Trichotillomania

When Hair Loss Is Connected to Hair Pulling

When we talk about hair loss, we tend to immediately think about what might be happening inside the body. Hormones, nutrition, genetics, stress, autoimmune conditions and medications can all be part of that conversation. But hair loss isn't always coming from a change within the follicle. Sometimes the hair is being physically pulled from the scalp.

When that pulling becomes repetitive, difficult to control and begins causing noticeable hair loss or distress, we may be looking at trichotillomania, also known as hair-pulling disorder. And before we go any further, I think there is an important distinction to make: trichotillomania isn't simply a bad habit. It is a recognized mental health condition and a type of body-focused repetitive behaviour (BFRB).

That changes how we need to approach the conversation. We can't simply look at the missing hair and focus all of our attention on getting it to grow back. We need to understand why the hair is missing in the first place and remember that a person is attached to the hair.

What Is Trichotillomania?

Trichotillomania involves repeatedly pulling out your own hair and having difficulty reducing or stopping the behaviour. The scalp is commonly affected, but pulling can also involve the eyebrows, eyelashes and other areas of the body.

The experience isn't necessarily the same for everyone. Some people are very aware of when they are pulling. Some people feel an urge beforehand or a sense of relief afterward. For someone else, the behaviour may happen almost automatically while watching television, reading, studying, working at the computer or doing something else that occupies their attention.

Hair pulling can also have a sensory component. A particular hair may feel different from the others. It might feel coarse, wiry or somehow stand out, and the person becomes focused on finding or removing that particular hair. These differences matter because there isn't one universal presentation of trichotillomania, and understanding the behaviour requires more than looking at the area where hair has been lost.

What Can Trichotillomania Look Like in the Hair?

From a trichology perspective, observation becomes particularly important. Different types of hair loss can create different patterns, and part of an assessment is understanding what those patterns may be telling us.

With trichotillomania, we may see irregular areas of reduced density rather than the more predictable distribution associated with some other forms of hair loss. Within those areas, there may be hairs of many different lengths. Some may be newly growing, some may be broken, some may have been repeatedly manipulated, and some follicles may temporarily have no visible hair at all.

Those findings can give us clues, but clues are not the same thing as a diagnosis. Broken hairs, reduced density and irregular areas of hair loss can occur for more than one reason. I would never want to look at a patch of hair loss and immediately decide that someone has been pulling their hair. We need context, history and examination before we start drawing conclusions.

This Is Where Observation Matters

If you've read much of my work, you've probably noticed that I come back to observation a lot. There is a reason for that. Before we decide what something is, we need to understand what we're actually looking at.

When someone comes to me concerned about hair loss, I want to know whether the hair is shedding from the follicle or breaking somewhere along the fibre. I want to know whether density has changed, whether individual hairs are becoming finer, whether the loss is diffuse or concentrated in certain areas and whether there are changes happening on the scalp. I also want to know when it started, what was happening beforehand and how the pattern has changed over time.

Trichoscopy can be useful here because magnification allows us to look more closely at differences in hair length, breakage, regrowth and the condition of the scalp and follicles. But there is also an important limitation to understand: trichoscopy shows me the physical evidence in front of me. It cannot tell me the whole story behind a behaviour.

And knowing where our information stops is just as important as knowing what it can tell us.

Hair Pulling Isn't a Character Flaw

This is one of the most important parts of this conversation because shame has absolutely no useful role here.

Someone experiencing trichotillomania may already feel embarrassed or frustrated by the pulling and the resulting hair loss. They may change their hairstyle to hide areas of reduced density, avoid situations where someone might notice or use wigs, toppers, fibres, makeup, extensions or other forms of camouflage. They may also have tried repeatedly to stop.

Telling someone to “just stop pulling your hair” misunderstands what is happening. If it were that simple, they probably would have stopped already.

Trichotillomania can involve automatic, focused behaviours, emotional triggers, sensory experiences, urges, and learned patterns. That means the person sitting in front of us doesn't need judgement or another lecture about self-control. They need understanding, appropriate support and a plan that considers more than the cosmetic result.

Understanding the Patterns Behind Hair Pulling

There isn't one simple cause of trichotillomania, and the circumstances surrounding hair pulling can differ greatly from person to person. For some people, stress, anxiety, frustration, boredom or tension may be associated with pulling. For others, the behaviour can happen with surprisingly little conscious awareness.

This is where I think awareness becomes incredibly useful, but not awareness as blame. Awareness as information.

Instead of only asking, “Why can't I stop doing this?” it can help to notice when the behaviour happens, what was happening immediately beforehand, where you were, what your hands were doing, and whether you were looking for a particular sensation or texture in the hair. Noticing what happens afterward can also provide useful information.

We're not collecting those observations to judge the behaviour. We're looking for patterns. And patterns give us somewhere to begin.

Can Hair Grow Back After Trichotillomania?

