Is Trichotillomania an addiction? Really? Clearly, it is a disorder. I’d say it is an addiction in the sense that it can be treated very effectively in the same ways that addiction to substances can be treated. And it usually centers around the belief that the puller “just can’t stop” even though they want to. Sufferers often refer to it as an addiction.
Pulling your hair out?
Maybe it’s trichotillomania?
It’s pronounced trick-o-till-o-mania.
I’ve seen a number of clients who suffer from “Trich”. It is often a devastating, embarrassing condition.
What is it? There are many manifestations but the most common are pulling out your hair – often from your head, arms, hands, legs, eyebrows and eyelashes, even hair in your private regions, sometimes putting it in the mouth or swallowing it. Swallowing can be dangerous and need medical attention, in some cases emergency attention.
Trichotillomania has several close cousins such as skin picking, nail-biting, scratching, gnawing or rubbing to soreness, OCD and more.
People generally report feeling great stress or tension and find that they get a release from pulling out hair. There is often some amount of sting or pain when hair is pulled and they report they feel a little calmer after specifically feeling that. Others say they pull when they are bored. Most suffers do not pull in the presence of others or they try to hide what they are doing.
Many of my clients have said they “can’t help themselves”; some say it is even pleasurable.
Lots of people pull their hair out until baldness is clearly noticeable, and then hide it with scarves, hats, over combing, etc. There’s often irreversible damage to the hair growth and the quality of the hair.
The new DSM-5 now gives these diagnostic criteria:
A. Recurrent pulling out of one’s hair, resulting in hair loss.
B. Repeated attempts to decrease or stop hair pulling.
C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
E. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).
There aren’t many studies that are large enough in scope, but pulling appears to have a genetic component, possibly brought on by stress at a fairly early age, since it often develops or becomes active, or becomes more so, just before or after puberty. However, each sufferers’ experience is unique to themselves.
Is there hope for Trich suffers? Some report help from drugs, a number of which seem effective for some, but psychotherapy, or therapy combined with drugs seems to be very effective for a number of people.
How can it be treated? Here are my methods, which I customize for each person. Talk to your own health care provider about what steps they take to aid sufferers.
I want to discover as much as possible about when it happens, who might be present, what body part is hair pulled from, is there a particular time of day, a place or event that triggers it? What was upsetting or the cause just before, and what is the feeling during the pulling and afterwards? Do you feel ashamed and pull secretively? Have you employed anything in the past that helped you stop pulling?
Then we take these steps to achieve the goals:
Become much more aware of when and how often the pulling happens. Often, keeping a log is necessary in the beginning.
I encourage a visit to your primary care physician, especially if you are willing to discuss trying one of the drugs that may help. Regardless, your doctor needs to know what is going on with you and be able to rule out other factors that may be present.
Initially, many clients do not have the goal of stopping immediately, so some find an acceptable alternative is using a small piece of fur, rug, carpet, a doll’s hair or anything with a surface that allows pulling and gets the hands away from the problem area, which is usually their head. A few insist they “need” the pain, but will substitute holding an ice-cube until it hurts – which I don’t like for many reasons.
Therapists work to control the behavior by creating an incompatible action, so identifying several things to do, as an alternative is very important. If one fails, or does not appeal on a certain day, it helps to have an arsenal of others. Clients need to be very actively involved in identification of alternative behaviors b/c if a therapist, parent or significant other makes or supplies the list; it is unlikely to be helpful as helpful.
For ideas, here are some that clients have come up with: computer games, sewing, play a guitar, knitting, basketball, bike riding, jewelry making (one started a side income business), chewing gum, sunflower seeds, corn on the cob, crunchy foods that need two hands – like peanuts in the shell and pistachios. Many of my clients have been teens or young adults who list Mike and Ike’s, taffy, Gummy Bears, Hot Tamale candies and items that require considerable chewing but really only employ one hand to eat – yet rapid chewing itself is often a stress reliever. A good one is active gardening, but so are model building, carpentry, and painting, working with clay, needlework, making something such as carpentry, gingerbread houses and so many more. These are called Habit Reversal Training (HRT) or Distraction Techniques.
A Band-Aid on the fingertip(s) of the primary pulling fingers is very helpful, and sleeping in lightweight gloves helps those who pull in their sleep. These are called Barrier Assistance.
When at work or school some people like to play with a tension relieving ball, or having a small “goal” figure to finger and play with. I urge getting a small car that you’d really like to own, a tiny plastic palm tree if you want a tropical vacation, a little airplane, an infant or a house figure, etc. These have the added advantage of an object with multiple surfaces and edges to finger, but also can remind of goals that would be enjoyed more after mastering this problem.
