Trichotillomania, also known as trich or hair-pulling disorder, is when someone experiences an uncontrollable urge to pull out their own hair. They may pull out hair from their head or from other places on the body, such as their eyelashes or eyebrows. On this page, we’ll explore trichotillomania in more detail, including the symptoms and causes, and how therapy can help.
What is trichotillomania?
Although trichotillomania is listed under ‘Obsessive-Compulsive Disorder and Related Disorders’ in the latest Diagnostic and Statistical Manual of Mental Disorders (DSM), it is not the same as obsessive-compulsive disorder (OCD).
With OCD, behaviours are preceded by an intrusive thought, compelling the person to complete an action. But, this is not necessarily the case with trichotillomania. The behaviour might be a result of tension, stress or out of habit. Therefore, it might be better described as a type of ‘body-focused repetitive behaviour’.
Body-focused repetitive behaviours (BFRPs)
Trichotillomania is often grouped with other types of self-grooming disorders, such as skin picking (dermatillomania) and nail-biting (onychophagia). As the term suggests, these behaviours cause people to repeatedly touch their body or hair in ways that result in physical damage.
In this video, psychotherapist Eve McIntyre explains what trichotillomania is, and how CBT and habit reversal therapy can support you to stop hair-pulling.
People with trichotillomania often report a feeling of tension or a tingling sensation immediately before or when attempting to resist pulling, accompanied by an urge to search for the ‘right hair’. Pulling the hair out is often accompanied by an immediate release of tension, and feelings of relief or a sense of achievement.
However, this is often shortly followed by a renewed urge to search for the next hair. Other behaviours or rituals that are often reported include examining the hair closely after it has been pulled out, rolling the hair between fingers or lips, or biting it.
Depending on the number of hairs pulled out, trichotillomania can cause significant hair loss in the form of bald patches. Some people with long hair can cover up these patches so they are not noticeable, but can still feel incredibly self-conscious about them. It can also prevent them from joining in activities they previously enjoyed, such as swimming.
At the age of 13, I had near enough no eyelashes, no idea why I couldn’t stop pulling them out, and an ever-decreasing sense of self-esteem. I hated myself for what I was doing but, equally, I couldn’t make myself stop. I came to rely on makeup as a masking tool, hiding the physical signs that something was going on inside my head.
- Becky shares her experience of struggling with trichotillomania as a teenager.
People with trichotillomania often feel shame as they think that these behaviours are unique to them when, in fact, they are a relatively common feature of trichotillomania. The hair loss resulting from prolonged pulling can also have a huge impact in terms of feelings of embarrassment, isolation and low self-confidence.
What causes trichotillomania?
The exact cause of trichotillomania is not known. It’s believed that the onset of the hair-pulling disorder can often be linked to a particularly stressful life event such as the death of a relative, but this is not always the case.
Some researchers think that trich may have a genetic basis, but others propose that it is a normal grooming behaviour that has developed into a stress-related or tension-reducing habit. Alternative thoughts are that it could be an attempt to increase concentration or to combat boredom.
Some research suggests that people may be more likely to develop trichotillomania if they have perfectionist traits and beliefs which fit with an often reported need to pull out “bad” hairs. It has also been suggested that people with difficulty accepting and/or expressing emotions may be more likely to develop a behavioural strategy like trichotillomania.
- Chartered psychologist Louise Watson (MA MSc CPsychol) explores the realities of trichotillomania.
Is trichotillomania the same as Body Dysmorphic Disorder (BDD)?
BDD is a condition that causes people to have a distorted view of how they look. This is rooted in anxiety and can make those affected perceive themselves as abnormal or ugly. Sometimes this can lead to behaviour like hair pulling, so it can be confused with trich.
According to the Diagnostic and Statistical Manual (DSM) however, they are separate conditions. So while they may have similar presentations, the thoughts and feelings driving behaviour are different. For example, those with BDD may pull their hair to try and ‘fix’ a perceived flaw while those with trichotillomania will likely do this behaviour for the sensory response.
The treatments for trichotillomania are very similar to those for OCD, with the most effective form of treatment thought to be a type of cognitive behavioural therapy (CBT), known as habit reversal training. Hypnotherapy is another popular treatment option.
Habit reversal training (HRT)
As with skin picking, cognitive therapy may be introduced to help patients with trichotillomania - in particular, a technique called habit reversal training. This form of treatment works by helping the person recognise and be more aware of their hair pulling and what is triggering it, and sometimes help a person replace hair picking with less harmful behaviour.
The benefit of this CBT technique is that it also helps you address the emotional side of trichotillomania, as well as the physical action of hair-pulling. It allows you to work through thoughts about yourself and your relationships with others.
Hypnotherapy for trichotillomania
Body-focused repetitive behaviours such as trichotillomania can also be helped with hypnotherapy, which works in a different way from traditional talk therapy or CBT. The hypnotherapist will look to isolate the cause, helping the person to make the changes or accept something in the past, thus removing the need for destructive behaviour.
A hypnotherapist is likely to regress the sufferer's cause to find out what exactly started the hair pulling. The next step is to make suggestions to bring into context what exactly happened in that event and what the implications were.
- Michael Geerthsen (Dip Hyp & CS, MHS) explores how hypnotherapy can help trichotillomania sufferers.
There are, of course, some things you can do to help yourself. The success of self-help techniques will vary depending on your own experience of the condition.
For instance, if your hair-pulling is done consciously, the focus will be on replacing the urge to pull with an alternative action. Whereas, if you are unconsciously pulling out hair, the focus will be on bringing your attention to your hands and body to prevent it from happening.
Try the following tips:
- Keep your hands busy - try squeezing a stress toy or putting on gloves to help you identify when and where you most commonly pull at your hair.
- Try keeping the length of your hair short.
- Try resisting the urge to pull for longer and longer each time.
- If you are able to open up to a loved one, ask them to tell you when you are pulling to help you recognise when you’re pulling at your hair.
- Don’t keep tweezers or implements you use for hair pulling in an easy-to-access location.
- Keep a diary or journal to document how you’re feeling. Noticing how certain emotions, such as stress and anxiety, affect your urge to pull can help you to understand your triggers.
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