TRICH Education

TRICH Education contains a summary of the latest research and information about trichotillomania. Please read through all the sections by clicking on the following links and learn more about this disorder that affects so many people.

What is trichotillomania or “trich”?

Currently, trichotillomania is classified as an Obsessive Compulsive and Related 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders. TTM is defined as:

  • Recurrent pulling of one’s own hair resulting in noticeable hair loss,
  • The disturbance is not better accounted for by another mental disorder and is not due to a dermatological condition, and
  • The disturbance causes significant distress or disturbance in social, occupational, or other important areas of functioning (APA, 2012).

Many people do not meet all of these criteria, but still pull their hair to a bothersome degree. A newer understanding of trich is that it falls under a broader classification of behaviors called Body Focused Repetitive Behaviors (BFRBs). This classification of BFRB’s include hair pulling, skin picking, nail biting, nail picking, lip and cheek biting, and knuckle cracking.

Myths and misunderstandings

  • Trich is not OCD. Many people mistake trich for Obsessive Compulsive Disorder (OCD) because of the repetitive nature of the behavior. Actually, the treatment for OCD is quite different from that of trich, both from a therapy and a medication perspective. Although it is not classified under Obsessive Compulsive and Related Disorders, it is quite different in process and treatment from OCD.
  • Trich is not the result of past trauma or abuse. There is NO evidence to support that trich is a result of trauma, abuse, molestation, or a bad childhood. That said, some people with trich do have a history of trauma. However, there is no evidence that the trauma was the cause of the trich because many people who have a history of trauma do not pull hair and many who do have trich do not report and trauma in their history.
  • Trich does not predict future problems such as self-mutilation, suicide, eating disorders, or depression.
  • Trich is not a form of self-mutilation. Hair pulling is better understood as a self-soothing behavior, one that makes a person feel better in some way.
  • Trich is not the result of some underlying, unresolved issue such as low self-esteem or self-hatred. Trich is better understood as a behavior, much like nail biting, that occurs in a variety of situation and in response to various triggers.

Who pulls out their hair?

  • Research indicates that trich affects far more women than men (about 93 percent of people with trich are female).
  • Research suggests that the high female to male sex ratio for trich may be artificially inflated as, in general, more women seek psychological treatment than men. It is also possible that men are more able to hide their bald spots or attribute them to male pattern baldness, thus avoiding treatment altogether. However, it is widely believed that predominantly more women pull their hair than men.
  • In children, the incidence of hair pulling is 50 percent male and 50 percent female. It is not until puberty that the balance tips in the female direction. This likely means that the majority of people who begin to pull in adolescence are female, possibly due to the high influx of female hormones during puberty.

Problems hair pulling can cause:

Psychological problems

  • Many people with trich report feeling depressed or unattractive due to hair pulling. This is a very confusing scenario because hair pulling is self-inflicted. In other words, people become frustrated because they don’t like the way trich impacts their lives, yet they keep pulling because it somehow feels good.
  • Oftentimes, people with trich express feelings of shame, irritability, and low self-esteem secondary to their pulling. Over the years, people who feel this way may become depressed or anxious. Early intervention is preferable for this very reason.
  • Most people with trich keep their hair pulling secret from their loved ones. The hidden nature of the disorder can lead to more shame and possibly fear of discovery, interfering with a sufferer’s ability to accept herself and her behavior.
  • People with trich often report pulling when they are worried. Sometimes addressing worry is as important is addressing the hair pulling. Worry can be about life events or about the trich specifically.

Social problems

  • People with hair loss due to pulling tend to avoid certain activities such as professional hair cuts, swimming, sports, intimate sexual encounters, and windy or well-lit places. Avoidance of these activities can lead to isolation or withdrawal from social interaction, leading to feelings of loneliness and isolation.
  • In addition to avoiding relationships and places, many people with trich wear wigs, hair extensions, make up, false eyelashes, scarves, hats, long sleeves or other hair “appliances” to cover the loss. Those with less obvious hair loss are able to cover it by styling the hair in a certain fashion or wearing make-up to cover bald areas.
  • Hair pulling can become a source of relationship turmoil, such as nagging from a spouse or parent; degrading remarks or put downs from friends or loved ones, which can feel like punishment for the behavior; being accused of not trying hard enough to stop; and, rude or insensitive remarks from strangers or acquaintances.

