What is hair pulling disorder? The causes of the urge to pull out hair, eyebrows or eyelashes, coping with shame, and therapy using habit reversal training.
It is midnight and you are writing a report under the desk lamp, or reading something on your phone. After a while you notice that your left hand is in your hair again; your fingers have found a coarse, thick strand and pulled it out. There are a few hairs lying on the desk. For a moment you feel relief inside, followed immediately by a familiar shame and anger at yourself. "From tomorrow I won't touch it," you promise; you have made this promise hundreds of times before. Hair pulling disorder, known in medical language as trichotillomania, is a condition that people often hide for years, blaming themselves for a "lack of willpower". Yet it is not a matter of willpower; it is a cycle that has become embedded in the way the brain deals with tension and stimulation. In this article we explain how hair pulling works, why it cannot easily be stopped and which methods can help bring about change.
What Is Hair Pulling Disorder (Trichotillomania)?
Trichotillomania is a condition defined by a person repeatedly pulling out their own hair, eyebrows, eyelashes or hair from other parts of the body, and being unable to stop despite efforts to do so. In clinical classification it belongs to the disorders related to obsessive compulsive disorder. Together with behaviours such as skin picking and nail biting, it is also referred to as a "body-focused repetitive behaviour".
Hair pulling usually begins in adolescence, but it can also start in childhood or adulthood. The person is generally aware of this behaviour, is troubled by it and wants to stop; but when the urge comes, stopping it is extremely difficult.
Hair pulling is not a suicide attempt and does not carry an intention to self-harm. The person pulls not in order to feel pain but, most often, to soothe tension, distress or a need for physical stimulation. Even so, shame and helplessness can over time lead to serious unhappiness; we will return to this later in the article.
How it differs from stress-related hair loss
Hair falling out during periods of stress is a bodily reaction that happens outside the person's control. In hair pulling disorder, the hair is pulled out by the person's own hand. These two conditions are sometimes confused; we discuss this separately in our article on hair loss from stress. If the cause of hair loss is unclear, an assessment by a dermatologist is also important.
What Are the Symptoms of Hair Pulling Disorder?
- Noticeable thinning or bald patches on the scalp, eyebrows, eyelashes or beard area
- Repeated unsuccessful attempts to reduce or stop pulling
- Rising tension or an itch-like urge before pulling
- Brief relief, even a kind of satisfaction, after pulling
- Searching for particular "right" hairs: thicker, coarser, curly or differently textured ones
- Examining the root of the pulled hair, rolling it between the fingers, rubbing it on the lips or biting it
- Hiding bald patches with hats, headscarves, hairstyles, eyebrow pencil or false eyelashes
- Avoiding the hairdresser, the swimming pool or going out in windy weather
Automatic and focused pulling
Hair pulling can occur in two different ways, and in most people both are seen together:
Automatic pulling: The person pulls their hair without realising it while watching television, studying, waiting in traffic or scrolling on their phone. By the time they notice, a few hairs have often already been pulled out.
Focused pulling: The person pulls deliberately, driven by a particular tension, distress or the urge to "find the right hair". This usually happens in front of a mirror, in the bathroom or when alone, and can go on for a long time.
Knowing which form is in the foreground is important in deciding which methods will be used in therapy.
What Causes Hair Pulling?
There is no single cause of hair pulling. Biological predisposition, ways of regulating emotions and triggers in the environment all play a part together.
Emotion regulation: In many people, hair pulling develops as a way of soothing feelings such as anxiety, distress, anger, boredom or tiredness. Because the behaviour works in the short term, the mind records it as a "tool for relief".
Under- or over-stimulation: Some people pull when they are bored and feel a lack of stimulation, while others pull when they are extremely tense and over-aroused. Both have to do with the body's search for balance.
Sensory factors: The texture of the hair, the feel of the root and the small sensation at the moment of pulling can give the person a particular sensory satisfaction. This also contributes to the behaviour continuing.
Predisposition: Having similar behaviours in the family can increase vulnerability. Research points to some of these behaviours having biological foundations.
Trigger situations: Certain places (the bed, the bathroom, the desk), certain times (late at night) and certain activities (reading, looking at a screen, talking on the phone) are situations in which pulling is common.
The Effect of Hair Pulling on Daily Life and Emotions
The heaviest burden of hair pulling disorder is often not the hair loss itself but the cycle of shame and secrecy that forms around it.
Imagine a seventeen-year-old girl preparing for the university entrance exam who, as the YKS (Turkey's national university entrance exam) period approaches, starts pulling out her eyebrows while studying. First a few hairs, then part of one eyebrow is completely bare. She tries to cover the gap with eyebrow pencil and shies away from her friends looking at her face too closely. Every time her mother notices, she warns her, "Take your hand away from your eyebrow!"; with every warning the girl feels a little more ashamed and starts pulling in her room with the door closed. As this example shows, even well-meant warnings often do not reduce the behaviour; they only lead to it being hidden.
Common effects of hair pulling include:
- Anxiety about appearance: Avoiding looking in the mirror or, conversely, examining the bald patches in the mirror for a long time
- Social avoidance: Being unable to go to the hairdresser, avoiding the pool or the sea on holiday, fearing being noticed in close relationships
- Secrecy in relationships: Hiding it from a spouse or family for years
- Physical problems: Irritation of the scalp, ingrown hairs; and if pulled hair is swallowed, serious problems with the digestive system. If there is hair-swallowing behaviour, a doctor must be consulted.
