HAIR PULLING a.k.a., TRICHOTILLOMANIA
A simple habit or a complex diagnosis?
by Steven Phillipson, Ph.D., Clinical Director
Dr. Christopher Gibson, Ph.D. staff psychologist
Center for Cognitive-Behavioral Psychotherapy
What is Trichotillomania?
Trichotillomania (TM) involves the anxious pulling or removal of body hair, to such an extent that it produces a disruption to one's life functioning. This insidious condition is associated with feelings of depression, shame, anxiety and disgust. Individuals with this condition often engage in social isolation and other extensive efforts to mask the perceived damage that the hair pulling has produced. The term "trichotillomania," refers specifically to the final event (i.e. removal of body hair) in a sequence of behaviors or experiences that lead up to the actual hair pulling. Although hair pulling is most often associated with the condition, there are a number of individuals who engage in elaborate hair cutting episodes that are intended to bring about symmetry or perfect evenness. Trichotillomania, although often conceived of as a simple habit, has baffled behavioral psychologists and produced only moderate success in treatment outcome studies.
It is our belief that this seemingly simple condition is actually an enigma. We believe that the historical lack of success in treating this disorder can most likely be attributed to the "one size fits all" treatment approach implemented in most research protocols and clinical settings. A common shortcoming in the profession of psychology is the tendency for researchers and clinicians to create paradigm-based, rather than empirically-derived, models that pertain to the understanding and treatment of certain conditions. People who invest a great deal of time training in one conceptual paradigm, tend to process most conditions through their own bias. It seems that after buying a hammer, the world is full of nails. The truth is that cognitive-behavioral psychotherapy is not effective in treating everything and not everything that seems bizarre and out of control is OCD.
Thus far, TM has spawned debate as to which of four diagnostic categories would best describe it. Our contention is that within the condition of TM there are four distinct conceptualizations and categorizations. The official and historical classification of TM exists as an impulse control disorder. This is the case even though research suggests that a significant number of TM sufferers evidence no urge to engage in hair pulling. The most likely diagnosis (to be explained later in this paper) for the majority of suffers, is a habit control disorder. Recently, there has been a tremendous debate as to whether TM is just another OCD spectrum disorder. This question persists, despite evidence that anxiety plays a relatively small part in the justification for most hair pulls. Also, more than ten percent of those who engage in hair pulling report no tension release following an episode. When studies compare groups of hair pullers with the variables associated with OCD, results consistently indicate that the differences outweigh the similarities. The presence of perfectionist tendencies is almost never mentioned in association with TM, yet a large number of sufferers report that this is the driving mechanism which compels the initiation of most pulling binge episodes.
Our contention is that one's rationale for pulling out hair sheds light on a differential diagnostic picture. This differentiation can have a significant impact on the selected treatment strategies applied toward the individual condition. Additionally, the shame, disgust and self loathing most often associated with the act of hair pulling within TM has been pervasively neglected as an essential portion of a successful treatment. The notion of hair pulling being a multi-determined behavior strongly suggests that an extensive diagnostic picture be formulated prior to initiating a treatment course.
The experience of shame, although profound and pervasive within this condition, has been minimally researched or discussed in clinical literature. The degree of self-consciousness experienced within this condition presents such disabling effects that it would most likely need to be an integral part of any effective treatment package. For the trichotillomania population, the shame experienced with this act is generally associated with the belief that others will notice the perceivable hair loss produced by the “self mutilation.” There is also a pervasive experience of horror associated with believing that one must be deviant and disgusting for engaging in this self-destructive behavior. A great deal of time and effort is generally dedicated toward concealing or masking the effects of the hair loss. Shame and disgust can also be associated with the existence of the hair in the first place. For example, hair growth existing in undesirable areas of the body is often perceived embarrassing. These areas may include but are not limited to hair above a female's lip, hair between one's eyebrows, ear hair, or unruly pubic hair.
