Trichotillomania (Hair-Pulling Disorder)

The short version

●Trichotillomania is recurrent pulling out of one's own hair (scalp, eyebrows, eyelashes, or elsewhere) resulting in hair loss, with repeated unsuccessful attempts to stop and significant distress or impairment.
●It is a body-focused repetitive behavior in the obsessive-compulsive-related disorders family — not a habit you can simply will away, and not self-harm in the usual sense.
●Pulling often happens automatically or to relieve tension/discomfort, and is frequently followed by shame; it commonly co-occurs with depression and anxiety.
●First-line treatment is a specific behavioral therapy — habit reversal training (a form of CBT) — which is more effective than medication for the pulling itself.
●N-acetylcysteine (NAC), a glutamate-modulating supplement, has randomized evidence in trichotillomania — notable because it points at the same glutamate system ketamine acts on.
●Ketamine is not an established treatment for trichotillomania; its relevance is the co-occurring depression or anxiety.

Clinical definition

Trichotillomania (hair-pulling disorder) is defined by recurrent pulling out of one's own hair leading to hair loss, repeated attempts to decrease or stop, and clinically significant distress or impairment, not better explained by another condition. Common sites are the scalp, eyebrows, and eyelashes, though any body hair can be involved. Pulling occurs along a spectrum from "automatic" (outside awareness, e.g., while reading or watching TV) to "focused" (a deliberate response to an urge, tension, or negative emotion, often followed by transient relief and then shame). It is classified within DSM-5's Obsessive-Compulsive and Related Disorders alongside excoriation (skin-picking) disorder, and is understood as a body-focused repetitive behavior with both habit and emotion-regulation components. It frequently co-occurs with depression, anxiety, and other OCD-spectrum conditions, and the resulting visible hair loss can drive significant social distress and avoidance.

How it differs from related conditions

vs. OCD

Same broad family and some shared circuitry, but trichotillomania is a body-focused repetitive behavior driven by urges and tension relief rather than by obsessions neutralized with compulsions.

vs. Body dysmorphic disorder

BDD centers on perceived appearance flaws; trichotillomania centers on the hair-pulling behavior itself, though both are OCD-spectrum and can co-occur.

vs. Excoriation (skin-picking) disorder

The sibling body-focused repetitive behavior, with the same treatment approach (habit reversal); the two often co-occur.

vs. Depression / anxiety

Common comorbidities that both worsen pulling and follow from the shame of it; treated alongside.

First-line treatments

Habit reversal training (HRT)

The first-line behavioral therapy — awareness training, competing-response training, and stimulus control; more effective than medication for the pulling itself.

Comprehensive behavioral (ComB) and ACT-enhanced models

Extend HRT to address the sensory, cognitive, and emotional drivers of pulling.

N-acetylcysteine (NAC)

A glutamate-modulating supplement with randomized evidence for reducing hair-pulling; generally well-tolerated, though results vary.

Treating comorbid depression/anxiety

SSRIs help co-occurring mood and anxiety (their effect on the pulling itself is modest), reducing a common trigger.

When standard treatments fail

When habit reversal and initial medication do not adequately reduce pulling, the steps are to ensure a genuinely adequate, BFRB-specific behavioral course was delivered (HRT is frequently under-dosed), add or extend ComB/ACT-enhanced approaches, trial NAC, and treat co-occurring depression and anxiety that fuel the behavior. Ketamine is not part of this ladder; where a treatment-resistant depression accompanies trichotillomania, ketamine for that depression may be considered while behavioral treatment leads.

Where ketamine fits

Ketamine is not an established treatment for trichotillomania, and the first-line approach is behavioral (habit reversal training), with NAC and treatment of comorbid conditions as adjuncts. There is a mechanistic thread worth noting honestly: NAC, which modulates glutamate, has randomized evidence in trichotillomania (Grant 2009), and ketamine also acts on the glutamate system — but that is a research-level rationale, not evidence that ketamine treats hair-pulling, and it should not be presented as such. Ketamine's real-world relevance here is the depression or anxiety that commonly co-occurs: treating a co-occurring treatment-resistant depression may reduce a driver of pulling and the distress around it, while behavioral therapy does the core work.

Where this fits with Tovani

Tovani treats the depression or anxiety that commonly accompanies trichotillomania — not the hair-pulling itself, which calls for habit reversal training and BFRB-specific behavioral care. Eligibility screening captures comorbid mood and anxiety; patients are encouraged to engage behavioral treatment for the pulling. Where a treatment-resistant depression co-occurs, ketamine for the depression is considered alongside that care.

Check eligibility Find treatment options The science behind ketamine

Frequently asked

Is trichotillomania just a bad habit?

No. It's a recognized body-focused repetitive behavior in the OCD-related family, driven by urges and tension relief, not a habit you can simply will away. Repeated attempts to stop and real distress are part of the diagnosis. It's treatable with specific behavioral therapy.

What actually stops hair-pulling?

Habit reversal training — a specific behavioral therapy (awareness training, a competing response, stimulus control) — is first-line and more effective than medication for the pulling itself. N-acetylcysteine has randomized evidence as an adjunct, and treating co-occurring depression or anxiety helps.

Is it related to OCD?

Yes — it's in DSM-5's obsessive-compulsive and related disorders, alongside skin-picking. But unlike classic OCD, the pulling is a body-focused repetitive behavior driven by urges and tension relief rather than obsessions and compulsions.

Can ketamine help?

It's not an established treatment for hair-pulling. There's an interesting mechanistic thread — NAC (glutamate-modulating) has evidence in trichotillomania, and ketamine also acts on glutamate — but that's research-level, not proof ketamine treats it. Its real role is a co-occurring treatment-resistant depression, alongside behavioral therapy.

References

Grant JE et al. 2009, Archives of General Psychiatry — Randomized controlled trial of N-acetylcysteine, a glutamate modulator, reducing hair-pulling in trichotillomania. (PMID 19581567)
Stein DJ et al. 2019, Nature Reviews Disease Primers — Review of obsessive-compulsive and related disorders, the family that includes trichotillomania, and their treatment. (PMID 31371720)
Sanacora G et al. 2017, JAMA Psychiatry — APA consensus on ketamine, relevant to the depression that co-occurs with trichotillomania. (PMID 28249076)

Last reviewed by Dr. Ben Soffer, DO on May 31, 2026. This page is educational and not a substitute for clinical evaluation. A physician determines whether ketamine therapy is appropriate for your specific situation.