Understanding and Treating Trichotillomania: Not Just a Benign Habit

By Christopher A. Flessner, Ph.D., and Abbe Marrs Garcia,

Trichotillomania (TTM) is a psychiatric disorder characterized by the repetitive pulling out of one's hair, resulting in noticeable hair loss as well as clinically significant academic, social, and/or occupational impairment. Estimates suggest that as many as 3 million children and adults in the United States alone suffer from the disorder. Generally, TTM is much more prevalent among women, but it is believed that this gender disparity may be less pronounced during childhood.

October 2010 Vol. 26, No. 10

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This article was published in the Brown University Child and Adolescent Behavior Letter
in cooperation with Bradley Hospital.

Although TTM can be diagnosed at any age, the average age of illness onset is during childhood (9-11 years of age), with cases also reported as young as 18 months. Unfortunately, compared to other psychiatric disorders (e.g., anxiety, depression) very little information is available about what TTM is - and what it is not. Consequently, pediatricians, psychiatrists, psychologists, and other mental health practitioners are often misinformed about the disorder. In turn, some simply classify TTM as nothing more than a benign habit, particularly among children. However, as many children (and their families) with TTM will tell you, this is far from the truth.

Manifestations and consequences

Children with TTM pull from anywhere that hair can grow, including the scalp (most common), eyebrows, and eyelashes. Very young children (e.g., toddlers) typically pull from only the scalp. Compared to adults, fewer children report pulling from the pubic area, though pulling pubic hair may become more frequent during adolescence.

Hair pulling occurs most frequently via use of the fingers, though implements or devices (e.g., tweezers) are also used. Aside from hair loss, TTM is not thought to have many serious physical consequences associated with it. However, a significant number of individuals with TTM also bite, chew on, and occasionally swallow their hair. Ingesting one's hair, trichophagia, can result in hairballs (or trichobezoars) that may become a serious health threat and often require surgery.

A number of social consequences may also accompany hair pulling during childhood. For example, studies in which child actors mimicked hair pulling demonstrated that they were perceived as less socially acceptable by their peers. These findings are supported by reports obtained from clinical samples of children with TTM. Families typically attempt a variety of different strategies to conceal the physical consequences of hair pulling, including the use of make-up, hair extensions, hairstyles, glasses, or wigs. In turn, these negative physical and social consequences may lead to or exacerbate comorbid psychiatric illnesses.

TTM and comorbidity

Relatively little research has examined comorbid mental health concerns among children with TTM. One recent study found that 39% of children with TTM presented with a comorbid psychiatric diagnosis. Of those children with a comorbid diagnosis, 30% and 11% presented with an anxiety or externalizing disorder, respectively. Within these respective domains, generalized anxiety, social phobia, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, and oppositional defiant disorder were among the most common diagnoses. Similarly, a recent internet-based study found that 38% of children with TTM had been diagnosed with at least one other mental health disorder.

Families typically attempt a variety of different strategies to conceal the physical consequences of hair pulling, including the use of make-up, hair extensions, hairstyles, glasses, or wigs.

TTM in young children has been studied with even less frequency. One investigation found that 50% of toddlers (e.g., <3 years of age) who pulled their hair met requirements for a comorbid anxiety disorder; 40% displayed developmental problems; 20% had chronic pediatric concerns; and 100% had family stressors such as parental separation, homelessness, unemployment, or parent mental illness. Taken together, available evidence suggests that a variety of comorbid diagnoses can present among children with TTM. This line of evidence also suggests, however, that each child with TTM is different. This highlights the importance of an adequate functional assessment of the child's pulling.

Automatic vs. Focused Pulling

Recent evidence suggests that children (e.g., 10+ years of age) with TTM exhibit two distinct styles of hair-pulling, referred to as automatic and focused pulling. Automatic pulling is best described as pulling that occurs primarily outside of a child's awareness. For example, a child who engages in automatic pulling may pull their hair while watching television, reading a book at night, or listening to the radio. Often times, there is no realization that pulling has occurred until after the fact, perhaps brought to the child's attention by a parent.

