset of the population, they should not be regarded as a first-line intervention.  Habit reversal training remains the most scientifically substantiated intervention for hair pulling disorder – and adjuvant dialectical behavior therapy (DBT) may bolster therapeutic efficacy.

Other interventions that may be helpful for the treatment of hair pulling disorder include: ACT (acceptance and commitment therapy), biofeedback, and hypnotherapy.  Further research is necessary to confirm/dismiss the efficacy of the aforestated interventions.  Additionally, it should be understood that innovative, futuristic pharmacology may hold promise to correct the underlying neural abnormalities associated with the condition.  Until effective treatments are established in randomized controlled trials – HRT should be utilized by all individuals with trichotillomania.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/21440858
• Source: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0024684/

Pharmacological interventions: Those that seek professional help for the treatment of trichotillomania may end up testing various psychiatric medications as an adjunct to psychotherapy.  Some patients derive significant benefit from such drugs, while others will find them completely ineffective.  For most individuals, it is likely to take several bouts of trial and error to find a medication that successfully attenuates hair pulling urges and behaviors.

In most cases, pharmaceutical medications are not recommended for children and early adolescents with trichotillomania.  The side effects and other neurophysiological complications (e.g. interference with neural development) tend to exceed the (hypothesized) therapeutic effects in such populations.  Therefore, utilization of pharmaceutical agents in the treatment of trichotillomania is most often reserved for adults with chronic hair pulling disorders and/or comorbid psychiatric conditions.

Those interested in pharmaceutical treatments for trichotillomania should understand the fact that there are currently no FDA-approved medications indicated for the condition.  In other words, although a psychiatrist may prescribe a drug that he/she thinks may provide benefit, its usage is relatively unsubstantiated in that it has not been thoroughly evaluated in randomized controlled trials and compared to a placebo.

It should also be mentioned that just because certain drugs haven’t gone through clinical trials for trichotillomania does not mean that they automatically don’t work.  Most professionals will prescribe an agent that they think is most likely to work – but interindividual effects will vary.  Below are some pharmacological agents that may improve symptoms among those with trichotillomania.

Anafrinil (Clomipramine): Research published in the 1980s investigated the therapeutic efficacy of tricyclic antidepressants in cases of trichotillomania.  A study published in 1989 incorporated a double-blind, crossover design that compared the tricyclic antidepressants clomipramine and desipramine.  For the study, researchers recruited 13 women diagnosed with severe trichotillomania and were assigned to receive each agent over a 10-week term.

Results indicated that treatment with clomipramine significantly improved symptoms of trichotillomania compared to desipramine.  Symptomatic improvement was measured by physician-ratings of women’s clinical progress on a scale.  Severity of symptoms at pre-treatment baseline were around ~15.9 whereas after treatment with clomipramine they were reduced to ~10.6.

Treatment with desipramine barely reduced symptoms from ~15.9 to ~14.4 – indicating a relatively weak change.  Patients reported that they were able to resist the urge to compulsively pull their hair while taking clomipramine.  Researchers of this study concluded that clomipramine appears efficacious as a short-term intervention for trichotillomania.

A report published in 1991 documented that while clomipramine may initially reduce symptoms of hair pulling disorder, most patients will end up relapsing.  Relapses most commonly occur within 3 months of treatment initiation without any adjustments in dosing.  While the tricyclic antidepressant clomipramine may be useful as a short-term intervention for extreme hair pulling, it appears unable to manage symptoms over a long-term.

Other studies have documented success in treating trichotillomania with clomipramine and adjunctive topical steroid cream.  That said, it remains unclear as to how long the combination of clomipramine with the topical cream will remain effective after initiation.  Nonetheless, this may be something to consider among those who are unresponsive to standalone tricyclics.

• Source: https://www.ncbi.nlm.nih.gov/pubmed/2761586
• Source: http://www.ncbi.nlm.nih.gov/pubmed/1303620
• Source: http://www.ncbi.nlm.nih.gov/pubmed/2005076

Prozac (Fluoxetine): There is some evidence to suggest that Prozac (an SSRI) may be an effective intervention as a treatment for trichotillomania for certain individuals.  A study published in 1991 recruited 21 individuals characterized as “chronic hair pullers” for an 18-week, placebo-controlled, double-blinded trial.  The trial involved administration of Prozac (up to 80 mg/day) for 6 weeks, followed by a 5-week washout period, and thereafter – a placebo daily for 6 weeks.

Results indicated that Prozac didn’t appear to improve number of hair pulling episodes and the estimated amount of hair pulled per week.  Therefore, it doesn’t appear that Prozac provides benefit to those with trichotillomania.  Another study published a year later involved 17 adults with trichotillomania and administration of Prozac (up to 80 mg/day).

The hair pulling behavior was assessed at pre-treatment baseline using the YBOCS (Yale-Brown Obsessive-Compulsive Scale) and compared after 8-12 weeks.  Scores on the YBOCS in regards to hair pulling decreased from 10.15 to 5.92 – indicating a significant response to treatment.  It should be noted that 3 patients refrained from hair pulling altogether after receiving treatment.

Yet another study investigating Prozac (up to 80 mg/day) was published the same year and incorporated 12 participants in an open-label 16-week trial.  Trichotillomania severity was measured at baseline and compared after the 16-week term.  Results indicated that half of those receiving Prozac exhibited significant symptomatic improvement.

Another study that was published in 1995 that assessed the efficacy of Prozac (up to 80 mg/day) compared to a placebo among 16 patients with trichotillomania.  The trial took place over a 31-week duration and involved an initial treatment phase of 12 weeks, a 5-week washout period, and a second treatment for an additional 12 weeks.  Results indicated no significant differences between Prozac and a placebo.

Although clearly Prozac cannot be touted as a scientifically effective intervention for trichotillomania, evidence suggests that it may alleviate symptoms in a subset of those with the condition.  Therefore, individuals with extreme cases of trichotillomania may want to test Prozac to determine whether it provides any benefit.  That said, Prozac should be regarded as clinically ineffective for trichotillomania.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/1928474
• Source: http://www.ncbi.nlm.nih.gov/pubmed/1513916
• Source: http://www.ncbi.nlm.nih.gov/pubmed/1517191
• Source: http://www.ncbi.nlm.nih.gov/pubmed/7625469

Wellbutrin (Bupropion): Among those that fail to derive therapeutic benefit from Prozac as a treatment for trichotillomania, another pharmacological intervention to consider is Wellbutrin.  This drug is considered an atypical antidepressant in that it functions as an NDRI (norepinephrine-dopamine reuptake inhibitor).  Various clinical reports indicate that certain patients with trichotillomania may respond well to Wellbutrin.

One such case report, published in 2011, told the story of a 23-year-old woman who had pursued treatment with Prozac and Klonopin – neither of which helped.  She then tapered off the Klonopin and discontinued the Prozac in favor of Wellbutrin.  When starting the Wellbutrin (300 mg/day), she noticed modest benefit in symptoms within 2 weeks of commencement.

At around the same time of staring Wellbutrin, she also began using CBT.  After the initial 2 weeks of treatment, her Wellbutrin dosage was titrated up to 450 mg/day.  Within 1 week of this upward titration in dosing, her trichotillomania symptoms were reportedly “much improved” (based on the Clinical Global Impression Scale) and this improvement was maintained at 12-month follow-up appointments.

Researchers noted that among those who are non-responsive to SSRIs, treatment with Wellbutrin may provide benefit.  They speculate Wellbutrin provides benefit via altering function in the mesolimbic pathway, an area that may be implicated in the manifestation of trichotillomania.  Another case report was noted of a 35-year-old woman who didn’t respond to serotonergic antidepressants, but derived significant benefit from Wellbutrin at 450 mg/day.

While lower doses of Wellbutrin seem to provide slight/modest benefit to those with trichotillomania, case reports are suggestive of the fact that dosage may necessitate an upward titration to 450 mg/day for optimal symptomatic relief.  It is speculated that the dopaminergic modulation within the reward pathway at the 450 mg/day dose may be responsible for improving symptoms.  Randomized controlled trials of Wellbutrin at 450 mg/day for trichotillomania is clearly warranted.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/15367058
• Source: http://www.ncbi.nlm.nih.gov/pubmed/22129450
• Source: http://www.ncbi.nlm.nih.gov/pubmed/22388165

Other possible options…

In addition to using standard antidepressants for the treatment of trichotillomania, there appear to be some other viable options.  The efficacy of alternative pharmacological approaches isn’t well-established.  That said, the efficacy of SSRIs isn’t established at all, perhaps increasing the appeal to test various other interventions.  Arguably the safest option for adults is the amino acid N-acetylcysteine.

Abilify (Aripiprazole): A study published in 2011 investigated the efficacy of Abilify, a well-tolerated atypical antipsychotic for the treatment of trichotillomania.  Abilify functions as a partial D2 agonist, targeting a different neurotransmitter system (dopamine) than serotonergic antidepressants.  The study recruited 12 patients for an 8-week, open-label, flexible-dose study administering Abilify.

