We humans spend a lot of time, money, and effort on keeping our hair on certain parts of our bodies and keeping it away from others. Generally, we regard the hairs on our heads as keepers—a full head of hair is associated with health and beauty, and so many things can cause that hair to fall out.
For some—particularly those with androgenic alopecia, also known as male pattern baldness—hair loss is a question of genetics. For others, it can be attributed to changes in hormones, medical conditions, nutritional deficiencies, stress, weight loss, medications, or simply the process of getting older.
But there are also a couple of ways we might play an active, if unwitting, role in our hair’s density and coverage. One is traction alopecia, which results from wearing tight braids and ponytails, hair extensions, or styling our hair with chemical relaxers and rollers. Another way we can cause hair loss is by actively pulling hairs from our scalp, eyebrows, and eyelashes with our fingers. It’s the outward manifestation of a distressing but treatable mental disorder called trichotillomania.
In this article, we’ll discover what trichotillomania is and how it causes balding. We’ll discuss its categorization as a body-focused repetitive behavior (BFRB), and how it can be treated with an effective and increasingly accessible therapeutic technique called habit reversal training (HRT).
What is trichotillomania?
Trichotillomania is a mental health disorder in which people have an irresistible urge to pull out their hair, and it’s pretty common. The lifetime prevalence of trichotillomania is estimated to be between 0.6% and 4.0% of the overall population. That equates to between 2 and 13 million people in the United States alone. The disorder usually appears in pre-or early adolescence and develops equally in boys and girls. However, by adulthood, 80-90% of reported cases are women. Without treatment, hair-pulling disorder tends to be a chronic condition; one that may come and go throughout a lifetime.
While some people with trichotillomania don’t realize they are pulling their hair—known as “automatic pulling”—others feel rising tension leading up to pulling a hair out, followed by pleasure, gratification, or relief, once they’ve done it—known as “focused pulling.”
Whether it’s conscious or not, hair pulling can—and often does—lead to noticeable hair thinning and bald patches, leading many to attempt to camouflage these areas by styling their hair a certain way, wearing a wig or hair extensions, or covering these areas with a hat. Others may simply avoid social situations altogether due to the embarrassment or shame they feel about the results of their hair-pulling.
Diagnosing hair-pulling disorder
Trichotillomania has been included in the Diagnostic Statistical Manual of Mental Disorders (DSM) since 1987. At first, it was categorized as an impulse control disorder, but since 2013, it’s been classed as a body-focused repetitive behavior (BFRB) along with skin picking (excoriation disorder), nail-baiting (onychophagia), nose-picking (rhinotillexomania), and others.
BFRBs are not forms of Obsessive-Compulsive Disorder (OCD) but belong in an adjacent category called Obsessive-Compulsive and Related Disorders. This grouping also includes: hoarding disorder, an obsession with arranging, ordering, and/or collecting items; body dysmorphic disorder, an obsession with perceived flaws in one’s appearance; olfactory reference disorder, an obsession with your body odor; misophonia, an obsession with certain sounds; and emetophobia, an obsession centered around a fear or vomit or vomiting.
The DSM-5 diagnostic criteria for trichotillomania are as follows:
- Recurrent hair pulling, resulting in hair loss
- Repeated attempts to decrease or stop the behavior
- Clinically significant distress or impairment in social, occupational, or other areas of functioning
- Not due to substance abuse or a medical condition
- Not better accounted for by another psychiatric disorder
Now that we have a better understanding of what trichotillomania is, who it affects, how it shows up, and the criteria providers use to make an accurate diagnosis, let’s address the question we posed to begin with: can hair pulling cause balding?
Trichotillomania and balding
Yes, trichotillomania can indeed cause balding. For many who pluck their hair automatically, visible balding may even be the first indication that their habit is beyond their control.
“With trichotillomania, balding will typically happen in patches,” says Monique Williamson, LMFT, a therapist with NOCD. “Some people will have a preferred spot they’ll frequently pull from. Multiple patches tend to appear when there’s no hair left in that preferred spot. It’s also important to remember that trichotillomania doesn’t only mean pulling hairs from the scalp. Some people pick their eyelashes and eyebrows, not to mention their pubic or leg hair. But by the time most people seek help, it’s because they’ve noticed a deterioration in their hair or someone else has pointed it out to them.”
