Trichotillomania—“trich” for short—is a hair-pulling disorder which is believed by researchers to have neurodevelopmental roots. It falls under the umbrella of obsessive-compulsive disorders in the DSM-5, and is an example of a “body-focused repetitive behavior,” or BFRB. BFRBs include trich, excoriation (skin picking disorder), nail biting, and other behaviors like chewing on skin on the lips.
People with trichotillomania can pull their hair from any location, but places like the head, eyelashes, eyebrows, and pubic region are very frequently reported as targeted areas. Effects can include bleeding at the pulling location, thinning of hair, bald spots, irritation, even infection of the skin. But in addition to the potentially severe physical consequences mentioned, trich is often associated with psychological difficulties like anxiety, depression, and negative self-perception.
Which makes sense, because trich is a disorder with highly visible, self-evident physical impact, and this visibility can often cause social difficulties. The stories I hear from clients with trich often reflect their experience of being judged, misunderstood, and stigmatized. How can a person hide the fact that they’ve been picking at their hair or skin? Attempts to maintain “normal” social interactions can lead to people with the disorder resorting to wigs, hairpieces, and elaborate hairstyles to cover bald spots. It can lead to false eyelashes, and/or headbands and scarves. The degree to which the disorder impacts a person can vary, which means that the effort they put into trying to conceal the effects of pulling will also vary in response.
When considering trich’s effects, some of the more common life events—like getting a haircut—become far more complicated. The patient with trich knows that they can avoid getting a haircut altogether instead of potentially being confronted by a barber or hairstylist that asks what is wrong with their hair and scalp. Additionally, patients have discussed avoiding spending time in other environments in which their trich might be noticeable—such as swimming, spending time outdoors, and participating in sports/physical activities. Avoidance and negative views of themselves often contribute to patients not seeking romantic relationships, only spending time with “safe” people, and taking action to make themselves as invisible as possible. They do not pursue goals and life achievements with vigor and energy due to the overwhelming desire to conceal the effects of the disorder.
In this way shame—one of the least useful and paralyzing emotions—dictates behavior and life choices. Some of my patients have reported that they have not had their hair styled professionally since their symptoms became noticeable–some say that they never have. Others discuss self-imposed limitations on physical intimacy that has not allowed them to have satisfying or prolonged romantic relationships. Finally, some do not advance professionally because they take action to avoid being seen instead of standing out and pushing for recognition of work well done. The shame and fear of being judged really becomes clearer as we listen to the stories of those that have to live with trich.
There is no easy way to change the social impact of trich. At USP we try instead to provide treatment that has been shown to be effective in helping the way a person handles difficult social situations along with reducing the frequency, amount, and time spent pulling hair. Habit Reversal Training, the primary approach I use to treat hair-pulling, focuses on helping a person identify when/where/how they pull. From there I work with them to alternate behaviors in place of the pulling or picking, while addressing urges and thoughts about pulling and also creating a plan for preventing relapse. I think that creating a plan and approach to treatment that is individualized can be incredibly helpful and also most effective for the areas of the disorder that a patient finds most distressing.
Overall, trich can be a tricky disorder, but it can be treated with evidence informed treatment, creativity, and an open and collaborative therapeutic relationship.
If you have any other questions about Trichotillomania, feel free to get in touch with Dr. Pelosi via Twitter @DrSheltonPelosi!