The compulsion to pull one’s hair repeatedly and routinely until it causes impairment in functioning or physical injury is known as trichotillomania, or compulsive hair-pulling disorder (APA, 2013). The disorder is still not well-understood, and the stigma associated with those who suffer from it magnifies the mental and emotional anguish.
Who Gets It
Trichotillomania (trich) is a body-focused repetitive behavior that affects 1-2% of the population, most of them female. Symptoms usually start in adolescence around the time of puberty. The compulsion to pull is chronic and lasts a lifetime, although for most people it runs in episodic cycles that can be managed. Research also suggests that people who have first-degree family members suffering from obsessive-compulsive disorder (OCD) are more likely to have trich (Bhandare, Kotasde, Bhavar, Bhangale & Wagh, 2016). However, trichotillomania is different from OCD even though some people with OCD compulsively pull hair.
The primary indicator of trich is the recurrent compulsion to pull out one’s hair. Any area of the body can be a target; however, the most common areas are the scalp, eyebrows, and eyelids. Episodes of hair pulling vary over time and can be cyclical, but a person will spend a considerable amount of time doing it, sometimes several hours per day. Hair-pulling results in physical damage such as bald spots; damaged hair follicles that prevent hair from growing back, skin ruptures, or blepharitis. Thus, a considerable amount of time is spent covering up the physical damage.
Another critical diagnostic feature is recurring attempts to stop or decrease hair-pulling behaviors. These failed attempts to quit also lead one to feel shame and embarrassment.
Finally, the behavior causes significant distress in a person’s life. This distress causes dysfunction at school, work, or in social settings are other areas of functioning. Sometimes, the distress is so great, that people will experience problems at school, work, or in relationships often because they isolate themselves, withdrawing from social interactions for fear of judgment.
Finally, the compulsion to pull hair cannot be explained by another medical problem or another mental health problem.
Related, but not the same
Trich is related to OCD, but there is a significant difference between the two. The confusion often leads to misdiagnosis. A person with OCD will have obsessions or compulsions which drive their behavior. Sometimes an obsession or compulsion may cause someone to pull their hair, but it is the obsession or the compulsion in the driver’s seat. Even after pulling the hair, the obsession or compulsion that caused it does not go away. Someone with trich, on the other hand, is focused primarily on the pulling of hair which is usually triggered by stress, boredom, or tension and the hair pulling alleviates the stress, boredom, or tension.
There are many triggers to pull hair. In some cases, hair pulling provides an emotional release, a way to focus on a different type of pain, or a way of soothing. For some, pulling hair leads to gratification or pleasure. These types of behaviors are done with full awareness. Not all who pull hair do it consciously, and when that occurs, it is called automatic pulling behaviors where someone does it without noticing what is happening. Regardless of the type of pulling behavior, most people do it in private and experience negative feelings of embarrassment or shame if others notice it.
Causes & Neurology
According to scientific research, it is difficult to determine a cause for trich. What scientists do know is that trichotillomania is more common when first-degree relatives have obsessive-compulsive disorder. This indicates a potential physical cause exists because the disorder can be passed on genetically.
Research has yet to confirm the physical component but suggests that people with obsessions or compulsions of any kind tend to have serotonin deficiencies and disordered reward processing (Bhandare, Kotade, Bhavar, Bhangale, & Wagh, 2016). This hypothesis is supported by the success of selective serotonin reuptake inhibitors by some people with trichotillomania. Not everyone experiences good results from these medications, however, so there are further explanations.
There are other studies linking trichotillomania to brain metabolism and reward processing. There is evidence suggesting that people with trich have high metabolic glucose rates in several parts of the brain (Bhandare et al., 2016). While this process is a mystery, metabolic disturbances in the brain are associated with other mental health disorders, dementia, Parkinson’s disease, Huntington’s disease, and Alzheimer’s disease. The brain needs the energy to operate; therefore, if the brain’s energy is disrupted in any way, it is safe to assume that brain functions would also be disrupted. The rewards processing theory suggests that those who pull hair experience a reward from it thereby creating an altered reward feedback loop associated with the behavior.