The Grooming Response and a Sequential Analysis of TM
Before presenting the four separate classifications of TM, it is essential to mention a prevalent precursor to the actual hair pulling behavior which exists in most of the following conditions. Prior to hair pulling, most persons engage in behavior otherwise known as the "grooming" response (i.e., hair twirling, eyebrow caressing, pubic hair tweaking, etc.). This repetitive action sets the stage for finding the specific hair or clump of hairs that become the target for the future pull. In most cases this portion of the habit serves as a self-stimulation component, and provides the mind with a positive experience during otherwise low activity times. Others find this stroking behavior to be soothing in times of stress. In these cases the stroking serves to calm down and pamper the emotional upheaval.
For the vast majority of persons with TM, there are specific settings that lend themselves toward prompting the grooming response. The most common settings include, but are not limited to, reading, watching T.V., speaking on the phone, lying in bed, or driving. Being alone is almost an essential part of providing the impetus for engaging in the act of hair pulling. There are occasions where being with a very familiar loved one doesn’t prohibit the habit, despite regular feedback from the loved one to stop pulling. It tends to be more common for the grooming response (i.e., hair twirling) to surface in public, since this behavior possesses less shame and tends to be performed without conscious awareness.
The grooming response is a targeted effort to seek out any hairs that are different or stand out in some tactile or visual manner. The use of a mirror (with or without magnification) and tweezers are common aids to facilitating the hair pulling. These instruments are often used when a perfectionistic outcome is sought after. Exhaustive amounts of time can be spent on literally digging into the skin to “go after” a follicle which exists just below the surface of the skin. On occasion, individuals will terminate the hair pulling binge when blood is drawn. However, the presence of blood is not always enough to bring the binge to a halt. Infections are common for these individuals. Evidence of the self-destructive behavior often leads to distress that can lead to more tweezing. The creation of scabs and scars are also common outcomes of using fingernails or tweezers. The further picking of these scabs can be associated with open wounds that rarely get a chance to heal.
Following a hair pull, many individuals engage in some behavior that further rewards the event by creating increased stimulation. This might entail chewing on the root of the hair or playing with the follicle. Very little is known as to why individuals engage in elaborate post-pull activity. There does tend to be a great deal of additive shame associated with these seemingly grotesque acts. A detailed sequential analysis is essential in formulating a diagnostic picture. The behaviors and experiences just prior to, and immediately following the actual hair pull, often provide insight into critical variables that provide reinforcing elements in maintaining this complex condition.
More Than Just a Hair Pull
The condition of hair pulling might actually fall under four separate diagnostic categories, those being: 1) Obsessive Compulsive Disorder (OCD), 2) Obsessive Compulsive Personality Disorder (OCPD as in perfectionisms), 3) a Habit Disorder, or 4) an Impulse Control Disorder. There is a great deal of debate in psychology as to whether TM falls under the category of a Habit Disorder or OCD. In order to illustrate the four possible diagnostic categories of hair pulling, the following four definitions and their corresponding vignettes are offered.
The definition of a habit, or that which presents clinically as a "bad habit", entails a repetition in behavior for the purpose of producing stimulation (during low activity times) or comfort from tension. The behavior is repeated due to the rewarding properties of the action. The excessive nature of the behaviors of TM (i.e. the enormous time devoted to engaging in the act) can produce either an avoidance of other chosen life endeavors or just create appearance or cosmetic challenges. Often the most troublesome aspect of a habit is the patient's perception that he or she is acting in an "out of control" manner. Attempting to self-impose discipline, so as to not perform the behavior again, often becomes quickly thwarted and great frustration follows. Common habits include, but are not limited to, nose picking, throat clearing, acne squeezing, thumb sucking, knuckle cracking, nail biting, cuticle picking, hair twirling, scab picking, hair pulling, and gum chewing. Habits are often engaged in without the person's conscious choice or awareness. It is usually at the end of the habit session that the effects of the behavior become known. With many habits, it is the patient's significant others who are most distressed at seeing their loved one engaging in this out of control and self-destructive behavior.
