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Twirling your hair around your finger, feeling for stubble on your legs, checking for loose eyelashes—all these behaviors are a totally normal part of, well, having hair. But what about when those habits involve a compulsive urge to pull out the hair? A little DIY "tweezing" may seem like NBD, but it could be a sign that you have something a little more serious going on: trichotillomania.
What Is Trichotillomania?
Trichotillomania (trick-o-till-o-may-nee-uh) is a hair-pulling disorder characterized by a recurrent, irresistible urge to pull out your hair—whether it's from your scalp, eyebrows, eyelashes, or other areas of your body. It often results in bald patches or noticeable hair loss.
"Hair pulling is an obsessive-compulsive spectrum disorder, under the category of body-focused repetitive behaviors," explains clinical psychologist Jenny Yip, Psy.D., a fellow of the American Board of Professional Psychology and an OCD and anxiety specialist.
Body-focused repetitive behaviors (BFRBs) are self-grooming behaviors in which people compulsively pull, pick, scrape, or bite their hair, skin, or nails to a point where it results in damage to the body. Other body-focused repetitive behaviors (besides trichotillomania) include skin-picking (excoriation) and nail-biting (onychophagia), and less commonly cheek and lip biting, nail picking, and scab eating, according to The TLC Foundation for Body-Focused Repetitive Behaviors.
Hair pulling isn't just a "bad habit" or a tic: "We all have our preferences and our habits, but those don't make something a disorder," says Yip. "However, when it interferes with your functioning, or with your work, school, social interactions, family interactions, or daily activities, that's when it becomes a disorder." (See: Why You Should Stop Saying You Have Anxiety When You Really Don't)
The symptom criteria for trichotillomania, according to the Diagnostic and Statistical Manual of Mental Disorders (fifth edition), include:
- Recurrent hair pulling, resulting in hair loss
- Repeated attempts to decrease or stop the behavior
- Clinically significant distress or impairment in social, occupational, or another area of functioning
- Not due to substance abuse or a medical condition (e.g., dermatological condition)
- Not better accounted for by another psychiatric disorder
"The best way to describe it is if you've ever had a scab and it’s half falling off, and you just can't help but pick it off," says Yip. "Or if you have a hangnail: How many of us would leave the hangnail and how many of us would want to pull it off? You feel the hangnail and you can't stop touching it, and the best thing is to just pull it off. Or when you shave and you start feeling the stubble is growing back and you want to pull them out—that's what it's like for someone that has trichotillomania, skin picking, or nail biting, except times 100."
And it's actually quite common, says Yip. Studies estimate that trichotillomania affects anywhere from 0.5 to 2 percent of adults—with four times as many women affected than men, according to research published in The American Journal of Psychiatry.
Causes of Trichotillomania
You might be thinking: Why would you want to pull out your hair? But it's much more complicated than that.
"Trichotillomania isn’t just a learned behavior—there’s a biological component to it, a hormonal or neurochemical imbalance," says Yip. "People who have trichotillomania have more relatives with it, so you can partly blame genetics." In fact, that's why trichotillomania can surface in kids and infants as young as 12 or 18 months old.
The urge to pull often starts with some sort of stress or anxiety. "You have the urge to pull because you're feeling tension, and pulling your hair gives you some relief from that tension," says Yip. "Then, because of that tension relief, the behavior becomes negatively reinforced." It's similar to drinking in a social setting: If you're socially anxious and you go to a party and have a drink, you likely become more relaxed, your social inhibitions come down, and you feel better. Therefore, drinking becomes reinforced in social situations. Hair pulling can serve in that same way, explains Yip. (Negative reinforcement also works when you need motivation to exercise.)
It's often not that intentional, though: "Most people don’t even realize they are hair pulling," says Yip. "They do it when they’re bored, maybe sitting in front of the TV or computer, while in bed, or sitting at a stoplight." (That's also what makes it different from some more purposeful behaviors, like body checking or body dysmorphic disorder.)
Because trichotillomania is under the category of OCD, some people with trichotillomania also have OCD, says Yip. And because BFRBs can interfere a lot with social interaction and cause potentially embarrassing bald patches, social anxiety disorder could be present in people with this hair-pulling disorder as well.
It's important to note that "there's no cure for any mental health disorders, and trichotillomania is a mental health disorder," says Yip. That means—even though most skin and hair conditions fall under the expertise of a dermatologist—your best bet for treatment of trichotillomania and other BFRBs is to seek help from a psychologist, psychiatrist, or therapist. However, it's important to find someone who's experienced in these specific disorders, since it requires medication, education, and a specific type of therapy called habit reversal training, says Yip.
"Habit reversal training is about learning to identify what triggers lead to hair pulling so you become aware that you're doing it," she says. "Once you're aware, it's about giving yourself some sort of competing response. That could be holding or touching something else that occupies you (like a spiky stress ball) or anything that could feel like hair (even string)—it just has to serve a similar purpose. The third part is about teaching you how to relax so that you're not engaging in hair pulling as a way to deal with your anxiety or stress." (Related: Anxiety-Reducing Solutions for Common Worry Traps)
Even though trich is common, very few people know about it: "I think most people don't realize it's a condition," says Yip. That's why Lucinda Ellery, founder of NYC- and LA-based Lucinda Ellery hair extension studio, founded International "No Pulling" Week which happens each October to raise awareness about trichotillomania.
Ellery offers a solution to help women who choose to cover their bald patches, perhaps while they're seeking more extensive mental health treatment: Her salon offers a hair replacement prosthesis specifically designed for women with moderate to chronic hair loss. "The Intralace system is constructed from a breathable mesh and integrated into a client's existing hair," says Ellery. "It introduces a physical barrier to prevent them from pulling and with a solution that disguises the problem it allows them to feel more relaxed and happier."
If you think you're suffering from trichotillomania or another BFRB disorder, first go to the dermatologist just to make sure it's not due to an underlying skin or scalp condition, says Yip. To locate an appropriately trained therapist, you can go to the TLC Foundation's website.