Results indicated that Abilify appeared to be an effective treatment for trichotillomania.  Although clinical efficacy cannot be determined from this trial, it does suggest that Abilify may benefit certain patients with hair pulling disorder.  Clinicians may want to consider this antipsychotic among those who fail to derive benefit from traditional pharmacologic approaches.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/21694623/

Dronabinol: This is a cannabinoid agonist that has been discovered to decrease hair pulling among individuals with trichotillomania.  Administration of dronabinol is thought to decrease glutamatergic excitotoxicity within striatal regions of the brains, and may reduce compulsive tendencies.  A study that recruited 14 female subjects diagnosed with trichotillomania involved administration of dronabinol (2.5-15 mg/day) for 12-weeks.

It appears as though this cannabinoid agonist can decrease symptoms of trichotillomania without altering cognitive function.  Although further research is warranted to confirm or dismiss hypothesized efficacy, medically supervised administration of dronabinol may be helpful for those with trichotillomania.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/21590520/

Lithium: Several reports have noted efficacy of lithium in managing hair pulling behaviors.  A study published in 1991 administered lithium carbonate to 10 patients with chronic hair pulling for a term of 2-14 months.  Of these 10 patients, 8 exhibited significant reductions in hair pulling coupled with hair regrowth.

Researchers speculated that lithium’s ability to reduce hair pulling tendencies among those with trichotillomania may be due to the fact that it curbs aggressiveness, impulsiveness, and balances emotions.  Follow-up reports from 2003 and 2008 document the efficacy of lithium in the treatment of trichotillomania among those with comorbid bipolar disorder.  Lithium appears to stabilize mood and simultaneously minimize hair pulling.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/1900831
• Source: http://www.ncbi.nlm.nih.gov/pubmed/14533143
• Source: http://www.ncbi.nlm.nih.gov/pubmed/18677437

N-Acetylcysteine: N-acetylcysteine is an amino acid that is understood to modulate glutamatergic processes within the brain.  Particularly, N-acetylcysteine is thought to increase restore extracellular glutamate concentrations within the nucleus accumbens – thereby reducing compulsive tendencies.  A double-blind, placebo-controlled study published in 2009 documented the efficacy of N-acetylcysteine (1200-2400 mg/day) as a treatment for trichotillomania in 50 adults over the course of 12-weeks.

Results indicated that individuals taking N-acetylcysteine exhibited significantly greater reductions in hair pulling behavior (as measured by the Massachusetts General Hospital Hair Pulling Scale and Psychiatric Institute Trichotillomania Scale) by the end of the 12-weeks.  Over half of all individuals receiving N-acetylcysteine reported “much” or “very much” improvement in symptoms compared to just 16% of those receiving a placebo.

What’s more, no adverse effects were reported among those receiving N-acetylcysteine – indicating that it is well-tolerated in adults.  However, another study conducted revealed that administration of N-acetylcysteine failed to reduce hair pulling behaviors among pediatrics.  This study was double-blinded, placebo-controlled, and involved administration of trichotillomania to 39 children and adolescents from 8 to 17 years of age.

Results from the study indicated that there was no significant improvement in symptoms of those receiving N-acetylcysteine compared to a placebo.  Researchers speculate that the efficacy of N-acetylcysteine for trichotillomania may be contingent upon a user’s age.  Specifically, adults (over the age of 18) appear to derive benefit from N-acetylcysteine whereas pediatric populations do not.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/23452680
• Source: http://www.ncbi.nlm.nih.gov/pubmed/23180931
• Source: https://www.ncbi.nlm.nih.gov/pubmed/19581567

Naltrexone: Naltrexone is an opioid antagonist medication that has been investigated for an array of psychiatric conditions, including trichotillomania.  A randomized, placebo-controlled, double-blind, 8-week study published in 2014 documented the efficacy of naltrexone among 51 individuals diagnosed with trichotillomania (TTM).  All 51 individuals reported “urges” to pull their hair prior to the study and TTM severity was assessed at pre-treatment baseline.

Results from this study indicated that naltrexone wasn’t more effective than a placebo in reducing hair pulling.  That said, it was able to increase cognitive flexibility compared to the placebo and reduced the number of “urges” to pull slightly among those with a family history of addiction.  Another study published in 2008 investigated naltrexone as a treatment for childhood-onset trichotillomania.

The design of this study was less robust than the one published in 2014 in that it was an open-label pilot study.  It recruited 14 individuals diagnosed with trichotillomania (childhood-onset) and tested the therapeutic efficacy of naltrexone (25-100 mg/day) over a 10-month duration.  Results indicated no adverse effects associated with the treatment and that naltrexone may be useful for the treatment of childhood-onset trichotillomania.

Prior to both of the aforementioned studies, a case report emerged of a 45-year-old woman that had a 33-year history of compulsive hair pulling.  She tested Prozac at 60 mg/day for 12 weeks along with psychotherapy for 12 weeks.  Later, naltrexone was added to the mxi at a dose of 50 mg/day – for an 8-week duration.