John, at age 13, started to spend much of his free time, while watching television or talking on the phone, twirling and weaving his hair. This behavior was a replacement for another habit which his mother had always complained about, that being inner mouth gum chewing. At first, playing with his hair follicles seemed to provide a certain sense of stimulation and satisfaction. As time progressed, he noticed that more and more of his free time became occupied during periods of low stimulation, such as reading textbooks or watching television. Eventually, John noticed that in addition to twirling his hair, there was also a sense of gratification from pulling out hairs which felt in some way different, unusual, or coarser than the others. After plucking out a hair, John would become fascinated with the tip of the hair follicle (root) and often manipulate it, play with it, or periodically chew on it. John established a favorite spot on the back of his head near his calic where the vast majority of his hair play and pulling took place. He thought of his behavior as being slightly unusual and throughout his adolescence engaged in his hair twirling and pulling only during periods of being alone. When John was 18, a barber noticed a thinning spot on his hair and questioned him as to whether any of the males in his family had premature balding. John became mortified at the barber's mention of the thin spot and suffered a panic attack during the remainder of his haircut. John immediately went home and took out an old baseball cap to prevent anyone else from noticing the consequences of his habit. At that point, John decided that he would attempt to stop pulling by using his own discipline and would, on occasion, wear his baseball cap during solitary times in order to prevent him from having contact with his hair. This strategy proved to be unsuccessful as did his girlfriend's repeated efforts at slapping his hands when they made contact with his hair. John eventually sought professional help when his college dorm hall-mates made fun of him for always having to wear a hat. The treatment mapped out with John and his therapist involved in Habit-Reversal training (HRT) and cognitive therapy for depression and shame.
Perfectionism entails a rigid conceptual effort at exerting excessive control in pursuit of an outcome which is devoid of either any perceived flaws or incompleteness. Perfectionism is generally a dispositional handicap in which one's beliefs are detrimental due to their rigid nature. A perfectionist disposition might be applied toward managing one's image. An example would be someone needing to work hard at keeping others from seeing any flaws. For this person, the risk exists of having one's self-esteem seriously damaged by others possessing the opportunity to perceive things in one's life as incorrect or imperfect. Individuals also engage in excessive perfectionist pursuits for the sake of maintaining their rigidly held beliefs of being a “good” person. Perfectionist behaviors might entail, but are not limited to, writing and re-writing for the purposes of producing the best outcome, redundant and excessive cleaning, or placing objects in exactly their correct position. Rereading material to the point of memorizing every detail and therefore hindering productivity is also a common associated feature. Perfectionist tendencies can also be applied toward one's appearance. Hair tweezing to achieve perfect symmetry and uniformity or face picking to remove all blemish material are two such examples. Persons with this subtype of TM tend to be more upset by the cognition that a “bad” hair is present, which in some way disrupts their self-imposed rules about how hairs should be. All hairs should be the same color. A hair should not be too thick. A hair should not fall outside of the "appropriate" areas.
Lisa, at age 16, was going to her first prom and a beauty consultant gave her make-up tips, which included tweezing her eyebrows. Lisa was thrilled with the way she looked for her prom. She felt that her good time and popularity that evening were directly attributed to her appearance. Lisa felt that her eyebrows were major contributing factor to her pleasure with her face. After that evening she took up tweezing her eyebrows on a daily basis. In a short period of time it seemed as if Lisa could never be fully satisfied that she had removed every unruly hair follicle. Eventually she graduated to using a magnifying mirror in order to assist her in finding any hairs that were outside of the area that she preferred for her eyebrow line.
Lisa's daily tweezing provided her with an exaggerated sense of being in control of others' perceptions of her. She began to function regularly under the faulty assumption that as long as her eyebrows were maintained perfectly, life would be less threatening. After approximately four months, Lisa noticed that she would tweeze her eyebrows to the point of drawing blood and, on occasion, scabs developed.
