Trichotillomania (Hair Pulling)
If you or someone you know has an uncontrollable urge to pull out their own hair, you’re not alone.
Trichotillomania, or Hair-Pulling Disorder, is a condition that goes beyond a simple bad habit—it can impact your emotional well-being, self-esteem, and daily life.
While it can be a challenging condition to manage, there are effective treatment options, like Cognitive Behavioral Therapy (CBT), that can help individuals regain control.
In this post, we’ll explore what trichotillomania is, its causes and symptoms, and how CBT can be a powerful tool in treating it.
What Is Trichotillomania?
Trichotillomania is a mental health disorder classified as a body-focused repetitive behavior (BFRB).
Individuals with trichotillomania experience an overwhelming urge to pull out their hair, often leading to noticeable bald patches.
This behavior typically occurs in response to stress, anxiety, boredom, or even as a way to cope with emotions. It can happen anywhere on the body, although it most commonly affects the scalp, eyebrows, or eyelashes.
People who struggle with trichotillomania often feel an intense sense of tension before pulling the hair out, followed by relief, pleasure, or satisfaction after the action.
Over time, this behavior can become compulsive, making it difficult to stop despite the physical and emotional consequences.
Common Symptoms of Trichotillomania
Compulsive hair-pulling: Repeatedly pulling out hair, often resulting in visible hair loss.
Tension before pulling: A sense of anxiety or tension right before pulling out the hair.
Relief or pleasure after pulling: Experiencing a sense of satisfaction or relief once the hair is pulled.
Failure to stop: Difficulty controlling the urge to pull hair, even when one tries to stop.
Embarrassment or shame: Feelings of shame due to the visible effects of hair-pulling.
Hair and skin damage: Prolonged hair-pulling can cause permanent hair loss, scarring, or skin damage.
It's important to understand that trichotillomania is not just a "bad habit"—it’s a serious mental health condition that requires treatment.
It can affect various aspects of a person’s life, including social interactions, work, and self-esteem.
What Causes Trichotillomania?
While the exact cause of trichotillomania isn’t fully understood, several factors may contribute to its development, including:
Genetics: There may be a genetic link, as trichotillomania often runs in families.
Neurobiological factors: Brain chemistry imbalances, particularly in areas that regulate impulses, might play a role.
Emotional factors: Stress, anxiety, or trauma can trigger or worsen hair-pulling behaviors, especially when used as a coping mechanism.
Environmental factors: Life stressors, changes in routine, or environmental triggers can contribute to the onset or exacerbation of trichotillomania.
DSM-5 and ICD-10 Diagnostic Criteria for Trichotillomania
According to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), trichotillomania is classified under Obsessive-Compulsive and Related Disorders and is diagnosed when an individual exhibits the following:
Recurrent pulling out of one’s hair, resulting in hair loss.
An increasing sense of tension before pulling out the hair, or when trying to resist the behavior.
Pleasure, relief, or gratification after pulling out the hair.
The behavior causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The behavior is not better explained by another medical or mental health condition.
The ICD-10 (International Classification of Diseases, 10th Edition) classifies trichotillomania under F63.3, known as "trichotillomania, hair-pulling disorder," which shares similar diagnostic criteria.
The Impact of Trichotillomania on Daily Life
Living with trichotillomania can be incredibly challenging.
Beyond the physical consequences of hair loss, individuals often struggle with feelings of shame, embarrassment, and anxiety.
These emotional impacts can cause significant distress, leading to withdrawal from social situations, work, or daily activities.
Over time, the behavior can also lead to physical harm, including skin damage, scarring, and infections.
The cycle of pulling, followed by emotional relief, can become a compulsive behavior that feels nearly impossible to break.
This emotional and physical toll often reinforces the behavior, making it harder to stop.
How CBT Helps Manage Trichotillomania
Cognitive Behavioral Therapy (CBT) is considered one of the most effective treatments for trichotillomania.