As well as visible bald patches leading to people wearing hats and wigs or limiting their social interactions, the emotional distress they cause can also put people at risk of developing a co-occurring psychiatric condition, such as a mood or anxiety disorder. And it doesn’t stop there; trichotillomania can also cause physical effects beyond the bald patches themselves. These include itching, tissue damage, infection, and repetitive muscle and joint motion injuries. If the pulled hair is then eaten—a specific condition called trichophagia—the sufferer may experience gastrointestinal issues or, in rare cases, even develop a hairball that requires surgery to remove.
The emotional and physical effects that can attend trichotillomania underscore the urgent need to address your hair pulling behavior if you think you may be suffering from the condition. The most effective way to do that is by employing habit reversal training (HRT)—an evidence-based approach to treating all BFRBs.
How HRT works
There are five elements to HRT. The first thing a trained HRT therapist will do with you is help to raise awareness about when you’re pulling hair and, more importantly, help you recognize the emotions that bubble up immediately before you begin doing it.
“So with my clients, I’ll typically have a pretty deep discussion about the feelings that precede the hair pulling. The client I’m thinking about now had a lot of stress, and that’s what caused them to pick out hair. So we worked a lot on awareness training. I asked her to do a little finger flag when that stress came up, and she wanted to start pulling—just a little physical acknowledgment: okay, here it is, it’s happening again.
Sometimes I’ll do it in session with clients, and it may even look similar to the exposures we do in exposure and response prevention therapy for OCD. So maybe we’ll discuss something stressful for them at work; maybe it’s a project they’ve been avoiding. We’ll gradually increase that stress response and then have a conversation about feeling the urge to pick. This enables them to connect the stress and the behavior they’re trying to stop. And from there, we can start the real work.”
Once you can reliably identify what leads to a bout of hair plucking, your therapist will help you institute a competing behavior that you’ll perform instead. This is the second part of the treatment, and it can be a game changer for many people with BFRBs.
“I always tell my clients that, when we’re choosing competing behaviors for hair pulling, we want to have a competing behavior that will be physically distant from where the plucking is happening,” says Williamson. “So if that hair pulling is happening on the head, we might want that competing behavior to occur below the waist. Silently snapping fingers is often good for hair pulling because you still get some stimulation in your fingers, which is often what people are looking for.”
Williamson adds that she sometimes even suggests that people play a two-handed game on their smartphone as a competing behavior, as it’s highly engaging and makes hair-pulling physically impossible.
“We try to get these competing behaviors to last for at least 60 seconds, which is often enough time for the urge to pull hairs to dissipate,” she says.
The third element of HRT is motivation and compliance: This could involve making a list of all the problems caused by the behavior to remind you of the importance of sticking with it. This stage can be bolstered by asking friends and family to acknowledge your progress along the way.
The adoption of relaxation skills is the fourth aspect of HRT. These skills may include deep breathing, mental imaging, mindfulness, and progressive muscle relaxation to keep urges at bay, particularly as the specific thoughts and feelings that precede the hair-pulling arise.
Generalization training, the fifth and final stage of HRT, involves practicing your new skills in several different situations so the new behavior becomes almost automatic. Between sessions, your therapist will ask you to complete a target behavior monitoring form.
“This is a sheet that helps you monitor when you are doing your picking and pulling behaviors,” says Williamson. “It asks you questions like ‘What was going on around you when you noticed you wanted to pull your hair? What did you do to try to avoid this thing? How were you feeling at that moment? If you didn’t avoid the picking, how long did it take you to stop? What was the process like for stopping?’ Some people may tell themselves to stop, but it can still take a few minutes before they fully disengage.”
By having this record on hand, you and your therapist can chart your progress and, if necessary, adjust what you do in and outside sessions.
BFRBs and NOCD
The close relationship and frequent co-occurrence between OCD and BRFBs, such as trichotillomania, led NOCD to train all 300+ licensed therapists in the NOCD Therapy network in HRT for treating BFRBs. HRT can be highly effective when delivered remotely, and a marked improvement is often seen in a matter of weeks.
If you or someone you know is struggling with trichotillomania—or any other BFRB—you can schedule a free call today with the NOCD Care Team to learn more about how a licensed therapist can help.