What is Trichotillomania?

Trichotillomania (TTM or Trich – pronounced “trick”) is a disorder in which a person repeatedly pulls out his/her hair, which results in hair loss. This condition is diagnosed when the person is unable to decrease or stop pulling, despite the willingness to do so and feels embarrassed, ashamed, and distressed.

Most people pull hair from the head, brows, and lashes, but they can also pull from other areas of the body (underarms, pubic area, legs, and face). The area of where one pulls may vary over time.

People usually attempt to conceal the bald spots by using scarfs, wigs, or by changing the hairstyle.

Trichotillomania is a Body-Focused Repetitive Behavior (BFRB). Other examples of BFRB are Excoriation Disorder (skin picking), nail biting, cheek biting or chewing, knuckle cracking, and thumb sucking.

How does Trichotillomania develop?

Many people start pulling in childhood and early adolescence, usually during or after the onset of puberty. But sometimes it can start in the late teens or in adulthood.

Once a person starts pulling, trichotillomania usually escalates and it becomes increasingly difficult to stop this behavior. Sometimes, there is a gradual increase in pulling, and at other times there may be waxing and waning of the disorder.

This behavior could also be related to life circumstances and situational factors – stress, location, and emotional state. For example, a person may stop pulling completely during a vacation and resume pulling when she comes back home.

Who suffers from Trichotillomania?

It is estimated that about 3% of people pull their hair to the extent that the hair loss is significant and noticeable. But, it is likely that about 10% to 15% of young adults pull hair, just to a lesser extent.

Trich is considered to be more prevalent among women. In reality, however, it may be the case that it is simply easier for men to hide the bald spots on their head. They can even shave their entire head to make it less visible. This may make them less likely to seek treatment and to be diagnosed.

Trichotillomania is more common in people with Obsessive-Compulsive Disorder (OCD) and among their first-degree relatives. Other disorders that seem to co-occur with Trichotillomania are depression, anxiety, ADHD, and Tics.

Why do people pull their hair?

We used to think that people pull their hair as a reaction to tension, an impulse, or an urge and then experience relief after they pull. While this is true for many hair pullers, we now know that some of them do not experience those urges. Some people just pull automatically – without even noticing that they are pulling their hair.

Most people engage in both automatic and focused pulling. Interestingly, the majority of people initially report only the focused pulling, but after monitoring their pulling habits closely, many of them discover that they pull automatically too.

In general, people pull their hair in response to external cues (their environment), internal cues (their moods, thoughts, or physical sensations), or a combination of both.

Most common pulling triggers are:

·      Physical sensations. This includes the feeling in the skin either while pulling or after the hair is pulled, feeling the texture of the hair or the follicle, or experiencing physical discomfort.

·      Thoughts about pulling or about the specific hair, such as “This hair is too thick or too curly and must come out.”

·      Emotions, such as anxiety, anger, or tension.

·      Automatic habits. “Cruising” the scalp for the “right” hair, twirling, or stroking hair.

·      Physical environment. Pulling often occurs at specific places – in the bathroom in front of the mirror, in the office while reading, in bed before sleep, etc.

Treat the trich! How is the trich treated?

 Trichotillomania (and other BFRB) are treated using the Habit Reversal Training (HRT), Stimulus Control Procedures, and the Comprehensive Behavioral Model (ComB).

Many therapists specializing in the treatment of trichotillomania also use Acceptance and Commitment Therapy (ACT), which helps you stay motivated by encouraging you to remove the obstacles (in this case – pulling hair) in order to live the life you want according to your values.   

What to expect during the treatment?

 1.     Your therapist will conduct a comprehensive assessment of your pulling and assign self-monitoring homework using special records. This step is important to determine the pulling behavior, which includes triggers (internal or external) that precede your pulling, how you pull, and what maintains the pulling or what helps you stop.

Be prepared to examine all these elements in great detail. You will even talk about what you do with the hair after you pull. This is a very embarrassing part of the treatment to many people, but if your therapist specializes in the treatment of trichotillomania, she or he sees this as just another symptom of this disorder and nothing to be ashamed of. While some people discard the hair, others may play with it, feel it between their fingers, examine it, bite it, sort it into piles, or even eat it.

You will also likely be asked to count how many hairs you pulled in every situation that you record.

The main message here is that everyone pulls hair in a unique way.

2.     You and your therapist will carefully examine your self-monitoring records and identify which of your triggers are the most powerful. Those are the triggers that you will address in treatment.

You will also develop an awareness of your “premonitory phase” — the tension building that precedes the pulling. The therapist will help you develop a competing response to pulling (such as making a fist instead of reaching for your scalp).

3.     Your therapist will help you come up with a very specific plan to address the triggers that lead to pulling. You will go trigger-by-trigger and write down a list of strategies and materials/tools to address them.

If the treatment is provided for a child, positive reinforcement using reward charts and points is usually recommended. Importantly, the rewards are provided for using the anti-trich strategies and not for the reduced amount of hair pulled.

4.     At the final stage of the treatment, you will evaluate the effectiveness of the strategies you tried and, if needed, modify them. Then, you’ll add the next steps to your existing strategies until the pulling is significantly reduced or eliminated.

When to seek treatment for trichotillomania?

Are you experiencing the negative effects of hair pulling in any of the following ways?

- Are you changing the way you look in an undesirable way trying to conceal the bald spots?

- Are you spending a lot of time pulling instead of doing other things?

- Are you constantly feeling embarrassed?

- Are you having arguments with your family members because they beg you to stop?

- Are you avoiding going swimming or visiting a hairdresser?

- Are uncomfortable in public?

- Are you worried about your hair when it’s windy outside?

If you answered yes to any of those questions, this is time to face trich and seek treatment. Find a therapist in your area that specializes in the treatments of BFRB mentioned above (HRT and ComB) and schedule your first appointment. Please don’t let the embarrassment stand in your way!

Have you been pulling your hair (or maybe picking your skin (excoriation, dermatillomania), biting your nails, chewing your lips or cheeks, or engaging in other BFRBs)? Have you found your triggers? Have you found what helps? Share your story in the comments below!

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Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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