Treatments To Overcome Trichotillomania (Compulsive Hair Pulling)

All of us have felt the urge to tear out our hair in frustration at some point or the other. But did you know there’s a medical condition known as trichotillomania where exactly that happens? People with this condition may pull out hair from their scalp or other areas like eyelashes or eyebrows. This is an impulse-control disorder, that is, the person is unable to restrain the impulse to pull out their hair. They experience an intense urge to do so and feel mounting tension until it’s done. And usually, there’s a sense of relief afterward.¹ About 1 or 2 people in 50 experience trichotillomania at some point in their lives and it is more common in women.²

Trichotillomania generally starts in late childhood or early puberty and can be triggered by stress or depression.³ This body-focused repetitive behavior can also cause physical effects like tissue damage and infection. Sometimes people who pull out their hair also ingest it. This can lead to the formation of hairballs in the stomach or intestines which might need surgical removal.⁴

Here’s a look at what could cause this condition and how you can deal with it.

What Causes Trichotillomania?

We don’t yet know what causes trichotillomania but experts have put forward certain theories – it is thought to be a kind of addiction, a way of relieving anxiety or stress, and, in some cases, a type of self-harm. As it’s a kind of compulsive behavior, some experts consider it to be related to obsessive-compulsive disorder (OCD). It is also thought that genetics, brain chemistry, and hormonal changes play a part in this disorder.⁵

How To Recognize Trichotillomania?

Many times, people with trichotillomania may deny pulling their hair out because they feel embarrassed or ashamed. Or they might not be consciously aware that they’re pulling out their hair. In either case, a few clues can point out whether a person has trichotillomania:

• In cases where a person is unaware of their behavior, ask if they “play” with their hair; for instance, twisting or twirling hair or pulling at the ends. This step helps avoid direct confrontation. It’s also useful to explain to the person that some people often pull out their hair subconsciously while watching television, reading, or studying. This way, the patient doesn’t feel like they are being blamed.
• People with trichotillomania often have other similar repetitive habits focussed on the body like skin picking, nail biting, or lip biting. Checking for these habits can be helpful.
• Hair does not pull out easily in trichotillomania whereas it’s easier to pull out in a condition like alopecia areata which causes hair loss. A hair pull test can determine if the hair is loose and help confirm this medical condition.
• Naturally occurring hair loss tends to leave a smooth bald patch. But in trichotillomania, you may be able to feel a stubble in recently pulled areas. You may also find broken hairs of varying lengths and some strands broken mid-shaft.
• Trichotillomania of the eyelashes is usually associated with the upper lid lashes. The lower lid lashes, which are shorter, more difficult to grip, and more painful to pull out, and may be left intact.⁶

How To Overcome Trichotillomania?

Cognitive behavioral therapy (CBT), a kind of talking therapy, is the favored treatment for trichotillomania. Some doctors may prescribe medication in addition to advising therapy. CBT focuses on identifying thoughts and behaviors that can be problematic and changing them so that you can function better. Habit reversal training and comprehensive behavioral treatment are commonly used in CBT to tackle trichotillomania. The addition of approaches like acceptance and commitment therapy and dialectical behavior therapy have been found to improve the effectiveness of these therapies.

1. Habit Reversal Training

Habit reversal training works by seeking to help the patient identify and focus on situations during which hair pulling usually occurs. This is known as awareness training. It is combined with competing response training, where the patient is taught to substitute their behavior with another response which will stop hair pulling. For example, the hair pulling could take place when the person is bored or when they watch TV. Once they are aware of this, it can be substituted with another action when they feel the urge to pull at their hair. For instance, they could ball up their hand into a fist or tighten arm muscles to “lock” the arms to stop themselves from pulling out hair. Another component of habit reversal training is social support and it involves family and friends providing positive reinforcement when the person adopts a competing response instead of hair pulling.

2. Comprehensive Behavioral Treatment

According to the comprehensive behavioral model, a person engages in hair pulling because it meets a specific need (or needs). For instance, it could help them fall asleep, relax, or feel like they’ve accomplished a goal. After understanding why, how, and where a person engages in hair pulling, this model designs an intervention that addresses the need that’s being met through hair pulling. For instance, if itching works as a trigger that leads to hair pulling, the patient might be encouraged to use a comb to get relief from the itching, without the fingertips touching the scalp. Or, if a person uses hair pulling to lessen worrying thoughts, they might be taught alternative ways of dealing with stress.

3. Acceptance And Commitment Therapy

Acceptance and commitment therapy seeks to promote an increased acceptance of the urge to pull out hair without trying to eliminate it. During this therapy, a patient is encouraged to experience negative emotions that lead to or come after hair pulling without judgment. And they will be taught that thoughts, emotions, and urges are temporary events which they can choose not to react to.

4. Dialectical Behavior Therapy

Dialectical behavior therapy is another approach that can improve the effectiveness of other behavioral therapies. It incorporates components like mindfulness, emotion regulation, and distress tolerance. Mindfulness focusses on living in the moment and experiencing sensations and feelings without judgment (a concept borrowed from Buddhism). Emotion regulation focusses on teaching individuals to manage emotions better without engaging in hair pulling. Distress tolerance focusses on enabling an individual to get through a short-term crisis by accepting the reality of the distress and seeking not to make things worse by engaging in negative behaviors (like hair pulling). This therapy might involve techniques like visualizing a successful outcome to the crisis, finding reasons to be grateful, helping someone else, relaxing through deep breathing, listening to music etc.⁷

5. Support Groups

Hearing about the struggles of other people with this disorder lets a person know that they are not alone. This can also be a source of inspiration in their own battle against trichotillomania. The emotional support and sense of community that a person gets from a support group can be invaluable when dealing with this condition.⁸

6. Alternative Therapies To Consider

Since trichotillomania may be related to conditions like anxiety and OCD, you might also want to ask your doctor whether alternative therapies that work for these conditions will be helpful for you. You could check out therapeutic techniques like hypnosis, biofeedback, and deep breathing.⁹

Trichotillomania In Children

Trichotillomania usually develops in children aged 11 to 15. But there is the possibility of it occurring earlier as well – trichotillomania has even been reported in children as young as one.¹⁰ According to experts, hair pulling in very young children is similar to activities like thumb sucking or nail biting and simple guidance by parents may help them grow out of it. Also, young children respond really well to treatment though parents need to manage the treatment process with the guidance of a therapist. As children grow older, allowing them to participate in developing strategies and intervention techniques will better the chances of success.^{11 12}