CBT is a structured, goal-oriented therapy that helps individuals identify and change negative thought patterns and behaviors.
Studies have shown that CBT, especially when combined with habit-reversal training (HRT), can significantly reduce hair-pulling behaviors and improve emotional well-being.
Here’s how CBT works in treating trichotillomania:
Identifying Triggers: CBT helps individuals recognize the emotional, environmental, or situational triggers that lead to the urge to pull hair. By identifying these triggers, individuals can develop strategies to avoid or manage them.
Developing Coping Strategies: CBT teaches healthier coping mechanisms, such as using relaxation techniques, engaging in alternative behaviors (like using a stress ball), or practicing mindfulness to manage stress and anxiety.
Behavioral Substitution: Habit-reversal training focuses on replacing the hair-pulling behavior with a less harmful action. For example, individuals may use a rubber band on their wrist to snap when they feel the urge to pull.
Addressing Negative Thought Patterns: CBT helps individuals challenge the negative thoughts and beliefs that fuel the behavior, such as feelings of shame or anxiety. This can lead to a healthier self-image and reduce emotional triggers for hair-pulling.
Setting Goals and Monitoring Progress: Individuals work with their therapist to set specific, measurable goals for reducing hair-pulling, track progress, and celebrate small victories along the way.
Relapse Prevention: CBT prepares individuals for potential setbacks by teaching them to recognize when the urge to pull may resurface and creating a plan to manage those moments.
NICE Guidelines for Treating Trichotillomania
According to the National Institute for Health and Care Excellence (NICE) guidelines, CBT with habit reversal training is recommended as a first-line treatment for individuals with trichotillomania.
NICE emphasizes that psychological therapies, especially CBT, are often more effective than medication for treating this condition.
In cases where CBT alone may not be sufficient, a combination of CBT and medication (such as selective serotonin reuptake inhibitors or SSRIs) may be considered.
If you're considering medication, It’s important to consult your GP or psychiatrist to find the right medication for you.
They can help determine the best course of treatment based on your individual needs and circumstances.
Efficacy of CBT for Trichotillomania
Numerous studies have demonstrated the effectiveness of CBT in treating trichotillomania.
One randomized controlled trial by Diefenbach & Tolin (2009) showed that individuals who received CBT, particularly with habit-reversal techniques, experienced a significant reduction in hair-pulling behaviors.
Similarly, Flessner and Woods (2006) found that CBT combined with habit-reversal techniques had a substantial impact on reducing the frequency and intensity of hair-pulling, with long-term improvements.
How Shenwise Can Help
At Shenwise, we understand the challenges of living with trichotillomania, and we’re here to help.
Our compassionate therapists use evidence-based CBT techniques to address the emotional and behavioral aspects of hair-pulling.
We’ll work with you to identify your triggers, develop healthier coping strategies, and support you in achieving your treatment goals.
We’re here to help you regain control, rebuild your self-esteem, and improve your quality of life.
If you’re ready to take the first step toward managing trichotillomania, contact us today for a free 15-minute consultation.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.
Diefenbach, G. J., & Tolin, D. F. (2009). Cognitive-behavioral therapy for trichotillomania: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 77(5), 862–868. https://doi.org/10.1037/a0016237
Flessner, C. A., & Woods, D. W. (2006). Habit reversal and cognitive-behavioral interventions for the treatment of trichotillomania and other body-focused repetitive behaviors. Behavior Modification, 30(5), 753-770. https://doi.org/10.1177/0145445506288326
National Institute for Health and Care Excellence (NICE). (2017). Trichotillomania: Diagnosis and management [CG157]. National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/cg157
Wilhelm, S., & Keuthen, N. J. (2011). Trichotillomania: An overview. Psychiatric Clinics of North America, 34(4), 723-740. https://doi.org/10.1016/j.psc.2011.08.006
World Health Organization. (2016). International classification of diseases 10th revision (ICD-10). Geneva, Switzerland: World Health Organization.