Trichotillomania (Hair-Pulling Disorder) — Diagnosis and Treatment

Trichotillomania is a body-focused repetitive behavior (BFRB) characterized by recurrent and difficult-to-resist pulling of one's hair, resulting in noticeable hair loss. Hair pulling may target scalp (most common), eyebrows, eyelashes, beard, pubic, or body hair. The behavior is preceded by mounting tension or anxiety, accompanied by gratification or relief during pulling, and often followed by shame, guilt, and attempts to conceal hair loss with wigs, makeup, or hairstyles.

Two pulling subtypes are described: focused pulling (deliberate, conscious, often ritualistic with examination of pulled hairs) accounts for approximately 25%, while automatic pulling (occurring outside awareness during sedentary activities like reading, watching TV, or driving) is more common. Many individuals exhibit both patterns. Approximately 5-20% engage in trichophagia (consuming pulled hairs), which can rarely lead to trichobezoar (hair mass in stomach) requiring surgical removal—'Rapunzel syndrome.'

Onset typically occurs in late childhood or early adolescence with bimodal age distribution. Conceptual frameworks emphasize habit-based behavior, emotional regulation function (relief from negative emotions), and reinforcement through both negative reinforcement (anxiety reduction) and positive reinforcement (sensory pleasure). High comorbidity with depression, anxiety disorders, and other body-focused repetitive behaviors (skin picking, nail biting). Effective treatment is primarily behavioral: habit reversal training (HRT) involves awareness training, competing response training, and motivation/social support; comprehensive behavioral treatment adds stimulus control and emotional regulation skills; acceptance and commitment therapy targets experiential avoidance. N-acetylcysteine (1200-2400 mg/day) shows modest evidence in reducing pulling, while SSRIs are reserved for comorbid mood/anxiety disorders.