Trichotillomania and BFRBs

Hair Pulling and Skin Picking

What is Trichotillomania?

Trichotillomania is part of a cluster of behaviors often referred to as body-focused repetitive behaviors (BFRBs). These behaviors include skin picking (dermatillomania), nail biting, and trichotillomania. Commonly referred to as “trich” or hairpulling, trichotillomania is characterized by consistently pulling out one’s own hair. Individuals may pull hair from any part of their body, but commonly target the scalp, eyebrows or eyelashes, and pubic area.

The core feature of trichotillomania is noticeable hair loss, often in the form of bald spots or the presence of broken or short hair strands. Many children, adolescents, and adults report an irresistible urge prior to pulling, often in the form of a localized tension or tickle. This is called a premonitory urge. After individuals pull, they often report feeling a sense of relief, a release of tension, or a sense of satisfaction.


Diagnosis of Trichotillomania in Children, Adolescents, and Adults

Trichotillomania in children and adolescents can be difficult for parents to detect. While some youth may share their pulling problem with a parent or trusted adult, others may pull in a strategic way to hide any hair loss. Caregivers who suspect a hairpulling problem may need to do some “detective work.” This may include looking for hairs in a bathroom or bedroom garbage can, behind the child’s bed, or on the couch where the youth sits to watch TV. Trichotillomania in adults may present with symptoms similar to those found in pediatric cases.

To diagnose trichotillomania in children, adolescents, and adults, our team of psychologists will look for the following clues:

  • Visible hair loss as a result of the pulling or plucking 
  • Repeated attempts to decrease or stop hair pulling
  • Significant distress or impairment in daily life, such as at school, work, or when trying to get things done.


Research-based Treatment Approaches for Trichotillomania

The most effective treatment for trichotillomania is a specialized behavioral intervention called habit reversal training (HRT). HRT is a specialized treatment that involves identifying triggers, implementing competing responses, and providing support and encouragement. Tourette syndrome and tic disorders have similarities to trich and are typically treated using the same evidence-based behavioral intervention.

HRT is a goal-oriented treatment that lasts about 10-12 sessions in clinical trials, although the actual time frame for sessions may be greater or fewer depending on a few different factors. This can vary based on the severity of the pulling, the individual’s level of awareness of their pulling, and their willingness to utilize strategies. Although HRT is considered a cognitive behavior therapy (CBT) based intervention, HRT is a unique specialty and parents should look for providers with specific expertise in this approach. Many children, adolescents, and adults struggling with trichotillomania may also suffer from anxiety, mood dysregulation, or other psychological conditions. A comprehensive treatment approach will consist of additional CBT techniques and/or DBT skills to address the full scope of issues.

In some cases, healthcare professionals may consider natural supplements or pharmacological treatment options. In a small number of studies, including one with youth, N-acetylcysteine (NAC) has shown promising effects in the treatment of trichotillomania. NAC is a natural supplement which may help reduce the urge to pull hair. Therefore, this may be an option as an adjunct to HRT treatment for individuals who pull their hair. Medications, such as selective serotonin reuptake inhibitors (SSRIs), can treat anxiety or other conditions that may exacerbate pulling. However, there is limited research to date that supports the use of medication for the treatment of trichotillomania.


Supporting a Child or Loved One with Trichotillomania

Parents play an active role in their child’s journey with trichotillomania. By educating themselves about trichotillomania, promoting awareness of pulling, and implementing positive reinforcement techniques, they can help their child resist urges to pull and develop healthy attitudes and approaches towards their pulling behavior. Parents can also help their child by being mindful of their own distress about their child’s hairpulling, and by taking steps to create a safe and understanding environment devoid of criticism. Pushing a child to stop picking or criticizing them for doing so will likely result in additional stress that exacerbates the pulling.

For children and adolescents, collaboration with educators can also ensure appropriate accommodations and interventions are in place at school. While these strategies can vary and should be tailored to each student, one example is to create a discrete sign a teacher can make to prompt the child to utilize their strategies.

For adults dealing with trich, a spouse or close friend can play a crucial role as a support person or coach. In this capacity, they may offer reminders to employ strategies or engage in self-monitoring exercises recommended by their psychologist. It is vital for the support person to have an open discussion about how they can most effectively provide assistance. Without such communication, well-intentioned efforts may unintentionally prove counterproductive, leading to friction and potentially exacerbating the picking behaviors.


Living with Trichotillomania

Pediatric trichotillomania is a hair pulling disorder that can significantly impact a child’s life. It can cause significant emotional distress and social challenges. Children, adolescents, and adults who pull their hair may experience feelings of shame or embarrassment due to hair loss or the inability to control their hair-pulling behavior. 

In school settings, children and adolescents with trichotillomania may be teased or bullied. In work or school settings, children, adolescents, and adults may be distracted from their work when they become engrossed in their pulling. The pulling behavior may result in the distress of parents and loved ones as well. Fortunately, there are effective evidence-based strategies to support individuals struggling with trichotillomania. Children, adolescents, and adults can learn to manage their condition and lead fulfilling lives.