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They are not sure yet. My guess is hormonal issues, as it is very common for trich to start in the puberty years. I also think that certain people with trich have predisposition to anxiety and depression and perfectionism. I there is also a genetic component, however that link is still being further studied. Food, vaccines, etc do not cause trich. There have been some speculation that trich might originate in the amygdala part of the brain, where your fight or flight response resides. There have been injuries to people in these areas that then bring on trich symptoms. This research is inconclusive and more is needed.