Trichotillomania is recurrent pulling of hair leading to noticeable hair loss, despite repeated attempts to decrease or stop the behavior, with clinically significant distress or impairment. The act often functions as soothing or grooming-related rather than driven by intrusive thoughts. The patient typically knows the behavior is causing problems but cannot stop.
The pattern: hair pulling from any body site — scalp most common (visible hair loss, sometimes bald patches), eyebrows, eyelashes, beard, body hair. Pulling may be focused (deliberate attention on specific hairs) or automatic (during reading, watching TV, conversations, often without awareness). Many patients describe a brief tactile or visual pleasure at the act, sometimes pulling specific hairs based on texture or appearance.
Body-focused repetitive behavior (BFRB): trichotillomania and excoriation disorder are the canonical body-focused repetitive behaviors. They differ from OCD in mechanism — soothing/grooming-related rather than intrusive-thought-driven. The patient is not trying to neutralize an obsession; they are engaging in a self-regulating motor behavior that has become problematic.
Prevalence is roughly 1-3% lifetime, with female predominance (3:1 or more). Onset typically in childhood or adolescence. Many patients hide the behavior and the hair loss — wigs, hairstyles, hats, avoidance of swimming or activities that might reveal pulled areas. Substantial shame and social impact often hidden from clinical view.
Habit Reversal Training (HRT) is the cornerstone of treatment and the most evidence-based intervention. Three components: awareness training (the patient learns to detect prodromal urges and circumstances that precede pulling), competing response training (a deliberate motor behavior incompatible with pulling — making a fist, holding an object — performed when the urge occurs), social support (family or therapist providing reinforcement for non-pulling). Effective in many patients without medication.
Pharmacotherapy: SSRIs less effective than in OCD. N-acetylcysteine (NAC) at 1200-2400 mg/day has emerging evidence — appears to modulate glutamate signaling in striatum. Olanzapine has some evidence at low doses. Combined HRT + medication often outperforms either alone for moderate-severe cases.
When you encounter a patient with visible or hidden hair loss from pulling, trichotillomania is the diagnosis. Treatment is effective and underused — many patients have hidden the behavior for years without knowing structured treatment exists. HRT is brief, targeted, and produces meaningful improvement in many patients.