be triggered by feelings of anxiety or boredo m, may be preceded by an increasing sense of
tension (either immediately before pulling out the hair or when attempting to resist the
urge to pull), or may lead to gratification, pleasure, or a sense of relief when the hair is
pulled out. Hair-pulling behavior may involv e varying degrees of conscious awareness,
with some individuals displaying more focused attention on the hair pulling (with pre-
ceding tension and subsequent relief), and other individuals displaying more automatic
behavior (in which the hair pulling seems to occur without full awareness). Many individ-
uals report a mix of both behavioral styles. Some individuals experience an “itch-like” or
tingling sensation in the scalp that is alleviated by the act of pulling hair. Pain does not
usually accompany hair pulling.
Patterns of hair loss are highly variable. Ar eas of complete alopecia, as well as areas of
thinned hair density, are common. When the sc alp is involved, there may be a predilection
for pulling out hair in the crown or parietal regions. There may be a pattern of nearly com-
plete baldness except for a narrow perimeter around the outer margins of the scalp, par-
ticularly at the nape of the neck (“tonsure trichotillomania”). Eyebrows and eyelashes may
be completely absent. 
Hair pulling does not usually occur in the pr esence of other individuals, except imme-
diate family members. Some in dividuals have urges to pull hair from other individuals
and may sometimes try to find opportunities to  do so surreptitiously. Some individuals
may pull hairs from pets, dolls, and other fi brous materials (e.g., sw eaters or carpets).
Some individuals may deny their hair pulling to others. The majority of individuals with