Medical problems

  • Repeated pulling of the hair can lead to damage to the hair follicle, which can affect hair re-growth.
  • Damaged follicles will produce gray or white hair, and often hair that is more coarse or kinky, which can lead to more pulling.
  • Skin damage from pulling, picking, scratching or the use of tweezers can lead to serious infections requiring medical attention.
  • Repetitive hair biting has been reported to cause gum disease and enamel erosion on the teeth.
  • Hair ingestion can lead to the development of gastric and/or intestinal trichobezoars (hair balls) which can be life threatening and, when large, must be surgically removed.
  • Repetitive hair pulling can lead to muscle fatigue and can result in carpal tunnel syndrome.
  • Avoidance of regular doctor/ophthalmologist visits out of fear of embarrassment or discovery can increase the chances that various medical problems will go undetected.

Why do people pull out their hair?

Over the past 30 years, scientists and clinicians have studied trichotillomania in an attempt to understand why people pull out their hair. Probably the most unique thing about trichotillomania and certainly what makes it a very difficult phenomenon to study, is that it seems to be experienced differently by each person. Regardless of the fact that all people who have trich pull hair, each person experiences the behavior in a somewhat unique way.

What we know about hair pulling is that it occurs when certain triggers are present. Triggers can either be internal (inside of a person like a sensation, thought, or emotion) or external (outside of a person like a place, activity, or thing). One person may have multiple triggers or combinations of triggers.

Dr. Charles Mansueto and his colleagues at the Behavior Therapy Center in Greater Washington have organized what researchers know about trichotillomania and call it the Comprehensive Behavioral Model (ComB Model). This model organizes hair pulling behavior/triggers into five areas or modalities that form the acronym SCAMP.

  • Sensory: Hair pulling can involve one or more of the five senses.
  • Touch: Hair pulling satisfies sensations both on the skin (scalp, eyelids, etc.) and on the fingers (touching hair or rubbing it on the face).
  • Visual: Many people examine the hair once it is pulled, to observe the root or to evaluate the texture of the strand of hair. Others search visually for certain types of hair (those that look different or have a split end).
  • Taste: It is not uncommon for people to bite the hair, to bite off the root, or to eat the hair or hair follicle.
  • Auditory: Sometimes individuals will notice how the hair sounds as it is pulled and this sound adds to the pulling experience. Others will notice the noise that the eyelid makes as it hits the eyeball after a pull. This sound can be reinforcing to the puller.
  • Smell: The sense of smell is involved for some people with trich. It is not uncommon for people to smell the hair once it is pulled.
  • Cognitive: Sometimes people have thoughts that accompany or trigger pulling. Thoughts can be about hair, e.g., “I don’t like the thick, coarse hairs” or can be about life, e.g., worries, fears, problems.
  • Affective: Many people report pulling in response to feelings such as anxiety, boredom, tension, fear or anger. Sometimes pulling seems to occur to increase positive emotions such as relaxation or satisfaction. Unfortunately, many times pulling leads to uncomfortable feelings such as guilt and anger, possible leading to further pulling episodes. Another commonly reported feeling is procrastination (pulling when a person is supposed to be doing something that they do not really want to do). In this way pulling is a kind of avoidance of unpleasant activity.
  • Motor: There are a variety of motor behaviors that come before or after pulling, i.e., face touching, stroking of the hair, and playing with the hair once it is pulled. Sometimes these behaviors are so automatic that they happen outside of a person’s awareness. When this happens, hair pulling also can happen outside of a person’s awareness. StopPulling.com is designed to help increase awareness so that appropriate interventions can be used to thwart hair pulling.
  • Place: Where are you and what are you doing when you tend to pull? Most people have situations and activities that they associate with pulling, e.g., in the den watching TV, in the bathroom looking in the mirror, in bed, etc. Further, certain items such as tweezers, mirrors, or even the absence of other people can trigger a pulling episode.

In addition, there is evidence that points to a genetic component to trich (it runs in families). In other words, people with trich have likely inherited a gene that is responsible for causing the trich to come into their lives.