Another study showed promising data that the brains of people with trichotillomania are slightly different, but more research is needed before the information will be clinically useful (Chamberlain et al., 2017). Brain imaging showed “significantly increased cortical thickness in a right frontal cluster.” This region of the brain is involved in suppression of inappropriate motor responses. In other words, the part of the brain that tells the body to stop a function is different in people with trichotillomania. The study did not explain how or why the thickness contributes to trichotillomania. It hints at the possibility that if someone with a compulsive movement, such as moving the hands to the hair on the head and pulling it out, the malfunction of the brain mechanism which should say “stop, don’t do that” may be the culprit of the disorder.
The study also looked at whether the structural abnormalities were linked to symptom severity. For example, was the thickness of the right cortical region different in those who have extensive problems managing hair pulling behaviors? The authors said there was no relationship, which may or may not provide further research questions. This finding contrasts with previous brain imaging studies of obsessive-compulsive disorder. The imaging studies of OCD showed reduced right frontal cortical thickness. This finding suggests that the neurobiology of trichotillomania is not like OCD as previously thought.
A cycle of negative emotions goes with pulling hair including guilt, shame, and embarrassment. Many people who suffer from compulsive hair pulling choose isolation, withdrawing from social interaction for fear of judgment. A person is left to deal with the disorder alone, internalizing negative emotions and often struggling with depression and anxiety. Not only do those feelings spark anxiety, but anxiety can worsen hair pulling activity. Many people who struggle with trichotillomania, or compulsive hair pulling, associate hair pulling with anxiety. One study found that out of 894 people struggling with trichotillomania, 84% of them said anxiety was associated with it (Woods et al., 2006). Others report that hair pulling gets worse when anxiety increases.
The internal turmoil is substantial enough, but the physical complications that arise from trich complicate things. Bald spots on the scalp, missing eyelashes or eyebrows, and the unusual patterns of regrowing hair are only a few of the physical effects seen by others. Sometimes, these physical effects result in scalp damage, hair follicle damage, or other types of physical illness which mean going to a health provider. Many people with trich avoid going to doctors because of the fear of discovery and the shame of having to explain how it happened.
A person who compulsively pulls their hair not only spends a considerable amount of time pulling, but also a significant amount of time covering it up. They feel unattractive, ashamed of the work they have to do to blend in. On a social level, sometimes it is preferable to avoid people, and not go out in public. What if someone sees? What if the work to cover up bald spots fails? Other people may not know what caused it, but they are looking. The person suffering from trich internalizes nonverbal cues, further separating them from “normal.” The further one separates from “normal,” the more difficult it becomes to accept that “normal” is achievable.
Hope with Treatment
The good news is that even though trich is chronic, evidence-based treatments exist that help people manage their behaviors. The gold standard for treatment is a combination of behavioral therapy, cognitive therapy, and social support. Those who struggle with compulsive hair pulling should look for a provider who specializes in treating body-focused repetitive behaviors. Treatment begins by building awareness of pulling behaviors and what triggers them, followed by finding ways to counter habits and triggers. Concurrently, treatment of emotional issues that increase symptoms of anxiety and depression often help. There is not a medication to help with trichotillomania specifically, but medication to treat anxiety or depression often helps someone through the treatment process. Social support is also integral to not feeling alone and decreasing the shame and embarrassment associated with trichotillomania.
Trichotillomania is a chronic, recurring disorder that never goes away. When people do not seek help, the psychological and physical effects get more complicated. However, there is treatment available that help people manage their behaviors. There are healthcare providers, therapists, and support groups who specialize in body-focused repetitive behaviors like trich and can help people learn to manage it.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, Fifth edition. Arlington, VA: American Psychiatric Association.
Bhandare, S., Kotade, K., Bhavar, S., Bhangale, C., & Wagh, V. (2016). Trichotillomania: A hair pulling disorder. World Journal of Pharmacy and Pharmaceutical Sciences, 5(5), 596-615. doi: 10.20959/wjpps20165-6760
Chamberlain, S. R., Harries, M., Redden, S. A., Keuthen, N. J., Stein, D. J., Lochner, C. & Grant, J. E. (2017). Cortical thickness abnormalities in trichotillomania: International multi-site analysis. Brain Imaging and Behavior. https://doi.org/10.1007/s11682-017-9746-3
Woods, D.W., Flessner, C.A., Franklin, M.E., Keuthen, N.J., Goodwin, R.D., Stein, D.J. et al. (2006). Trichotillomania learning center-scientific advisory board: the trichotillomania impact project (TIP): exploring phenomenology, functional impairment, and treatment utilization. J Clin Psychiatry, 67, 1877–1888