Conversely, focused pulling is characterized by pulling in response to an unpleasant emotion (e.g., anxiety, stress, anger, etc.) or an intense thought or urge. For example, a child who is anxious about school the following day may pull their hair as a means of reducing his/her anxiety. The vast majority (roughly 96%) of children, however, exhibit both styles of pulling. Researchers have speculated that hair pulling may begin as primarily automatic in nature (during childhood), and as the child matures, focused pulling develops and begins to play a larger role (Flessner et al., 2009).

Perhaps the most important aspect to these findings in relation to automatic and focused pulling is the notion that these different pulling styles may require different therapeutic interventions.

Habit Reversal Training

To date, no studies have been published examining the efficacy of pharmacological interventions for childhood TTM. Regarding behavioral interventions, cognitive behavior therapy (CBT) is thought to hold the most promise. Habit reversal training (HRT) is generally considered the core component to CBT for children. HRT generally consists of three primary components: awareness training, competing response training, and social support.

Awareness training: During awareness training, the child is required to describe his/her hair pulling in great detail and to detect instances of the behavior (i.e., simulated or actual behavior). Subsequently, the child practices detecting precursors to hair pulling (e.g., tingly feelings, feelings/ emotions), and the therapist helps the child identify environmental stimuli (e.g., settings) likely to elicit hair pulling.

Competing resource (CR) training: CR training involves teaching the child to engage in a competing behavior (e.g., clenching fists, crossing arms) contingent on hair pulling or its early warning signs.

Social support training: The social support component of HRT consists of having family members praise the client when he/she notices the client correctly engaging in the CR. The family member(s) also reminds (in a nonpunitive manner) the child to use the CR when he/she fails to do so. Although yet to be tested, some researchers have hypothesized that HRT may best address automatic hair-pulling, while additional components to treatment (see below) may be necessary to more adequately address focused pulling.

To date, one open CBT trial (N= 22 child hair pullers; 8-17 years of age) utilizing HRT as the core treatment component found that 77% and 66% of children were classified as treatment responders at posttreatment and 6-month follow-up, respectively (Tolin et al., 2007). A small, randomized controlled trial of CBT for children had similarly encouraging results, and a larger trial is currently underway at the University of Pennsylvania.

For children who engage in primarily focused pulling, additional treatment components are often necessary in addition to HRT. These might include developing a behavioral reward system (i.e., to reward the child for treatment compliance); self-monitoring (i.e., collecting hairs, using a golf counter to record each pulling episodes); stimulus control (i.e., modifying the child's environment to reduce cues or triggers for hair pulling); or relaxation training.

Clearly, additional research is necessary to develop a more comprehensive understanding of the cause(s), maintenance, and treatment of childhood TTM. This is particularly true for very young children diagnosed with the disorder. To aid in this process, the Trichotillomania Learning Center (TLC; www.trich.org), a large patient-support organization for children and adults with TTM, has begun to invest greater resources towards obtaining a better understanding of this largely misunderstood disorder. Those children, families, and practitioners interested in learning more about TTM are encouraged to make contact with the TLC and request more information.

Christopher A. Flessner, Ph.D. is a Psychology Fellow, Rhode Island Hospital & Warren Alpert Medical School at Brown University; and a member of the Trichotillomania Learning Center-Scientific Advisory Board.

Abbe Marrs Garcia, PhD is an Assistant Professor (Research) at Warren Alpert Medical School at Brown University, and Assistant Director of Child Outpatient Psychiatry at Rhode Island Hospital.


Flessner CA, Woods DW, Franklin ME, et al.: Cross-sectional study of women with trichotillomania: A preliminary examination of pulling styles, severity, phenomenology, and functional impact. Child Psych Human Devel 2009; 40(1):153-167.

Tolin DF, Franklin ME, Diefenbach GJ, et al.: Pediatric trichotillomania: Descriptive psychopathology and an open trial of cognitive behavioral therapy. Cog Beh Ther 2007; 36(3):129-144.