- Emotional burden: Anger at oneself, worthlessness, hopelessness; at times depressive symptoms
Hair pulling in adulthood: the hidden years
Although hair pulling often begins in adolescence, it can continue into adulthood and is hidden even more skilfully at this stage. An engineer in his forties may only admit that he has been pulling hairs from his beard while waiting in traffic for twenty years when his wife points out the hairs in the car. A teacher may never tell anyone that she pulls out her eyelashes during the moments she stands facing the board. Adults often dismiss the behaviour as "a bad habit" while also being angry with themselves for being unable to stop. Learning that this behaviour has a recognised name and is not a flaw unique to them is, for many adults, the first step towards asking for help.
If you would like to understand how shame turns into a cycle, our article on skin picking, which describes people who pick at their skin with a similar urge, may also be helpful.
Hair pulling is not a weakness of character but a way the brain has learnt to soothe difficult feelings; and a learnt way can be replaced with a new one.
Practical Suggestions for Coping With Hair Pulling Disorder
The following suggestions can help you notice the pulling behaviour and reduce how often it happens:
- Keep a record for a week. Note when, where, during which activity and with which feeling you pull. With this record, most people notice how specific their triggers are.
- Put a barrier on your hands. During high-risk times, wearing thin gloves, plasters on your fingertips or a ring creates a small pause in front of automatic pulling.
- Make your hair harder to reach. Tying your hair back, wearing a cap or bandana, or wearing glasses for your eyebrows can make touching harder.
- Give your hands something else to do. Keep options to hand that occupy your hands and give a similar sensory feel, such as a stress ball, modelling clay, a rough pebble or knitting.
- Change trigger environments. For example, removing the magnifying mirror from the bathroom, sitting in a different arrangement rather than at the desk when studying, or not looking at your phone in bed.
- Do not scold yourself. Getting angry with yourself when you notice you have been pulling can increase tension and trigger a new wave of pulling. Saying "I've noticed; now I'm lowering my hands" is enough.
- Involve someone you trust in the process. You can agree with your spouse, a sibling or a close friend on a gentle signal they will use when they notice you pulling, such as lightly touching your shoulder or saying a word you have agreed in advance. It is important to agree from the start that this signal is a reminder, not a criticism. Sharing your records and small steps of progress with this person also helps you keep up your motivation.
When Should You Seek Professional Support?
- Noticeable bald patches have appeared in your hair, eyebrows or eyelashes
- You have tried many times to stop but have not managed it
- Hair pulling keeps you away from social settings, the hairdresser or holidays
- You bite or swallow the hairs you pull out (in this case a doctor's assessment is also necessary)
- You feel hopeless, worthless or helpless
Shame and helplessness can sometimes turn into thoughts of ending your life or harming yourself. If you are having such thoughts, do not wait; call 112 (emergency services) or go to the nearest emergency department.
How Is Hair Pulling Disorder Addressed in Therapy?
For trichotillomania, the approach most supported by research is Habit Reversal Training, which is part of Cognitive Behavioural Therapy. Where needed, this approach is supported by emotion regulation and acceptance-based methods. Because hair pulling often begins in adolescence, you can see how work with young people proceeds on our adolescent counselling page.
Awareness training
The first step is to notice the behaviour. The person learns to recognise the signs just before pulling: the hand rising towards the hair, the fingers searching for a strand, a particular feeling of tension. The earlier they notice these signs, the easier it becomes to intervene.
Competing response
When the urge comes, a movement that cannot be done at the same time as pulling is carried out: for example, gently clenching the fists, pressing the hands onto the knees or gripping an object. This response is kept up until the urge passes, usually for a minute or two.
Stimulus control
The environment is arranged according to the person's pulling pattern: gloves, a cap, the position of the mirror, the layout of the study area, and so on. Which trigger will be met with which measure is planned together with the person.
Working with emotions
If pulling is used to soothe a feeling, other ways of coping with that feeling are worked on. Personal alternative skills are developed for boredom, anxiety, anger or tiredness. Shame and self-blame are also an important subject in the process.
Making peace with setbacks
Change in hair pulling often progresses in ups and downs. An exam week, a break-up, a busy period at work or sleepless nights can lead to a temporary increase in pulling. In therapy these periods are treated not as failures but as information showing which triggers are still strong. The person learns, when they slip, to return to the awareness record and the competing response rather than saying, "It's all been for nothing."
Working with the family
With children and adolescents, the family is included in the process. Instead of criticism and constant warnings, parents may be advised to use signals agreed together in advance that support the child's awareness.
Frequently Asked Questions
Will my hair grow back when I stop pulling?
In many cases, as pulling decreases, hair, eyebrows and eyelashes grow back. However, if one area has been pulled intensively for many years, some thinning may remain. An assessment by a dermatologist can provide guidance on this.
Does pulling out eyebrows and eyelashes also count as trichotillomania?
Yes, trichotillomania is not limited to the scalp. The repetitive pulling out of hair from the eyebrows, eyelashes, beard or other parts of the body, in a way the person cannot stop, can also be considered within this definition.
I've noticed my child pulling out their hair; what should I do?
First stay calm and avoid scolding or constantly warning your child; this usually leads to the behaviour being hidden. Talk to your child without judgement, observe in which situations the behaviour increases, and get support from a child or adolescent mental health professional.
If I have my hair cut very short, will the pulling stop?
Short hair can make pulling temporarily harder for some people and can be used as part of stimulus control. But when the source of the urge is not addressed, pulling often shifts to the eyebrows, eyelashes or another area. That is why a haircut should be thought of not on its own but as part of a comprehensive plan.
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Eda Erkan Alapala
Klinik Psikolog. İstanbul Kent Üniversitesi Klinik Psikoloji Tezli Yüksek Lisans mezunu; bilişsel davranışçı terapi, çocuk merkezli oyun terapisi ve çocuk-ergen psikoterapisi alanlarında eğitimlerini tamamlamıştır.
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