Lisa found herself spending hour upon hour, during her free time and rapidly diminishing study time, through both high school and into college, in front of her magnifying mirror. Lisa reported that during these times, what seemed like five minutes of hair pulling or tweezing, was actually two to three hours. This trance-like state, where time becomes distorted, tends to be a common experience reported within each of the different variants of trichotillomania. The primary motive for Lisa's tweezing was to achieve the perfect eyebrow line and thus feel confident about her looks and appearance, and in control of the others’ perceptions. She lived under the faulty assumption that negligent people had messy eyebrows. Lisa felt strongly that if others noticed her unruly hairs, they would appraise her negatively.
In addition to being preoccupied with her facial hair placement, Lisa's perfectionist nature was evidenced in other circumstances. While running for senior class president, Lisa found that she encountered a great deal of conflict amongst her friends who didn’t quite agree with her proposed class policies. The efficiency of her excellent school performance also became impaired by her excessive need to check and recheck her work until she felt sure that there were no imperfections.
Lisa told absolutely no one about her hair tweezing. She felt that this behavior was evidence that she was very emotionally sick and depraved. “How could a normal person spend so much time preoccupied with such a disgusting, self-absorbed act?” Lisa finally sought professional assistance two years after college graduation. Her hair pulling at that time had gone out of control and she also developed a concern that she might have a great deal of difficulty maintaining intimacy in relationships due to her overly critical nature.
Obsessive Compulsive Disorder
Obsessive Compulsive Disorder (OCD) is a condition in which individuals experience anxiety related to the possibility of a focused threat, and work hard to relieve the anxiety by assuring themselves that the threat will definitely not be realized. Most commonly known are the forms of OCD which entail elaborate rituals involving mental problem solving, cleaning and/or checking. Recently, in clinical literature, there is a growing body of material related to OCD's focus on the anxious effort to remove an unwanted thought or experience. The effort to remove uncomfortable associations might also involve hairs that are perceived to be different or wrong. Persons become fixated in the belief that in every waking moment they will be distracted by a nagging reminder that “the bad hair is still there.” The ritual in this case, hair pulling is performed to absolve the mind of the reminder that the hair is still there and allows for clearness of thought to prevail. The hair pulling is also linked to an ardent belief that one's unattractiveness or body hygiene can be controlled by removing unsightly hairs. This type of OCD predominantly occurs among women, many of whom spend hours picking out minute hairs in an effort to rid themselves of the grotesque defects. This condition within the OCD literature is referred to as a type of Body Dysmorphic Disorder, (BDD).
While playing with her hair, Joan periodically notices that some of the follicles are more coarse and kinky than others. The awareness of the aberrant hair creates a distraction for her. She fears that the distraction will persist until she locates and removes the different hair. The idea that every waking moment will be polluted by its lingering presence, creates an overwhelming urge to rid herself of the follicle. Her effectiveness and concentration at work become impaired and she notices that she tends to make more mistakes. This actualization of the threat creates a panic that she is losing control and she responds by feeling that she needs to be more conscientious about removing all of the distracting hairs. After reading an article in a woman’s magazine about trichotillomania, she seeks professional assistance. She is instructed to wear a rubber band around her wrist and snap it upon each hair pull. She is also instructed to clench her fist when she experiences the urge to pull and keep her fist clenched until the urge passes. After four frustrating months, with minimal success, she reads an article on OCD and contacts an expert in the field.
Body Dysmorphic Disorder
Samantha was always self-conscious about her appearance. She rationalized that since she would some day be an actress, expending more effort in making herself look pretty was justified and sensible. After purchasing a mirror with a magnification side, Samantha became more aware that certain hairs above her lip and on her legs made her feel self-conscious about her appearance and created a sense of being dirty. It seemed to her that some select hairs were thicker than others were and, therefore, very noticeable. She became more entrenched in the belief that others were noticing her hairiness and were finding her repulsive to look at. Despite regular trips to have electrolysis performed, and the reassurance from friends that the hairs she was concerned about were nothing more than "peach fuzz", Samantha continued in her belief that the hair had to go. This anxiety and self-consciousness contributed to her spending a great deal of time in front of her mirror and, with the help of tweezers, pulling out anything that might come close to being a hair. Eventually she would pick to the point of bleeding. The presence of blood would bring only a temporary halt to her picking.
