Trichotillomania (TTM) is a disorder that seems to lurk in the shadows. We hear about it but rarely see it. The question of whether it is an anxiety disorder, an impulse control disorder, or a behavioral addiction remains murky. And if asked how to treat it, most of us would probably shrug our shoulders and guess some combination of an SSRI plus cognitive behavioral therapy. That answer, however, isn’t quite right, and in this article, I’ll bring you up to date on the disorder and its treatment.

What is TTM?
TTM (Greek for “hair-pulling madness”) is a syndrome where individuals pull out their hair despite repeated attempts to stop. The scalp, eyebrows, and eyelashes are the most common sites. In some cases, patients eat their hair after pulling it out (trichophagia), which in rare instances can cause gastrointestinal obstruction.

TTM was originally conceptualized as a stereotyped, repetitive behavior where mounting anxiety is relieved by the plucking of a hair follicle. Although some patients do engage in this type of “focused” hair-pulling, the majority pull their hair out “automatically” (ie, outside of their awareness). TTM typically has its onset in early adolescence and affects around one in 60 people. Rates are similar for women and men, but the effects tend to be more noticeable and more bothersome for women. 

Textbooks claim that TTM is underrecognized in practice, possibly because of the shame associated with the behavior. To test that out, I screened 100 consecutive patients in my outpatient practice who had no record of TTM, and indeed I was surprised by how common it was: 7% were actively pulling hairs and another 3% had done so in the past. But like most behaviors, ­hair-pulling occurs on a spectrum of what might be considered normal behavior, and most of the “new cases” I found were mild and caused minimal impairment or distress.

DSM-5 changed the classification of TTM from an impulse control disorder to an OCD spectrum disorder (along with hoarding, skin picking or “excoriation,” and body dysmorphic disorder), but its diagnostic resting place is far from settled. A recent study evaluating TTM’s comorbidity, for example, found that it had more in common with impulse control disorders such as kleptomania, pyromania, and bulimia. Additionally, a factor analysis study of 2,705 individuals in the community concluded that TTM might best be conceptualized as self-grooming behavior similar to skin-picking and nail-biting (Gerstenblith TA et al, Compr Psychiatry 2019;94:152123; Maraz A et al, PLoS One 2017;12(9):e0183806). In all likelihood, hair-pulling is the final common pathway whose roots may originate as a cognition, an impulse, or a stress-reduction behavior, depending on the individual. 

Pharmacotherapy
Before starting new medication for TTM, be aware that some of the medications we prescribe can actually cause the syndrome. Hair-pulling, nail-biting, and other compulsive behaviors can occur with dopaminergic drugs, such as stimulants, medications for Parkinson’s disease, as well as cocaine.

SSRIs generated early hope in small, open-label studies, but a subsequent series of ­placebo-controlled trials with sample sizes ranging from 20 to 40 each yielded negative results, and two meta-analyses have concluded that SSRIs are no more efficacious than placebo (Bloch MH et al, Biol Psychiatry 2007;62(8):839–846; Rothbart R et al, Cochrane Database Syst Rev 2013;(11):CD007662). 

With SSRIs off the table, researchers have had to travel down less conventional roads. One interesting candidate is the natural supplement N-acetylcysteine (NAC). NAC reduces synaptic release of glutamate, and glutamatergic dysfunction has long been implicated in the pathogenesis of OCD. In the largest positive study conducted to date for TTM, Grant and colleagues randomized 50 patients to either NAC 1200–2400 mg/day or placebo in a double-blind manner over the course of 12 weeks (Grant JE et al, Arch Gen Psychiatry 2009;66(7):756–763). Subjects receiving NAC reported significantly less hair-pulling at endpoint (p<0.001) and an overall improvement of about 40%. Side effects were minimal. Unfortunately, these results have never been replicated, and similar studies in pediatric populations have failed to find benefit, casting doubt on NAC’s true efficacy. 

Olanzapine was helpful in one small double-blind placebo-controlled trial (n=25) that used a flexible-dose strategy, arriving at a mean of 5.7 mg/day (Van Ameringen M et al, J Clin Psychiatry 2010;71(10):1336–1343). Clomipramine, naltrexone, and modafinil failed in small placebo-controlled trials, while a cannabinoid (dronabinol) yielded positive effects in 12 of 14 patients in one open-label trial (Grant JE et al, Psychopharmacology (Berl) 2011;218(3):493–502).

Psychotherapy
All of the above should suggest that medications play only a limited role when treating TTM. Indeed, in the few studies that have compared psychotherapy to medications, psychotherapy has typically been found to be more efficacious.

Pure cognitive therapy is not useful for TTM because patients usually can’t identify specific cognitions related to the behavior. Instead, the most promising and best-studied technique for TTM is habit reversal therapy (HRT). This is a sequential treatment that starts by focusing on increasing the awareness of the behavior (remember that hair-pulling is often done automatically). Awareness training can be done, for example, by keeping a log, watching oneself in the mirror, etc. Second, the patient learns to identify triggers of TTM both internally (eg, boredom, anxiety) and externally (eg, studying, driving). Once the patient has a heightened awareness of the behavior, the final step is to develop a competing action that replaces hair-pulling, such as squeezing a ball or gently biting down on one’s lips. This competing action should be continued until the urge to pull subsides. 

Ten randomized controlled trials of HRT for TTM have been performed to date. Though results are still preliminary, the bulk of evidence suggests that the technique is probably effective (Lee MT et al, Front Behav Neurosci 2019;13(79):1–15). Furthermore, one follow-up study found that the gains made with HRT were maintained through at least three to six months of follow-up (Grant JE and Chamberlain SR, Am J Psychiatry 2016;173(9):868–874). 

Unfortunately, finding a local therapist trained in HRT can be difficult, if not impossible. Teletherapy is one option, and there are therapist-guided (www.trichstop.com) and self-guided (www.stoppulling.com) programs available online. Another option is to offer HRT yourself. The techniques are easy to learn and can be taught to motivated patients in a 30-minute session (See: Woods D and Twohig M. Trichotillomania: An ACT-Enhanced Behavior Therapy Approach Workbook. Oxford University Press; 2008).

One last avenue being explored involves utilizing devices to break the TTM habit. Gloves (such as winter or driving gloves) offer the most accessible intervention and are certainly worth trying, but they may not be a realistic option in all settings. A high-tech option that is currently being investigated is a wrist band that senses early hair-pulling movements and alerts the patient when they occur (Himle JA et al, J Obsessive Compuls Relat Disord 2018;16:14–20). One device is commercially available, the Keen bracelet ($80 from HabitAware), and although patients have found it useful, I’m not aware of any specific studies of the Keen. 

Carlat Verdict: Hair-pulling is probably more common than you think, and when it causes distress or impairment, a diagnosis of TTM is likely. HRT is the best approach. Medication options are limited, and they include the low-risk antioxidant NAC and, for severe/refractory cases, olanzapine.