The woman in this case reported that she still often initiated a hair pulling episode, but derived no pleasure from it, and as a result, discontinued the behavior.  In this case, the combination of Prozac, naltrexone, and psychotherapy was helpful – she regrew her hair for the first time in over a decade.  It is possible that naltrexone decreased the pleasure associated with hair pulling and significantly reduced its duration/intensity.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/24145220
• Source: http://www.ncbi.nlm.nih.gov/pubmed/18294086
• Source: http://www.ncbi.nlm.nih.gov/pubmed/8748437

Oxcarbazepine: Another medication that may warrant consideration for the treatment of trichotillomania is oxcarbazepine.  This is a drug that functions as an anticonvulsant and mood stabilizer.  A case report published in 2010 highlighted a 43-year-old woman who had been diagnosed with trichotillomania and binge eating disorder who was given oxcarbazepine at 1200 mg/day.

Interestingly, her hair pulling and binge eating tendencies significantly improved.  Follow-up reports indicate that efficacy of oxcarbazepine was maintained for over 9 months with no sign of relapse.  Although there’s only one report mentioning oxcarbazepine as a treatment for trichotillomania, perhaps it warrants further investigation.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/20375658

Topamax (Topiramate): An anticonvulsant agent commonly prescribed for the treatment of epilepsy and migraine headaches may attenuate symptoms of trichotillomania in a subset of users.  A study published in 2006 discussed the fact that Topamax has demonstrated preliminary efficacy for the treatment of impulse control disorders.  This study specifically investigated its efficacy among 14 adults diagnosed with trichotillomania.

All 14 adults received flexible-dose Topamax (50-250 mg/day) for a duration of 16 weeks.  Trichotillomania symptoms were documented prior to treatment and after the 16-week term.  Of the 9 adults that completed the full 16-week study, hair pulling severity significantly decreased from baseline measures.  These results indicate that Topamax may be helpful in the management of trichotillomania.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/16877895

Zyprexa (Olanzapine): Zyprexa is an atypical antipsychotic known for its potency, and perhaps among patients, is best known for its ability to induce weight gain.  That said, it is a useful medication and is understood to modulate the dopamine system.  A 12-week trial with 25 individuals that fit DSM diagnostic criteria for trichotillomania implemented a randomized, double-blind, placebo-controlled design.

Results indicated significant improvement in 11/13 participants in the flexibly-dosed Zyprexa group compared to just 2/12 in the placebo group – based on the CGI-I scale.  It was concluded that Zyprexa at flexible doses can be a safe and effective intervention for the treatment of trichotillomania.  This may be another option to consider among those who fail to benefit from antidepressants.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/20441724/

How many people have trichotillomania?

Reports estimate that around 2.5 million individuals in the United States will fit diagnostic criteria for trichotillomania (hair pulling disorder) at some point during their lifetimes.  Onset of the condition generally occurs during childhood and early adolescence.  If treated properly, it tends to subside by early adulthood and/or a person will have learned how to effectively manage symptoms.

Only a small percentage of the population will struggle with lifelong, unremitting trichotillomania.  Most of those that struggle with lifelong forms of the condition never attain proper psychotherapeutic treatment with proven therapies such as HRT (habit reversal training).  Additionally, many diagnosed never consider pharmacological approaches or a combination of HRT plus medication, or even additional therapies such as DBT.

It should also be noted that females tend to struggle with the condition to a greater extent than males.  Statistics indicate that of all adults diagnosed with the condition, approximately 3 females are diagnosed for every male.

• Source: https://www.ncbi.nlm.nih.gov/pubmed/24049966
• Source: https://www.ncbi.nlm.nih.gov/pubmed/17403968

Do you have trichotillomania (hair pulling disorder)?

If you’ve been diagnosed with trichotillomania, feel free to leave a comment below mentioning when the condition first emerged.  In other words, share what age you first began pulling your hair and the bodily regions from which you were pulling (e.g. frontal scalp).  If you had to characterize your hair pulling behavior, would you classify it as “automatic” (unconscious) or “focused” (premeditated)?

Do you feel tension prior to pulling and/or satisfaction after pulling of hair?  What causative factors do you believe caused your hair pulling disorder (e.g. genetics, trauma, parenting, etc.)?  When you or others noticed excessive hair pulling behaviors, did you seek treatment from a psychotherapist such as with HRT?

Did you utilize pharmacological interventions such as SSRIs or tricyclic antidepressants?  To help others get a better understanding of your situation, share the therapeutic interventions that you’ve found most helpful and/or least helpful.  If you have any additional tips that could benefit others with the condition, be sure to include them in your comment.

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