One afternoon Samantha perceived that one cheekbone seemed to be higher then the other. She felt that the asymmetrical nature of her face contributed to her unattractiveness. After repeatedly consulting her family and friends about the perceived defect, she finally consulted a plastic surgeon who made the appropriate diagnosis of BDD.
Conditions involving impulse control entail an overwhelming experience
to immediately and uncontrollably act on an urge which feels compelling and irresistible. Just as a person with Tourette's Syndrome feels an overwhelming urge to bark out sounds or profanities, hair pullers have mentioned, on occasion, the experience of feeling the "need to just get rid of the hair." These hairs just seem to stand out, not because they are wrong but just because they seem different in some way. Kleptomania, exhibitionism, and voyeurism, are common examples of impulse control conditions.
A profound sense of shame tends to permeate each of the above-mentioned subtypes of hair pulling. Shame will be defined as the existence of a perceived defect within a person, which contributes to a loathsome and/or depraved identity, and also encompasses a desperate need for the focus of the shame to be kept hidden from the world. In many cases of trichotillomania, the associated shame is the greatest debilitating effect of the condition. The social isolation, depression (as a result of self-loathing), and mental preoccupation over loss of control tend to have far more damaging effects than the (often slightly noticeable) impact of the hair loss. The shame associated with TM is so paramount that it is one of the defining features of TM as a diagnostic condition. Hair pulling amongst the non-clinical population might either be for the fun of it or a controlled choice made to facilitate grooming. A significant disruption of one’s life due to excess time consumed is another essential element necessary for a diagnosis.
Extensive and desperate efforts are often expended to hide TM from others. The perceived need to conceal this behavior is so extreme that it is not unusual for persons to withhold their hair-pulling behavior from loved ones. Many individuals with this disorder often report significant social avoidance secondary to the pattern balding that may result. Some will avoid events that are most likely to expose their alopecia (hair loss), such as exercise or dancing, for fear of embarrassment. Many of our patients report wearing their hair differently in an attempt to avoid the self-perceived stigma that alopecia may engender.
When confronted, it is common for an individual to deny having the disorder. They will often develop elaborate explanations for their hair loss or compulsive pulling behaviors. Frequently, they will attribute the hair loss to a “medical condition” or a “reaction to a medicine.” Given the stress, social isolation, and shame that are associated with trichotillomania, it is not surprising that a significant number of individuals with this disorder also suffer from depression, anxiety, and substance abuse problems. These difficulties only add to the sufferer’s stress level, often increasing the urge to pull their hair. The outcome is a vicious and self-reinforcing cycle.
Despite the prevalence of hairpulling within the non-clinical population, persons with TM are deeply entrenched in the belief that they are especially corrupt for engaging in this seemingly sick and disgusting behavior. The vast majority of sufferers hold firmly to the notion that any “normal” person would be justified in rejecting them for having this horrific condition. Depression is a pervasive outgrowth of this shame. The extreme self-loathing and social withdrawal often combine to create a devastating impact on one's mood stability. What is not known is whether the depression comes prior to or after the onset of TM. Shame has been given little to no attention in relationship to treatment considerations involving the overall package of treating TM. Specific attention needs to be drawn toward helping people relate, in a more functional way, to their humanness, rather than toward loathsomeness. In this area, strategies pertaining to cognitive restructuring (an element of CBT) are essential.
The hidden rewards of hairpulling
For some individuals, prolonged periods of hair pulling may provide an almost narcotic-like experience. It is not a surprise that most persons with TM indicate that the condition is exacerbated during periods of stress. The actions surrounding the hairpulling sequence can be so preoccupying and therefore distracting, that daily stressors seem to fade into the background and lose their emotional presence. This hypnotic-like effect is responsible for persons often reporting that they get lost in hours upon hours of repeated hair pulling episodes, thinking that only a few minutes have gone by. During periods of low stimulation (e.g. book-reading, T.V. viewing, computer work and telephone conversations), hair pulling can also provide a gratifying experience, such as a child might derive from thumb sucking. A great deal of pleasure can be obtained from stroking one's hair or closely examining the root of a hair follicle. Engaging in this behavior can act as a procrastination facilitator in providing a distraction from confronting or completing meaningful life priorities. Persons will often rationalize putting off their obligatory tasks until they complete the daily grooming ritual. Unfortunately, we are all too familiar with the rewards of putting off today that which can be completed tomorrow.