Naturally, one of the first questions people want answered is whether the hair will grow back. The most accurate answer is that it depends.

Hair follicles are capable of producing another hair after a hair has been pulled, so regrowth can absolutely occur. But repeated physical trauma to the same area over a long period can complicate the picture. The condition of the follicle, the health of the scalp, how long the area has been affected and whether scarring or other damage has occurred can all influence what happens next.

This is one reason I don't like promising hair regrowth based on a photograph, and it's also why I don't believe the first response should automatically be another “hair-growth” product. Before we decide how to encourage hair growth, we need to understand why the hair is missing.

Sometimes the most important intervention isn't something we put on the scalp.

Treatment Needs to Address More Than the Hair

Because trichotillomania is a mental health condition, treating the hair alone doesn't address the behaviour contributing to the hair loss. Behavioural therapies can therefore be an important part of treatment. One established approach for trichotillomania is Habit Reversal Training (HRT), which can help someone become more aware of the situations, behaviours, and sensations associated with pulling and develop alternative responses.

Other psychological approaches may be appropriate depending on the individual, and an appropriate healthcare professional may sometimes consider medication. There isn't one universal treatment, which is why collaborative care becomes so important.

A dermatologist or physician may evaluate the hair loss and rule out other conditions. A mental health professional experienced with trichotillomania or body-focused repetitive behaviours can work with the behavioural and psychological component. A trichologist can contribute by examining, documenting and monitoring what is happening with the hair and scalp.

Different pieces of the problem may require different professionals. That isn't fragmented care. Done properly, that's collaborative care.

Where Does a Trichologist Fit?

My role isn't to diagnose or treat the psychological component of trichotillomania. My role is on the hair and scalp side of the conversation.

Through assessment and trichoscopy, I can look more closely at the areas of concern, examine the scalp and hair fibre, document density and breakage, establish a baseline and monitor changes over time. We can also talk about protecting the remaining hair and fibre while the appropriate support is being put into place.

If what I'm seeing suggests that medical or mental-health investigation is needed, referral is part of responsible trichology care. I don't need to be every professional involved in someone's care, nor should I try to be. My job is to recognize what sits within my scope, what doesn't, and help someone get to the right next step.

Sometimes More Than One Thing Is Happening

Another reason assessment matters is that evidence of hair pulling doesn't automatically mean every change in someone's hair can be explained by trichotillomania.

Someone can experience hair pulling and another form of hair loss at the same time. They may also have androgenetic alopecia, excessive shedding, scalp inflammation or significant hair-fibre damage. Human bodies don't politely organize themselves into one neat diagnosis at a time. It would certainly make my job easier if they did.

This is why I don't like viewing hair in a silo. My approach considers scalp, loss, growth, retention, fibre and care because each can give us another piece of the picture. We need to understand what is happening at the follicle, what is happening to the fibre, what has changed over time and what else may be contributing.

Most importantly, we need to remember that there is a person attached to all of it.

Start With Understanding

If you're experiencing irregular areas of hair loss, broken hairs or changes in density and aren't sure what's causing them, you don't need to diagnose yourself from photographs online. In fact, I'd rather you didn't.

Start with understanding what you're seeing. Look at the pattern and the timeline. Examine the hair and scalp. Ask better questions. And when the evidence points beyond the hair itself, bring the appropriate professionals into the conversation.

Hair loss tells us that something has changed, but it doesn't always tell us exactly what changed. That's where observation, assessment and the right questions become so important.

Because before we can decide what to do about hair loss, we need to understand what we're actually looking at.

Keep Exploring Hair Loss

Trichotillomania is only one possible explanation for hair loss. Different hair-loss conditions can look surprisingly similar from the bathroom mirror, and sometimes more than one thing is happening at the same time.

→ Explore All Types of Hair Loss

You can learn more about androgenetic alopecia, telogen effluvium, alopecia areata, traction alopecia, scarring alopecia, hormonal influences, nutritional factors and other patterns in my Hair Loss Library.

Concerned About Your Own Hair?

You don't need to determine what type of hair loss you have before reaching out. That's part of what an assessment is designed to help us understand.

My Comprehensive Trichology Assessment looks at the pattern and timeline of your hair loss, along with your scalp, hair growth, hair fibre, hair-care practices, and relevant context. The goal isn't to squeeze you into a one-size-fits-all answer. It's to understand the bigger picture, identify what may deserve further investigation and determine the most appropriate next steps for you.

→ Book a Complimentary 15-Minute Consultation

→ Explore the Comprehensive Trichology Assessment

Related Reading

• Androgenetic Alopecia + Pattern Hair Loss

• Hormones + Hair Loss

• Nutrition + Hair Health

• Telogen Effluvium

• Trichoscopy

Educational information only. This article is not intended to diagnose or treat trichotillomania or any other medical or mental health condition. If you're experiencing recurrent hair pulling that is causing hair loss, distress or interfering with your daily life, speak with an appropriate healthcare or mental health professional.