What Is Trichotillomania?
When hair pulling becomes a serious compulsion
Trichotillomania is a funny word, but the disorder it describes — hair-pulling — can be a serious problem for children and teenagers. Trichotillomania comes from the Greek words trich (hair) and tillein (to pull or pluck), and it is characterized by the purposeful pulling of one’s own hair from any part of the body. It is related to obsessive-compulsive disorder, because it’s compulsive in nature and tends to be done to alleviate discomfort or anxiety.
Trichotillomania can be difficult to diagnose since those with the disorder are often secretive about their hair pulling and subsequent hair loss. And treatment is challenging because the hair pulling helps them manage negative emotions.
What is trichotillomania?
People with trichotillomania may pull out hair from their head, eyebrows, eyelashes, arm hair, or pubic hair. It is slightly more common in women, but it affects individuals of all genders and all ages. One sign of the disorder is repeated attempts to reduce or stop hair pulling, without success. Another is that it causes significant distress or impairment, which can take the form of shame, embarrassment, and withdrawal from social and other activities.
If left untreated, trichotillomania can lead to hair loss, bald spots, lack of eyebrows or eyelashes and skin damage at the follicles. Kids may get teased or picked on for patchy hair. Then, when the hair does begin to grow back it is often itchy, which makes it more likely that the individual will pull it out again to ease the discomfort, thus creating a cycle.
And, for the more than 20% of people with trichotillomania who also engage in tricophagia (eating their own hair) this can also lead to something called trichobezoars, or gastrointestinal hairballs, which often need to be surgically removed.
Different types of hair pulling
Although all trichotillomania involves pulling out body hair, there are two types, explains Jerry Bubrick, PhD, senior clinical psychologist at the Child Mind Institute: automatic and focused pulling.
- In automatic hair pulling, the individual may not even realize she is doing it until after the fact. For example, she could be zoning out watching TV then look down and realize that the couch is full of hair she has pulled.
- In focused hair pulling, it is done very intentionally because it feels good. Often, focused hair pullers will wait until they are in private to engage in the behavior.
Determining which type of hair pulling a person is engaged in will help establish the treatment. “It’s not just looking at the behavior of hair pulling, it’s really understanding what the function is behind it,” explains Dr. Bubrick. This is done via interviews with the child and reports from parents and teachers.
In addition to the two types of hair pulling, another facet to the behavior is what people then do with the hair. “Sometimes the person will just pull the hair and flick it on the floor, or some people will save the hair in baggies,” explains Dr. Bubrick. “Other times people might pull the hair out and inspect whether they pulled what looks like the root, then they might play with the root or roll the hair in their fingers. They might put the strand of hair to their lips, they might bite it, and in some cases they might swallow it.”
And because eating the hair that they’ve pulled can result in medical complications, it’s crucial to find out not only how and when they are pulling their hair, but what they are then doing with the hair.
Signs of trichotillomania
Often, parents may not realize their child has trichotillomania until they start to notice large patches of hair are missing. Dr. Bubrick says that you may see what’s called “infant pulling” starting at around 18 months of age and going until three or four years old, but that is hard to treat and very often goes away on its own. A simple intervention like having them wear mittens at night can often do the trick. Overall, he says, it’s not something to worry too much about.
For regular trichotillomania, the typical age of onset for both boys and girls is 9 to 13. “Red flags are if parents are finding hair where it shouldn’t be, like on the couch, a lot on the bed, or a pile of hair on the floor,” advises Dr. Bubrick. He says that for girls with long hair, for example, it might take a while to notice hair missing from their head. Also take note if they are also spending much longer in the bathroom or looking in mirrors much more often.
Why hair pulling is challenging to treat
Treatment for hair pulling can be tricky, Dr. Bubrick says, because it has a real function for kids who do it. “The hair pulling works in some way to alleviate stress,” he says. “So we’re essentially asking kids to take away a coping skill for stress and replacing it with something that may not feel quite as good, so it’s a hard sell,” he explains.
Kids are often brought in for help by parents who — more than the child — are concerned about the hair loss. But sometimes it’s the child who is embarrassed by his appearance.
“I had a kid a couple of years ago, a really nice, smart guy who started pulling from the back of his head and created a bald spot. He was being picked on for it, made fun of. The kids behind him in class were hitting his hand when he was going to pull or they would wonder out loud was he eating it or was he just putting it on his lips?”
In this case, the student took the initiative to get help. “It was his idea. He researched it online, he figured out what it was, and asked his parents to come in for treatment,” Dr. Bubrick added, “Within two months he was quite a bit better.”
When approaching a child about getting treatment, he advises parents to open up a dialogue rather than asking point blank if they are pulling out their hair. Instead, you can try talking about how it’s normal for people to play with their hair, and say that sometimes people don’t even notice they’re pulling it out, then ask if that’s something they’ve experienced. “It’s more about normalizing that this is a common thing that everyone does to some degree, but is it becoming an issue for you?” advises Dr. Bubrick.
How treatment works
The first step is to find a specialist with specific knowledge of trichotillomania, since many traditional therapists won’t know the cognitive behavioral approach that has been proven most effective, called habit reversal therapy.
The clinician will zero in on whether it’s automatic or focused pulling, and then try to understand when the pulling tends to happen. Is it when they’re bored? Stressed? Watching TV? In science class? Hiding in the bathroom? The child begins to self-monitor and track the behavior.
Once a professional has gotten to the root of the problem they can work together to physically stop the behavior by replacing it with less destructive alternatives —called a competing response. “We’ll try to find ways to put up barriers or slow down the pulling,” he says. This can include wearing a headband or hat, or putting band-aids on the fingers.
Possible alternatives to hair pulling can include something like a Koosh ball, where they can isolate and pull the individual strands, finger fidget toys, and sensory finger puppets with a spiny back the kids can play with and pull on. “Anything that the child can use and focus on that’s easier to do than the pulling,” says Dr. Bubrick.
For focused pulling in particular, Dr. Bubrick says, the treatment includes the cognitive work of changing the way the person responds to negative emotions. “The treatment has to focus on teaching the person better coping skills for the distress, the ability to tolerate negative emotions without pulling, so they can achieve the goal of having hair.”