Within behavioral psychology, these hidden rewards are referred to as “secondary gains”. This term refers to the possible reasons that a seemingly self-destructive behavior might so resistant to treatment. Before a thorough treatment strategy can be formulated, these secondary gains must be given careful consideration to ensure that the patient does not undermine his or her success as a means to not confronting other life priorities. This focus should not be confused with an analytical approach which presupposes that all maladaptive human behavior is caused by deep-seated unconscious motives. A secondary gain refers to a "benefit" that a patient might reap by avoiding, escaping, or otherwise "not being able to" engage in a behavior as a function of being preoccupied with another behavior. For example, a circumstance could exist whereby a patient might feel unskilled in meeting new people and thus spend endless hours engaged in eyebrow tweezing, rather than face the potential humiliation of being rejected at some social affair.
One of the most confounding aspects of trichotillomania is the belief of either the sufferer or their loved ones, that stopping is just a matter of "willpower." We generally feel a great attachment to the notion of free will prevailing in the control of behavior. However, there is a great injustice in believing that, with enough discipline, one can simply stop the cycle. This belief discounts the fact that, for the majority of those who engage in this behavior, a great deal of the actions takes place below one's level of awareness.
Those entering behavioral psychotherapy tend to have a history of multiple failed efforts at bringing this habit under control. Often, the methods used to self-treat closely approximate those that would be suggested by a qualified psychologist. Our contention is that effective treatment packages for this condition are multifaceted. A single strategy that does not take the full diagnostic picture into account will most often fail in the long run. Simply squeezing a rubber ball as a substitute for pulling one's hair does not take into consideration the life stressors that initially compelled the sufferer to engage in the soothing habit. With a systematic and proper application of cognitive-behavioral psychotherapy and other well-established and validated psychological interventions, a more broad-based intervention can be tailored to the individual's particular case.
As behavioral psychologists, we have long been aware of the existence of this disabling condition. Behavioral psychologists have been attempting to develop effective treatments since the early 1970's. These treatments have generally focused on substituting the idle grooming behavior with less destructive activities, or by employing restriction methods which are aimed at preventing access to the afflicted area of the body. For example, many clinicians still employ rubber finger guards or ask patients to tightly squeeze their hands in order to prevent or interrupt the pulling process. Research results on the effectiveness of such behavioral treatments have been quite disappointing, with improvement rates generally in the range of 50%. However, considering the apparent behavioral cycle of trichotillomania, it is both curious and a source of frustration within the practice of behavioral psychology that we cannot achieve higher success rates.
In summary, this article has attempted to introduce the idea that TM may be a single behavior (hair pulling) with four subclassifications. Since each subclassification may require its own treatment protocol, it is not within the scope of this paper to present each of the specific treatments. There is a significant percentage of the TM population whose symptomology qualifies them for more than one classification. It is not unusual for a person to groom and pull while reading a book (habit disorder) and also spend a great deal of time in front of the mirror with tweezers preparing for a big date (perfectionism). Given the diversity of attributes associated with TM, it is imperative that the clinician and patient work together to ascertain the specific nature of the condition before treatment can begin. The paramount importance that shame plays across each of the four classifications was also discussed. Above all other aspects of this condition, it is most likely shame that creates the most debilitating effects. It is time for behavior psychology to re-examine the understanding of this complex disorder. The arguments over whether trichotillomania is properly classified within the OCD spectrum or is just a bad habit may now be replaced with the development of specialized treatment protocols that address the specific nuances of this complex condition.