How do we treat trich?

The most successful treatment for trich is the Comprehensive Behavioral Model, developed by Charles Mansueto and his associates at the Behavior Therapy Center in Greater Washington. This model involves helping a person to understand the thoughts (cognitions), feelings, and behaviors experienced as a part of hair pulling. Then, high-risk situations are identified and strategies for managing urges are introduced.

Medication therapy for trich has yielded differing results. Some studies have found that SSRI medications like Prozac and Paxil are helpful for treating trich, while others do not support the use of these medications. It seems that these medications (anti-depressants) may be effective with individuals who have an underlying depressive or anxiety disorder. More recently, a different class of medication, neuroleptic drugs, has been studied both alone and in conjunction with anti-depressants to determine whether or not this combination is effective. Results are still out regarding this combination of medications. What we do know is that there is, at this point in time, no medication that will permanently take away the urge to pull. Other classes of medication also are being studied, but results are not yet available.

In 2009, a study was released using N-Acetyl Cysteine (NAC) with a group of hair pullers. NAC is an amino acid that serves as a precursor to the synthesis of glutathione, a detoxifying agent in the body. Previous studies using NAC have shown decreases in pleasure seeking behavior in laboratory rats. Dr. Grant hypothesized that NAC may be helpful in the reduction of hair pulling for this very reason. This study demonstrated a significant reduction in hair pulling for 56 percent of the subjects taking NAC. To read more about the use of NAC for trich see www.trich.org/research/current.html for more information. Talk to your doctor about using NAC in conjunction with behavior therapy or StopPulling.com.

Because many people respond to the cognitive-behavioral approach, we have adapted this model to be used by individuals in the privacy of their home, through a confidential web-based application. StopPulling.com is designed to take you step by step through the process of learning about your individual thoughts, feelings, and behaviors, identifying your high risk situations, and teaching coping strategies that are right for you. StopPulling.com is not therapy, but an interactive self-help tool based upon behavioral and learning theories, which will guide you through analyzing and managing your problem.

Readiness for change

The advantages of using StopPulling.com on an ongoing basis are obvious: to manage hair pulling and increase hair growth, to decrease avoidance of activities because of hair loss, to improve self-esteem and confidence, to learn more about trich, and to feel in control of your behaviors.

However, working this program is a commitment that will involve some time and energy each day. In order to gain control of your pulling, you will need to pay attention to your behavior, your thoughts, your feelings, and a number of other things each day. Even if you are not able to log-on every day, you will need to “catch up” the next time you log-on for the day(s) missed. Although this is a commitment of time and energy, it will be worth it if you can change your behavior.

Sometimes people realize that they are not willing to put forth the effort required to gain control of their pulling. Oftentimes this is because they were not “ready” to make the changes in the first place. Readiness is a very important part of behavioral change. For example, many people want to start an exercise program and plan to do so and may even take some steps to begin a program (like join a health club). After a few weeks, however, they forget about the new program and fall back into old habits. The same is true with trich. Many people want to stop and may even make some efforts to make changes, but these efforts peter out after a short time and they “give up” or simply “forget” about their goals.

One goal of this section is to let people know that readiness for change is a very important ingredient in the recipe for success with trich. If by reading this section you decide that you are not ready, that is okay! Lots of people want to stop pulling, but are simply not yet ready. Another goal of this section is to help people get to the point of readiness. We are hoping to help people who are almost ready to get to the point of action. Ways to get to the point of action are:

  1. Begin to imagine yourself as a non-puller or as a person whose hair pulling does not significantly affect their life. Really fantasize about how this would be for you and really see yourself in a different way.
  2. Tell someone that you trust, that doesn’t know about your behavior, that you pull. Because trich is a behavior surrounded with shame, people hide their symptoms from most individuals in their lives. Telling others that you pull can start to break down the shame and foster self-acceptance. Joining a group of people with trich or attending a TLC retreat or convention can catapult you into action and self-acceptance.
  3. Start to educate others about trichotillomania. Once you have told some people about your behavior you can begin to educate others about what trich is, and is not, and how normal a behavior it is (i.e., no different from nail biting). You will likely be surprised at how others will not only support you, but may even tell you how they know people who do the same thing!