Tricho - Hair pulling


Trichotillomania is the fierce urge to pull hair from the scalp or other parts of the body.  Although bouts of hair pulling have been associated with stress, frequent episodes occur in periods of relaxation and distraction.

Trichotillomania is recognised as a body-focused, repetitive behaviour. This type of behaviour can include repetitive self-grooming activities such as picking, pulling, and nail or lip biting. These can cause emotional distress and damage to the body, but the people performing the behaviours cannot stop.


Obsessive compulsive disorders (OCD) and body-focus repetitive behaviours share similar characteristics on the surface: Both involve urges to perform repetitive behaviours. But unlike compulsions experienced with OCD, body-focused repetitive behaviours are soothing and can even be pleasurable.

The pulling, picking or biting behaviour is rarely the result of specific obsessions that would characterise a compulsive disorder.  This distinction is crucial because medication is a first-line treatment for OCD in the UK, but currently there is no approved medication to treat body-focused repetitive behaviours.

The critical distinction between ‘normal’ scab picking, nail biting, and hair plucking is when the behaviour does not stop, and goes on to cause significant distress, while the person feels unable to stop the actions.  The causes of body-focus repetitive behaviours are poorly understood, though responses to different interventions may provide clues to the biological underpinnings.

For example, medications that target the neurotransmitter serotonin, such as Fluoxetine (Prozac), have not proven effective in reducing body-focus repetitive behaviours for most people—though medications, such as Clomipramine that act as a serotonin and norepinephrine re-uptake inhibitor, have been shown to be effective for short term treatment of trichotillomania [1].

This is significant as it was proposed that norepinephrine is released from Merkel cells upon mechanical stimulation to subsequently activate β2 adrenergic receptors on Merkel disc nerve endings leading to nerve impulses [2].  It is likely it is this nerve impulse that attracts the pulling for the sensation it will give, rather than as an act of self-harm or a destructive venture.


• Watching a hair as it is being pulled out
• Examining a hair that has already been pulled
• Examining the hair bulb, checking its size etc
• Chewing and swallowing pulled hairs
• Biting pulled hairs
• Biting the hair bulb
• Pulling hairs between the teeth


• Touching or stroking hair
• Tugging at hair
• Pulling out a hair
• Handling and manipulating a hair
• Separating the hair bulb from the hair shaft
• Playing with the hair bulb
• Stroking the pulled hair across the cheek or lips


This hair pulling condition has a complex pathophysiology with many imputes and triggers that contribute to episodes.  If trichotillomania is to be treated successfully, various contributing factors must be identified and dealt with individually.  Once the complexity of the contributing factors for the individual have been considered, effective treatment plans can be put together.

Care must be taken to ascertain the psychological state of the person and any contributing environmental stressors that would be contributing to the anxiety issues.  Sources of activation of the sympathetic nervous system should be investigated to ascertain nutrient deficiencies or allergic reactions that act as stressors and further exacerbate the problem.  Supplementation with tyrosine (2 grams per day) may be effective in reducing pulling episodes.

Trichotillomania can be managed with attention to the individuals’ own needs and requirements, and studies show that hair pulling episodes can be greatly reduced, or even eliminated altogether, with a combination of treatments designed to restore the individuals own sense of self and wellbeing.

Talk about your trichotillomania to people you trust, as hiding the condition can make your anxiety worse.  Those who have learned to manage their trichotillomania have reported that speaking to others about the condition led to a reduction in hair pulling.


  1. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). New England Journal of Medicine. 1989 Aug 24;321(8):497-501.
  2. Molecular profiling reveals synaptic release machinery in Merkel cells. Proceedings of the National Academy of Sciences. 2004 Oct 5;101(40):14503-8.
  3. N‐Acetylcysteine in the treatment of trichotillomania: remarkable results in two patients. Journal of the European Academy of Dermatology and Venereology. 2016 Sep;30(9):1606-8.
  4. Extensive tonsure pattern trichotillomania-trichoscopy and histopathology aid to the diagnosis. International journal of trichology. 2013 Oct;5(4):196.
  5. Failure to convulse with ECT. The British Journal of Psychiatry. 1989 Dec;155(6):869-70.