You’ve probably heard the saying, “I’m so stressed I just want to pull my hair out!” This leads most people to think trichotillomania (soon to be renamed as hair pulling disorder) is a rare disorder involving stress and anxiety. This perception of hair pulling is based more on pop culture than reality. Researchers now know that trichotillomania is far more common than once thought and is uniquely different from anxiety disorders.
While estimates vary, about 1 in 50 or 2% of the general population has trichotillomania. This makes the disorder more common than Schizophrenia and Bipolar Depression. Unlike anxiety disorders (e.g. panic disorder, social anxiety, PTSD) where the main symptoms are stress and fear, trichotillomania has a far more complex and heterogeneous set of symptoms.
When trichotillomania first develops (often around puberty), most individuals don’t even realize they are pulling their hair. It happens automatically and without any conscious effort. Unlike anxiety disorders where fear becomes associated with specific situations, researchers believe that it is a complex integration of biology (genetics, hormones, neuroanatomy), psychology (emotional regulation), and environment that drives an individual to pull their hair. While some do pull their hair to lower anxiety, many also pull out of boredom, sadness, anger, frustration, loneliness, or excitement. There is also a different type of hair pulling called focused pulling. During focused pulling, individuals are consciously taking time out of their day to sit and pull their hair until a certain goal is reached (e.g. pulling out all grey hairs or creating symmetry in the hairline). This type of pulling is often relaxing and makes the person feel good when they have accomplished their goal.
The problem with trichotillomania is not fear or anxiety, but rather the cultural stigma associated with patches of missing hair (note: in some cases, such as the presence of a trichobezoar/hairball, hair pulling can pose significant health risks and a medical doctor should be consulted immediately). For this reason, researchers recommend thinking of trichotillomania as a body focused repetitive behavior problem (like skin picking or nail biting) rather than an anxiety disorder.
It is important that both health professionals and those with trichotillomania do not think of the disorder as an anxiety problem. Anxiety treatments (like exposure therapy) do not work for trichotillomania. The Trichotillomania Learning Center, the national organization for people with trichotillomania, their families, and mental health professionals, maintains a great outline of medications and psychotherapies that are effective at treating hair pulling. If you suffer from trichotillomania, you can also use TLC’s webpage to find trained health professionals and support groups. If you are a health professional, I highly recommend attending one of their Professional Training Institutes to better understand hair pulling and empirically supported ways of treating it.
In addition, there are some great books on the topic. For parents of a child with hair pulling, Stay Out of My Hair and The Hair Pulling “Habit” are wonderful resources. For adults, The Hair-Pulling Problem is a thorough guide to understanding trichotillomania. If you are a health professional, Treating Trichotillomania details the basics of Cognitive-Behavioral Therapy for hair pulling. Lastly, for those who do not have any access to health care professionals or want an adjunct to their treatment, Stop Pulling is a empirically based self-help website for those suffering from hair pulling (full disclosure: I am actively involved in research associated with this website).