Trichotillomania (Hair-Pulling Disorder)

Trichotillomania (Hair-Pulling Disorder) is a chronic psychiatric disorder characterized by the repetitive and uncontrollable pulling of hair from the scalp or other body regions. This condition typically begins during adolescence and can lead to significant impairments in psychosocial functioning. The hair-pulling behavior is not limited to the head but may also affect eyebrows, eyelashes, beard, and other body areas. The behavior often emerges following a momentary feeling of tension, followed by temporary relief after the act.

The diagnosis of trichotillomania is generally based on the patient’s clinical history and observation. According to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), diagnosis requires that the hair-pulling behavior be repetitive, result in noticeable hair loss, be preceded by increasing tension and followed by a sense of relief. This behavior may occur consciously in some individuals, while others pull hair automatically without awareness. The act commonly involves the use of the fingertips to pluck individual hairs one by one, a process often referred to as “pinching.” As a result, irregular and asymmetric bald patches may develop on the scalp. In differential diagnosis, it is essential to rule out dermatological conditions such as alopecia areata.

The lifetime prevalence of trichotillomania in the general population ranges from 0.6% to 2.4%.^【1】 The disorder is reported more frequently in females than in males.^【2】 The onset age typically coincides with adolescence, although cases beginning at earlier ages also occur.^【3】 However, hair-pulling behaviors observed in early childhood are often transient and may be triggered by environmental factors.

The etiology of trichotillomania is multifactorial. Genetic predisposition, neurobiological differences, neurochemical imbalances, and psychological stressors may all play a role. Neuroimaging studies have identified structural abnormalities, particularly in the right frontal lobe.^【4】 Furthermore, the disorder is associated with deficits in impulse control and emotional regulation. Hair-pulling often functions as a coping mechanism in response to anxiety, stress, or internal tension.

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Trichotillomania frequently co-occurs with other psychiatric disorders. These comorbidities include major depressive disorder, anxiety disorders, eating disorders, and excoriation disorder (dermatillomania). Co-occurring psychiatric conditions can complicate treatment and lead to further declines in quality of life.

The treatment of trichotillomania generally requires a multidisciplinary approach. Currently, one of the most effective treatment modalities is Habit Reversal Training (HRT), a subcategory of cognitive behavioral therapy. This approach aims to help the individual become aware of the pulling behavior, identify triggering situations, and replace the behavior with functionally alternative responses. Other psychotherapeutic techniques include third-wave therapies such as acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT). These therapies focus on improving emotional regulation and impulse control to promote more lasting recovery.

Trichotillomania is a chronic and recurrent disorder that can cause significant negative impacts on both psychological and social functioning. Increasing awareness during diagnosis and treatment, promoting early intervention, and expanding multidisciplinary approaches are essential. The absence of standardized treatment protocols and patients’ reluctance to seek treatment due to shame can negatively affect clinical outcomes. Therefore, integrating long-term follow-up and supportive approaches into treatment is recommended.

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