Diagnostic features

• Recurrent hair pulling resulting in hair loss.
• Repeated attempts to decrease or stop the behaviour.
• Hair pulling causes clinically significant distress or impairment in social, occupational, or other areas of functioning.
• Not better explained by another mental disorder, medical condition (e.g., dermatologic), or normative cultural practices.

Clinical presentation & subtypes

• Pulling sites: scalp, eyebrows, eyelashes, beard, body hair — patients may pull from one or multiple sites.
• Modes: automatic (habitual, low awareness) vs focused (triggered by emotional states or urges); many patients show mixed patterns.
• Associated behaviours: hair chewing (trichophagia) which may lead to trichobezoars and gastrointestinal complications.

Associated conditions

• Common comorbidities: depression, anxiety disorders, OCD spectrum disorders, body‑focused repetitive behaviours (skin picking), ADHD and substance misuse.
• Assessment of mood, suicidality, and impulse control is important — trichotillomania can be associated with significant shame, avoidance and social withdrawal.

Assessment checklist

1. Detailed history: age of onset, triggers, pattern (automatic vs focused), frequency/intensity, sites pulled, attempts to stop and functional impact.
2. Examine hair loss pattern and skin — consider dermatology input to exclude primary skin disease or infections.
3. Screen for trichophagia (ask about hair swallowing, abdominal pain), depression, anxiety, OCD symptoms and suicidality.
4. Use severity scales (MGH‑Hair Pulling Scale) to quantify baseline and monitor treatment response where available.

Treatment — behavioural therapies

• Habit Reversal Training (HRT): the gold‑standard behavioural therapy — awareness training, development of a competing response, relaxation, and social support. Delivered over weeks to months.
• Comprehensive Behavioral Intervention for Tics/Trichotillomania (CBIT): includes HRT plus stimulus control and functional assessment; effective in reducing pulling.
• Acceptance and Commitment Therapy (ACT) & CBT elements: helpful for emotional regulation, reducing avoidance and improving psychological flexibility.

Pharmacologic & adjunctive options

• Evidence for medication is mixed. Some options considered in specialist settings include N‑acetylcysteine (NAC) — glutamatergic modulator, and certain SSRIs or atypical antipsychotics for comorbid conditions or augmentation.
• Topiramate and olanzapine have been studied with limited evidence; pharmacotherapy is generally considered when behaviour is severe or therapy unavailable/insufficient.
• For trichophagia with trichobezoar risk, surgical/medical liaison is urgent; gastrointestinal review indicated if abdominal symptoms present.

Practical strategies for patients & carers

1. Identify high‑risk situations and implement stimulus control (hands occupied, wearing gloves, hair ties) to reduce automatic pulling.
2. Use competing responses — small, sustainable behaviours incompatible with pulling (e.g., clenching fists, squeezing a stress ball) when urge arises.
3. Keep a pulling diary to increase awareness of triggers and patterns; reinforce small wins and use contingency plans for setbacks.
4. Provide psychoeducation to family and reduce shame — supportive, non‑judgmental involvement aids engagement in therapy.

Key takeaways

• Trichotillomania is a treatable condition—behavioural therapies (HRT/CBIT) are first‑line.
• Assess for trichophagia, comorbid mental health issues and dermatologic or GI complications; escalate urgently when red flags present.
• Collaborative care (mental health, dermatology, gastroenterology) improves outcomes for complex cases.