Trichotillomania (hair-pulling disorder): treatment, causes and signs

The NHS says trich is commonly treated using a type of CBT called habit reversal training, which aims to help you replace a bad habit with something that is not harmful. OCD-UK describes this as helping the person recognise and become more aware of their hair pulling and what is triggering it, and sometimes replace it with a less harmful behaviour, which means repeatedly learning to tolerate the resulting discomfort. OCD-UK says CBT is the treatment found to be the most effective.

The NHS says treatment usually involves keeping a diary of your hair pulling, working out the triggers and learning how to avoid them, replacing hair pulling with another action such as squeezing a stress ball, and loved ones providing emotional support and encouragement.

The NHS says antidepressants are not usually prescribed to treat trich. OCD-UK says medication is no longer considered an effective treatment for trichotillomania itself, although it may be needed for any co-morbid depression.

• Keeping a diary of hair pulling.

• Working out the triggers and learning how to avoid them.

• Replacing pulling with another action, such as squeezing a stress ball.

• Emotional support and encouragement from loved ones.

Trichotillomania, known as trich or TTM, is a condition in which a person repeatedly pulls out their own hair and finds it very difficult to stop. OCD-UK explains that it is listed alongside obsessive-compulsive and related disorders and might be better thought of as a body-focused repetitive behaviour, similar to skin picking. It is not the same as OCD: OCD is driven by unwanted intrusive thoughts, while trichotillomania is characterised mainly by repetitive pulling to reduce tension or stress, or simply out of habit.

OCD-UK notes that the American Psychiatric Association first recognised trichotillomania as a mental disorder in 1987. It is a recognised condition, not a character flaw, and understanding this can take away some of the shame.

The NHS says it is not entirely clear what causes trich. It could be a way of dealing with stress or anxiety, a chemical imbalance in the brain, changes in hormone levels during puberty, or genetic, as more than one person in a family may have the condition. For some people, hair pulling can become a habit that is hard to break, and the more they pull, the more they want to keep doing it.

OCD-UK notes that medication is no longer considered an effective treatment for trichotillomania itself, although it may be needed for any co-existing depression.

The NHS says most people with trich pull hair from the scalp, but some pull from other areas. The pattern of hair loss can give a clue: bald patches on the head may have an unusual shape and affect one side more than the other.

• An intense urge to pull hair out, with growing tension until it is done, followed by relief.

• Pulling that may happen in response to stress, or without really thinking about it.

• Pulling from the scalp, eyebrows, eyelashes, the genital area, or beard or moustache.

• Bald patches of unusual shape, often more on one side of the head.

• Feelings of shame and low self-esteem, and attempts to hide hair loss or avoid social situations.

• In some people, chewing or swallowing hair, which OCD-UK says can lead to dental and digestive problems.

OCD-UK says trichotillomania is listed under obsessive-compulsive and related disorders but is not exactly the same as OCD, and might be better listed as a body-focused repetitive behaviour. It also draws a comparison with skin picking disorder.

The NHS advises seeing your GP if you are pulling your hair out or if you notice that your child is. You should also see your GP if you or your child has a habit of eating hair, as this can cause hairballs in the stomach and serious illness.

The GP may examine the areas where hair is missing to check that nothing else is causing the hair to come out, such as a skin infection. If they think you have trich, you may be referred for cognitive behavioural therapy (CBT). The NHS says if you are under 18 this may be offered through local children and young people's mental health services.

The NHS lists tips from people with trich that may help when the urge arises.

• Squeeze a stress ball, form a ball with your fist and tighten the muscles in the arm, or use a fidget toy.

• Wear a bandana or a tight-fitting hat such as a beanie.

• Take a soothing bath, practise deep breathing until the urge passes, or exercise.

• Put plasters on your fingertips, or cut your hair short.

• Open up to people you trust. The NHS says hiding it can make anxiety worse and that many people who have spoken to others report a reduction in hair pulling.

On the NHS the route is usually the GP, then CBT through local talking therapy services or, for children and young people, child and adolescent mental health services. Waiting times vary by area. Some people choose private therapy to start sooner. If you do, look for a therapist with specific experience of habit reversal training or body-focused repetitive behaviours, and check their registration with a professional body.