Trichotillomania: An Overview
What is Trichotillomania?
Trichotillomania, also known as hair pulling disorder, is a psychological condition characterized by recurrent and irresistible urges to pull out body hair despite wanting to stop. It falls under a group of self-grooming behaviors known as body focused repetitive behaviors (BFRB). The individual pulls, picks, scratches or bites their hair, nails, or skin, which results in damage to the body. Trichotillomania is not a habit or Tic disorder. It is a complex psychological condition that causes significant distress and discomfort in the individual’s life.
Trichotillomania is prevalent in our society and affects an estimated 2-4% of the population. There is a strong chance that more people are affected, but the shame and lack of understanding leaves many people undiagnosed. According to the TIPA study, 46% of individuals with TTM reported they were never diagnosed. It mostly affects women (9:1) and can be seen in babies, children, teens, adults and the elderly. It usually begins around the age of 12-13 and does not discriminate based on race. If left untreated it can lead to a chronic condition.
According to DSM, Trich is characterized by:
1. Recurred hair pulling, resulting in hair loss
2. Repeated attempts to decrease or stop the behavior or stop the behavior
3. Clinically significant distress or impairment in social, occupational or other areas of life “
4. Not due to substance abuse or a medical condition (e.g., dermatological condition)
5. Not better accounted for by another psychiatric disorder
The most common areas that individual’s will pull hair from is their scalp (79%), eyebrows (65%), eyelashes (59%), pubic hair (59%) and other extremities.
The severity of the pulling varies greatly. For instance, hair pulling can result in small areas of thinning hair, bald patches, or extensive baldness that is difficult to conceal. The frequency also varies in that an individual may pull compulsively for a few minutes or up to a few hours. The individual tends to pull alone and is reluctant to share their problem with others because of confusion, shame and embarrassment. This secrecy can lead an individual to suffer for years before receiving treatment.
Trichotillomania can negatively affect an individual’s life. According to the TIPA study, individuals with TTM tend to have lower self esteem, dismissed sense of attractiveness, feelings of shame/embarrassment, and problems with tension/ anxiety and depression/ mood disorders. The hair pulling leads to restrictions on daily activities like getting a haircut or being intimate. It causes extreme discomfort in a public setting. This distress can lead people to avoid swimming, playing sports, being outside in the wind, and even going on vacation. It leads to a life of secrecy and a preoccupation with concealing hair loss.
Shame is such a powerful influencer on individuals with Trich that many don’t get treatment, avoid doctors, struggle with interpersonal relationships, and have a skewed self imagine. The severity, frequency, and intensity of TTM vary from individuals to individual. Trichotillomania is a real, painful, isolating, and time consuming condition that lowers individual’s quality of life.
There is no one reason why someone pulls out their hair.
So Why Pull?
According to the research and ComB model of treatment there are five functional components to hair pulling. The cues to pull, the behavior, and the consequences are influenced by these five variables. TTM is not limited to one component and tends to be a complication of multiple variables. In addition, over time the pulling behavior can become intermittent patterns of reinforcements. Understanding this is a core component to treatment. Let us explore each one in detail.
Here the cue is triggered by a physical sensation (itching, burning, tingling) or visual, tactile or oral stimulant. An individual has a craving or urge to pull as a means to provide sensory stimulation. They may target a hair that is a certain texture or color. For example, a course or white hair. Then they pull out the hair. Afterwards they may either simply discard the hair or play/chew/rub the hair against their face for stimulation. In order to achieve the oral or tactile stimulation they may put the hair in their mouth or pull the root from the hair or play with the hair itself. By doing this they can reduce discomfort from the initial sensation.
This type of pulling is influenced by thoughts. An individual may think, “I need my hair to be symmetrical” or “It’s only one hair.” The pulling is done to achieve a goal.
This type of pulling is done to either provide pleasure, comfort, or stimulation. The individual feels an adverse emotion such as stress, anxiety, depression, boredom, frustration, indecisiveness, lethargy, fatigue, or a physical state (hungry or tired). They pull the hair to alleviate the uncomfortable feeling. It serves to reduce tension, provide arousal from boredom, or increase invigorating feelings.
Motor Habit/ Awareness Component
This type of pulling is based on awareness and body posture. According to this component there are three types of pullers. The automatic, focused, and combined. An individual either pulls purposely (focused) or unaware (automatic), or a mix of both. Posture and hand position can influence pulling. If you are sitting at your desk doing homework and rest your head on your hand, this may trigger pulling.
Place/Other Environmental Component
This refers to the cue and triggers that led to hair pulling. This includes location, time, activities, and implementations. The most common locations for pulling are the bedroom, bathroom, living room, car, and desk. People may be more inclined to pull when they are going to bed, waking up, or getting home from work/school. They may be triggered to pull when doing homework, grooming, talking on the phone, hard thinking, lying in bed, watching television, or being on the computer. Being around mirrors or having tweezers can influence the pulling behavior.
Treatment For Trichotillomania
Trichotillomania is complex and unique. It creates a cycle of pulling, shame, and discomfort. However, treatment for this condition exists and is effective. There are many different types of treatment that can be utilized.
One of the most effective forms of treatment is Cognitive Behavioral Therapy with an emphasis on the Comprehensive Behavioral Treatment Model (ComB). This treatment model is tailored to the individual. It emphasizes the learning and practice of techniques that are assigned to change the ingrained behaviors, thoughts, and feelings that contribute to TTM.
This model can help interrupt the established patterns with non-harmful alternatives. It uses habit reversal training to increase awareness of the behavior and focus on reducing tension that precedes pulling. It implements relaxation and breathing techniques. Stimulus control is implemented to change the environment. It helps identify sensory tools to distract, substitute or restrict pulling. It teaches how to reframe their thoughts and feelings to lead to better self-talk. Overall, treatment is extensive, individualistic, and hopeful. With practice and support the individual can learn to learn to effectively deal with their hair pulling and live a full life.
Social support is an important pillar of treatment. Finding a support group, therapist, or others to openly share your experience with is very powerful and relieving.
If you or anyone you know is suffering from Trichotillomania, please know that support exists.
You may have reached out and been disappointed that a professional didn’t know much about TTM. However, there are many resources that can provide you with the right support.
Check out the TLC Foundation for information on BFRBs. https://www.bfrb.org/
Sarit Fassazadeh is a LCSW with a private practice in Los Angeles, California. She specializes is Trichotillomania, Childhood Anxiety Disorders, and Panic Disorders. She is passionate about serving these underserved population and giving them the tools to increase their quality life. She is trained in CBT, ComB, and ACT. If you are interested in her services feel free contact her through her website. https://www.healingwithpurposetherapy.com
Woods, D. W., Flessner, C. A., Franklin, M. E., Keuthen, N. J., Goodwin, R. D., Stein, D. J., & Walther, M. (2006). The Trichotillomania Impact Project (TIP): Exploring Phenomenology, Functional Impairment, and Treatment Utilization. Journal of Clinical Psychology , 67(12), 1877–1888.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.