Trichotillomania (Hair Pulling Disorder)

Trichotillomania (Hair Pulling Disorder)

Trichotillomania (otherwise known as hair-pulling disorder) is the under acknowledged, yet quite common behavioural disorder, recognised in individuals who engage in habitual motions of removing substantial volumes of their hair from various localised areas of their body. The most common and noticeable areas include the scalp, eyebrows and eyelashes, however, less noticeable areas involve the chest, underarm, legs, and pubic region. Trichotillomania is categorised as a body-focused repetitive behavioural (BFRB) disorder, sharing similar characteristics to excoriation disorder (otherwise known as excessive skin-picking), nail, and cheek biting disorders.

What are the symptoms?

The symptoms of trichotillomania will vary for each individual, and again, each case can vary quite significantly in severity – some individuals may pull out large handfuls of hair at a time, while others may only pluck individual strands. Individuals may engage in their hair pulling behaviour in a ‘focused’ or ‘unfocused’ manner, whereby they may or may not be aware at the time of their hair pulling behaviour that they are doing it until the consequences of their actions become apparent (eg: some may pull out their hair mindlessly while watching the TV, reading, or other sedentary activities and only notice when they observe large amounts of their hair scattered around them). Alternatively, some individuals experience an irresistible and unsettling urge to pull out their hair until they achieve a ‘just right’ feeling. The most common signs and behaviours of individuals with trichotillomania include:

  • Some may experience various sensations prior to their hair pulling behaviour, such as a mild tingling, pain, or an itch in the surrounding area that can only be satisfied after they pull out a particular amount of hair.
  • Most cases of hair pulling disorder result in significant hair loss, however the extent of the hair loss depends on the severity of each case – some may experience thinning hair, bald patches or more obvious and difficult to conceal balding areas.
  • Individuals may experience intense urges to engage in their hair pulling behaviour as it gives them a sense of momentary satisfaction or pleasure as they are doing it – although these positive emotions soon subside and are typically replaced with intense feelings of guilt, shame and distress.
  • Once the individual’s hair is pulled out, there are several other behaviours that can occur – some may play with the hair in their fingers in a rolling motion, chew and/or swallow the hair, smell it, closely examine it, or rub it over their face or lips.
  • The hair pulling behaviour and hair loss is not a consequence of another medical or dermatological condition or psychological disorder.
  • Hair pulling behaviour can significantly impede an individual’s quality of life and ability to perform everyday tasks such as school, work and social events, as their behaviour is often associated with intense feelings of guilt, embarrassment, frustration and distress – all of which can significantly impair their concentration towards other tasks.
  • Behaviour can be quite time consuming (particularly for individuals who engage in ‘focused’ hair pulling, who may have to leave work early or interrupt tasks unfinished in order to satisfy their urge).
  • Individuals may wear various props to cover up areas associated with their hair loss – such as hats, wigs, glasses or excessive eye makeup.
  • Some may go to great lengths of avoiding intimacy with others, or activities that may result in areas of hair loss to be revealed or noticed by others – often resulting in social isolation, loneliness, missed opportunities and diminishing quality of life.

Why does it happen?

As is the case for most psychological disorders, there is not one, but a combination of external environmental and genetic factors that are thought to contribute to the development of trichotillomania. Further, it is important not to confuse the symptoms of trichotillomania with other unrelated psychological conditions such as those common to self-harm – however, individuals may experience coexisting depression and anxiety before or that develops as a result of their hair pulling behaviour.

How common is it?

Trichotillomania can develop at any age, although the first symptoms are typically detected between the ages of 11-13, however, the behaviour has also been recognised in infants as young as 9 months old. Hair pulling disorder is thought to affect around 2-5% of the population, in females and males equally as adults, although for children the behaviour is more commonly reported in females.

How is it treated?

Cognitive Behavioural Therapy (CBT) has been shown to be the most effective treatment for trichotillomania, as it delivers long lasting results, however, there are several alternative approaches to treatment and there are various medications on offer that may be beneficial when used in conjunction with psychotherapy to help with reducing the individual’s anxiety and urges to engage in their compulsive hair pulling behaviour. The main principle of CBT involves the ongoing support and guidance from a psychologist who helps the individual to firstly recognise and become more aware of their maladaptive thought patterns that are causing their behaviour. From here, they are taught various relaxation strategies and alternative ways of thinking to manage their unpleasant emotions more effectively, as they learn to gradually replace their destructive thoughts and behaviours with more positive cognitions.

An effective form of CBT for hair pulling disorder is called habit reversal training (HRT), involving components including self-awareness training, self-relaxation techniques, deep breathing, and competing response strategies that the individual learns to apply (as a replacement) when they experience the urge to engage in their hair pulling behaviour. Identifying the individuals environmental triggers and modifying them in some way may also be effective during treatment – for example if the individual’s hair pulling behaviour occurs after they experience a tingling or itching sensation, they may be able to satisfy their urge through alternate strategies, like using a wide tooth comb to brush to satisfy the sensation instead of approaching the area with their fingers.