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Trichotillomania (Hair Pulling Disorder)

In DSM-5 Trichotillomania (TTM) is categorized as an OCD Related Condition; previously it was considered as an impulse control disorder. TTM involves strong and hard-to-suppress urges to pull, or twist, hair from the scalp, eyebrows, eyelashes, or other areas of the body. It is OCD related because of the frequent presence of an “urge” that is neutralized by pulling, as well as other “ritualistic” aspects. However, it also has some qualities similar to tics. TTM patients present with highly variable experiences; some find hair pulling gratifying, some find it annoying or painful, others do it automatically, more of a “bad habit.”

Hair pulling can result in significant hair loss, causing bald patches in the affected areas of the body—and great emotional distress as well. People with TTM often try to disguise or hide their condition, e.g. by wearing clothing that covers problem areas, or by using hair clips, hats, hairpieces, or wigs.

TTM affects approximately one to two percent of Americans, mostly in pre- or early adolescence, and the majority of TTM sufferers are women. The disorder, however, may affect people of all ages, and of either sex. The severity of symptoms of TTM can vary tremendously. Mild symptoms might be possible to address one one’s own by making improvements in awareness and concentration on resisting pulling, but pervasive, severe, completely thought-consuming urges to pull hair require more intensive treatment. The emotional impact of TTM often includes feelings of depression and shame.

Treatments for TTM include Cognitive-Behavioral Therapy (CBT). CBT helps by identifying the hair pulling triggers (e.g. boredom, stress, seeing a hair that looks out of place) and learning skills to interrupt and redirect responses to those triggers. In this way, hair pullers can develop an increased awareness of the times of day, emotional states, and other factors that promote hair pulling. Self-monitoring by keeping records of hair pulling can also be helpful. However, the CBT that is most relevant to TTM is called Habit Reversal Therapy (HRT). HRT has a number of elements, including identifying and practicing behaviors that compete with pulling. HRT concepts for treating TTM have been expanded in the Comprehensive Behavioral (ComB) model.

Finding effective medication for TTM has been challenging: however, some patients will find medication beneficial. Current research continues to explore the possible advantage of combining medication with CBT.

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