252 Obsessive-Compulsive and Related Disorders
pulling may endure for months or years. Criterion A requires th at hair pulling lead to hair
loss, although individuals with this disorder may pull hair in a widely distributed pattern
(i.e., pulling single hairs from all over a site) such that hair loss may not be clearly visible.
Alternatively, individuals may attempt to conceal or camouflage hair loss (e.g., by using
makeup, scarves, or wigs). Individuals with  trichotillomania have made repeated at-
tempts to decrease or stop hair pulling (Crite rion B). Criterion C indicates that hair pulling
causes clinically significant distress or impa irment in social, occupational, or other impor-
tant areas of functioning. The term distress  includes negative affects that may be experi-
enced by individuals with hair  pulling, such as feeling a lo ss of control, embarrassment,
and shame. Significant impairment may occur in several different areas of functioning
(e.g., social, occupational, academic, and leisure), in part because of avoidance of work,
school, or other public situations. 
Associated Features Supporting Diagnosis
Hair pulling may be accompanied by a range of behaviors or rituals involving hair. Thus,
individuals may search for a particular kind of hair to pull (e.g., hairs with a specific tex-
ture or color), may try to pull out hair in a spec ific way (e.g., so that the root comes out in-
tact), or may visually examine or tactilely or  orally manipulate the hair after it has been
pulled (e.g., rolling the hair between the fingers,  pulling the strand between the teeth, bit-
ing the hair into pieces, or swallowing the hair). 
Hair pulling may also be preceded or acco mpanied by various emot ional states; it may