Obsessive-Compulsive and Related Disorders
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Recurrent pulling out of one's own hair, resulting in hair loss, with repeated attempts to decrease or stop the behavior.
Trichotillomania is a body-focused repetitive behavior: recurrent hair-pulling that leads to noticeable hair loss, despite the person having tried more than once to cut back or stop. Like other disorders in this chapter, it's organized around a repetitive, hard-to-resist urge-driven behavior directed at the body, distinct from an obsessive-compulsive pattern built around intrusive thoughts.
Onset is often around puberty, though it can begin earlier in childhood (where it sometimes resolves on its own) or later; a chronic course into adulthood is more likely when onset is in adolescence and the behavior has been present for an extended period before treatment.
Impact includes visible hair loss (which can be a major source of shame and social avoidance), skin damage from the pulling itself, and significant time spent pulling or attempting to conceal the resulting hair loss (wigs, styling, avoidance of situations where hair loss might be noticed).
Pulling can be 'focused' (deliberate, often preceded by tension and followed by relief, similar in structure to the impulse-control pattern) or 'automatic' (occurring with little awareness, often during other activities like reading or watching television) -- many people show both patterns at different times.
Hair has significant cultural and identity-related meaning across many contexts, which can shape both the distress caused by visible hair loss and the degree of shame or secrecy around disclosure -- clinicians should be attentive to what hair loss specifically means to a given patient's identity and community.
A common misconception is that hair-pulling is simply a bad habit the person could stop through willpower. The diagnosis specifically requires repeated unsuccessful attempts to decrease or stop the behavior, reflecting a genuine difficulty with control, not a lack of trying.
If the repetitive behavior is directed at skin rather than hair, reconsider Excoriation Disorder (both can co-occur). If the behavior is preceded by a specific intrusive obsessive thought about the hair, reconsider whether OCD better explains the pattern.
A 17-year-old has noticeable thinning at her hairline that she conceals with careful styling, describes pulling hair almost automatically while doing homework, and has tried several times to keep her hands away from her scalp without lasting success.
Know
Trichotillomania is recurrent hair-pulling causing hair loss, with genuine repeated attempts to stop -- a body-focused repetitive behavior, not simply a habit.
Notice
In a case, notice visible hair loss from pulling, attempts to stop that haven't lasted, and possibly a tension-relief cycle or automatic pulling during other activities.
Distinguish
Distinguish from Excoriation Disorder by target (hair vs. skin) and from OCD by the absence of a specific preceding obsessive thought driving the behavior.
Recognize
Recurrent hair pulling resulting in hair loss, repeated attempts to decrease or stop the behavior, and clinically significant distress or impairment -- not accounted for by another medical condition (e.g., a dermatological condition) or better explained by another mental disorder.
Distinguish
Distinguish from Excoriation Disorder by target (hair vs. skin) and from OCD by the absence of a specific preceding obsessive thought driving the behavior.
Excoriation (Skin-Picking) Disorder involves the same tension-relief structure but directed at skin rather than hair; a person can have both, and clinicians should assess for each separately rather than assuming one predicts the other. Obsessive-Compulsive Disorder's compulsions are typically performed to reduce anxiety generated by a specific obsessive thought, whereas hair-pulling here is not typically preceded by an obsession about the hair itself.
When hair loss from Trichotillomania becomes noticeable, a patient may develop camouflaging behaviors resembling Body Dysmorphic Disorder; asking specifically about the sequence -- did concern about appearance come first, or did habitual pulling come first and appearance concern follow as a consequence -- clarifies the primary diagnosis.
Students sometimes treat these as a single 'BFRB' diagnosis rather than two distinct, separately-criteria'd disorders that happen to share a common underlying structure and often co-occur.
Because both fall under the same DSM-5-TR chapter, learners may assume more clinical overlap than actually exists; this pairing is a useful reminder that the Obsessive-Compulsive and Related Disorders chapter groups conditions by a shared underlying obsessive-compulsive-spectrum mechanism, not by similar surface presentation.
Reason
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2 question(s) reference this disorder. Practice Trichotillomania (Hair-Pulling Disorder) →
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