An additional, very effective technique I use is: Wait a Minute. It allows you to wait just long enough to calm yourself before acting, or changing direction, and consists of using Breathing Training to calm the urge. A well-documented method quickly relieves both anxiety and tension. The easiest way to start is to make yourself comfortable where ever you are and place a hand over your stomach, covering your belly button. Breathe in and out, deeply – yet comfortably, relaxing until you feel your hand rising and falling quite a bit with each breath. This is Abdominal Breathing (which is what we all should be doing all day for optimum physical and emotional health). Continue as long as you reasonably can and allow the calm within you to make decisions, instead of the tension. Oddly, this is more calming than pulling, as many of my clients have told me over the years – to their great surprise. Some while say you must breathe in to a count of 4 or 5 hold your breath for 4 or 5, etc. I say no. Just breathe as slowly, deeply and calmly as you can without adding rules or counting that add to your tension about doing it right.
Progressive Muscle Relaxation is very effective for most if used before pulling, or to interrupt pulling in progress. It’s slightly different for Trich sufferers than the type you may commonly read about. Each time you want to pull take the hand you pull with and tighten, curl your fingers, make a fist and then tense your fingers as hard as you can for as long as you can. Then abruptly release them and feel the relief, which is similar to pulling’s tension and release. Do the same with the pulling hand’s wrist, then forearm, and arm – each in turn.
After that, go ahead and use the more traditional PMR, (which is very effective for insomnia also) and goes like this: You will tense specific muscle groups, one at a time and then relax them. This will give you a sense of calm and peace – more so every time you use it. It’s progressive since it addresses each muscle area, relaxing one at a time. Start with your scalp and forehead – Wrinkle your forehead, try to make your eyebrows touch your hairline for 4 or 5 full seconds. Relax. Then do the same with your eyes: then nose afterwards. Breathe deeply and calmly in the way most comfortable to you. Next, tense your lips, cheeks and especially your jaw – tighten the centers of your mouth back into a ridiculously tight grin or grimace for 4 or 5 seconds. Relax. Feel the calmness. Then, put your arms tightly out in front of you. Clench your fists as hard as you can for at least 5 seconds. Relax and breathe. While your arms are still out, pretend there’s a wall in front of you and push it hard with your arms for 5+ seconds. Relax and remember to breathe. Then bend your elbows and tense your biceps (upper arms) for 5+ seconds. Relax into deep breathing. Pull your shoulders tightly up to your ears for 5 seconds. Relax. Arch your back tightly and hold it stiffly for 5 seconds. Relax to feel the anxiety and tension leaving. Tighten your stomach next for 5 seconds. Relax.
Then tighten your hips and buttocks for 5 seconds. Breathe and let go. Now tighten your thighs by pressing your legs together as tightly as you can for 5 seconds. Relax. Bend your ankles toward your body as far as you can and tighten your feet for 5 seconds. Relax. Lastly curl your toes as tightly as you can for 5 seconds. Relax. Now – see if any muscle areas might still hold tension and go back to relax that particular area 2 or more times until it lets go of all the tension and stress it has held. Breathe and sense the calm you now feel. This will increase each time you do this exercise. It doesn’t take long after the first 2 or 3 times you do this. It can be repeated many times a day, as needed.
Meditation is an elegant and transformative way to calm yourself of any tension, including the type that leads you to pull. Learn how to do it your way, as there are many methods. I particularly enjoy the Deepak Chopra’s guided mediations because they are very professionally done, he is a master and they rarely take more than 12-15 minutes of my busy day – yet, they make a world of difference – plus he “minds the time” for us. Find what appeals to you. You will come to crave the type of peace it provides.
Psychotherapy. Now we come to Self Psychology, Behavioral Therapy, Cognitive Behavioral Therapy and many more.
“Behavior therapy (HRT), emotional regulation, and acceptance together represent the most promising treatment for trichotillomania (Walther, Ricketts, Conelea, & Woods, 2010).
Therapy can make the difference for many sufferers since some are soothing memories of pain, loss or hurt (even PTSD), others engage in faulty thinking (cognition) that harms their ability to be truly happy and relaxed in life. Others have learned “I can’t help myself” thinking in this and other important areas of life, which invites all sorts of undesirable outcomes. Some don’t realize how much tension they hold and that this is not normal – that it can be released. Others lack self-esteem and let tension build over time, believing they can never get what they want out of life because they aren’t good enough.
I haven’t listed all the techniques I’ve used over time, but have tried to post the more successful ones.
I’d be interested to hear what you may have used, not listed here, that lead to good outcomes.
Be kind to yourself. Therapy helps.
Sharon Valentino, CA LMFT, MA, ChT, Psychotherapist
Licensed Marriage and Family Therapist (51746)
Valentino Therapy @
3030 Bridgeway, Suite 108
Sausalito, CA 94965
Serving individuals & couples in the San Francisco Bay Area
Psychotherapist, Masters Counseling Psychology, Stress, Anxiety, Addiction Specialist, Relationships, Depression, PTSD, Pain, Family, Couples & Relationship Issues