Home > The BFRB Blog > What the DSM-5 Says About: Trichotillomania (Hair Pulling Disorder)

At most presentations I attend, the following is what is taken from the fifth edition of Diagnostic and Statistical Manual of Mental Disorders to talk about trichotillomania.

“Diagnostic Criteria

  1. Recurrent pulling out of one’s hair, resulting in hair loss.
  2. Repeated attempts to decrease or stop hair pulling.
  3. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
  5. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).”

It’s definitely a good place to start, but before I got my hands on the DSM-5, I felt like there must be more to it than that list. And there is. Overall, I personally feel like the DSM-5 has a pretty solid foundation of understanding trichotillomania.

I say a solid foundation of understanding as opposed to just understanding because while it covers most, if not all, bases of what I know about trich, everyone experiences the disorder differently. I hate to try to fit everyone into one box, but I honestly think that the DSM-5 does a good job addressing trich.dsm5

The DSM-5 recognizes that hair pulling can occur from any part of the body, with the head, eyebrows and eyelids being the most common pull sites. It also acknowledges the pulling of pubic hair, facial hair and pulling from pretty much anywhere else on the body. It talks about how some people pull for long sessions, whereas others pull in a more scattered way throughout the day. In that sense, it recognizes the diversity of the disorder and that different people pull in different ways, which is important because I know that so many people compare themselves to other pullers to determine how severe their disorder is or something of that sort. The pulling doesn’t have to look the same in everyone though in order for it to be trich and in order for it to be impactful on your life.

That being sad, the DSM-5 also gives a clear difference between what the disorder is and is not. For instance, the distress that is mentioned in part C of the diagnostic criteria is defined as “negative effects that may be experienced by individuals with hair pulling, such as feeling a loss of control, embarrassment, and shame.” But it is important to note that, “Trichotillomania should not be diagnosed when hair removal is performed solely for cosmetic purposes,” nor should it be diagnosed if someone bites instead of pulls the hair. This clearly separates hair pulling from common hair pulling that everyone might do every once in a while when they pull out a stray hair or pluck their eyebrows to shape them. It sets pullers apart and can narrow it down to the 1-2% statistic that the DSM-5 has found.

While the fact that the pulling isn’t solely for cosmetic reasons is specified, the fact that there are ritualistic behaviours is not ignored. The searching for particular hairs, the specific ways in which a hair might be pulled, and even examining the hair in different ways and putting the hair in the mouth are highlighted as common pulling behaviours. It outlines how all behaviours concerning trich can be triggered by a range of emotions (from anxiety to boredom), can include tension beforehand and tends to lead to some form of release or pleasure immediately afterwards. But through all of this, there is usually no physical pain.

Interestingly, the DSM-5 mentions other behaviours that I see people ask about in forums, such as pulling from other people, and also from pets, dolls and other materials or objects that satisfy the same need. I say it’s interesting because so many ask about it as if it’s not spoken about, and yet apparently it has been mentioned enough in the research leading up to the fifth edition of the DSM for it to be included.

Another question that is often asked is when someone has started pulling. According to the DSM-5, and other sources often agree, that pulling most commonly starts around puberty. Pulling can of course start earlier, but their sources show that when pulling starts in younger children, in particular infants, the child will outgrow it. When pulling starts that young, it is often a self-soothing strategy, much like thumb sucking, which the child will stop doing once it’s no longer needed. (Not to say that is how all cases will turn out, but keep in mind, despite its specificities, the DSM-5 is still speaking in general, broad tones.)

And once it starts, “[t]he usual course of trichotillomania is chronic with some waxing and waning if the disorder is untreated,” and it reiterates and elaborates by saying “[f]or some individuals the disorder may come and go for weeks, months, or years at a time.” What that means is without treatment, the disorder will be persistent, but it will have periods when it’s really strong and other times when it’s barely a problem, if a problem at all. Personally, I feel even with treatment there is still the potential for waxing and waning, but treatment provides a person with more tools with which to cope and deal with these behaviours.

For all you women out there: “Symptoms may possibly worsen in females accompanying hormonal changes.” That’s right, you’re not imagining it. ‘That time of the month’ and other hormonal challenges that women face can set you off kilter and put a dent into your efforts.

Is there a genetic component? There is evidence saying there is, and that evidence also suggests that people with first degree relatives (mother, father, siblings, children) who have obsessive compulsive disorder are more likely to have trichotillomania. That being said, those with trich are at high risk for having other mental health issues, in particular “major depressive disorder and excoriation (skin-picking) disorder.” This risk is called co-morbidity.

As we all know, there are consequences that come along with these behaviours; not just the emotional ones that we face, but also the biological ones. The DSM-5 mentions that when it comes to damage to the hair, in terms of it re-growth and how healthy it is, there is potential for it to be irreversible. When it comes to how the body itself may suffer, there is a list, some of which I had to look up the definition for. It says these are “[i]nfrequent medical consequences,” but here they are:

  • digit purpura (purplish discolouration of the skin cause by hemorrhaging)
  • “musculoskeletal injury (e.g., carpal tunnel syndrome; back, shoulder, and neck pain).”
  • blepharitis (chronic eyelid swelling)
  • “dental damage (e.g., worn or broken teeth due to hair biting).”

If you also have trichophagia (eating of the hair), one of the main risks for that is trichobezoars (hairballs), which can cause additionally:

  • anemia (decrease of red blood cells)
  • abdominal pain
  • hematemesis (vomiting blood)
  • nausea/vomiting
  • bowel abstruction
  • perforation

Despite this list of consequences, the DSM-5 doesn’t talk about treatment options for trichotillomania, which would help prevent these things. True, the DSM-5 is a diagnostic tool for helping identify disorders, but at the same time I feel like any inkling of how to treat the disorder would be helpful, too.

One thing that confused me and that I disagreed with in the DSM-5 is when it says, “Most individuals with trichotillomania admit to hair pulling.” It boggled my mind because I know how many people suffer in silence and are so shamed by their pulling that they will say anything other than the truth. So I’m really not sure what the DSM-5 means by this and it doesn’t elaborate.

Overall, this is what the DSM-5 has to say about trich. I think anything that may be incorrect or is lacking can be attributed to the fact that the medical community is still in the learning process. Although it says that people with trich admit to their pulling, more people need to talk about it so that more learning can be done. For now, this is what the medical community and treatment professionals have to reference for trichotillomania.

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What the DSM-5 Says About: