Why does trichotillomania (hair-pulling disorder) appear in teenagers? Signs, the shame young people feel and how a family can help without blame, explained.
While brushing her hair, you notice more hair in the brush than usual. After a while, a small, thin patch on the top of your daughter's head or behind her ear catches your eye. You ask; she says, "I don't know, it must be falling out." Perhaps a few weeks later, you see her running her fingers through her hair while studying and pulling out strands one by one. Hair-pulling disorder, known medically as trichotillomania, is defined by a person repeatedly pulling out their own hair, eyebrows or eyelashes and finding it hard to stop. It often begins in adolescence, and young people tend to live with it in secret and with great shame. Families, meanwhile, are usually caught between bewilderment, worry and the helpless feeling of "Why is she doing this? If only she'd stop!" In this article we look at why hair pulling arises, what goes on in the young person's inner world and how the family can offer support without blaming or shaming.
What Is Trichotillomania (Hair-Pulling Disorder)?
Trichotillomania belongs to a group known as "body-focused repetitive behaviours". Nail biting, skin picking and lip biting are similar behaviours. In mental health classifications it is listed among obsessive-compulsive and related disorders.
The main features of trichotillomania are:
- Repeatedly pulling out hair from the scalp, eyebrows, eyelashes or other parts of the body
- Repeated but unsuccessful attempts to reduce or stop the behaviour
- The behaviour leading to noticeable hair loss
- Distress, shame or marked difficulty in daily life because of the behaviour
Hair pulling is sometimes conscious and focused: the young person pulls their hair when they feel tense, bored or a particular urge, and is aware of it. Sometimes it happens almost automatically: while studying, looking at their phone, watching television or lying in bed, their hand goes to their hair without their noticing. In many young people both forms occur together.
It is important to stress that this behaviour is not a "bad habit" or a "lack of willpower". Young people very often genuinely want to stop but struggle to cope with the urge.
Why Do Teenagers Pull Their Hair?
There is no single cause of trichotillomania. Biological, psychological and environmental factors are thought to play a part together.
Emotional regulation
For many young people, pulling hair becomes a way of coping with intense emotions. In moments of anxiety, tension, boredom, anger or loneliness, pulling out hair can give a brief sense of relief or calm. This relief reinforces the behaviour, and the cycle begins: tension, hair pulling, brief relief, then shame and guilt, then tension again.
Sensory factors
Some young people get a particular sensory satisfaction from feeling the texture of their hair and finding and pulling out certain kinds of strands, for example thicker, curly or coarse ones. Playing with the pulled hair, rolling it between the fingers or running it across the lips can also be part of the behaviour.
The load of adolescence
Adolescence is a period in which hormonal changes, academic pressure, peer relationships and questions of identity intensify. Long and stressful processes such as preparing for the LGS or YKS (Turkey's national high-school and university entrance exams), sitting at a desk for hours and a constant sense of being evaluated can create fertile ground for hair pulling to start or increase.
Predisposition
Similar behaviours, anxiety or obsession-related problems in the family may contribute to a young person being more prone to this behaviour. But predisposition does not mean the behaviour is inevitable.
For more general information on problems in the obsessive-compulsive spectrum, have a look at our article What is OCD?. Our article on hair-pulling disorder, which looks at hair pulling in adults, approaches the subject from another angle.
Signs of Trichotillomania and Its Hidden Side
Young people often hide this behaviour for a long time. As a result, the first signs families notice are usually indirect:
- Thin or bare patches in the hair, eyebrows or eyelashes
- A sudden change of hairstyle, a constant wish to wear a hat, beanie or hair clips
- An unusual amount of hair in the room, on the pillow, desk or carpet
- Filling in eyebrows with pencil, wanting to wear false eyelashes
- Avoiding going to the hairdresser, swimming or going out in windy weather
- Constantly playing with their hair, especially while studying, looking at a screen or lying down
Let us say a fourteen-year-old girl starts avoiding PE lessons at school and having her photo taken with friends; her mother interprets this simply as shyness. Months later, after a friend notices the gap in her hair, the girl comes home in tears and tells her mother everything. This picture shows how long the behaviour can be carried in silence.
Secrecy is the most visible face of shame in trichotillomania. Young people may feel "weird", "out of control" or "broken". These feelings delay asking for help and deepen loneliness.
Why Does the Family's Attitude Matter So Much?
When parents notice this behaviour, their first reaction is understandably worry and sometimes anger. Sentences such as "Take your hand away from your hair!", "Look at yourself, you'll go bald!" or "Why are you doing this, are you mad?", even when said with good intentions, usually backfire. As shame and guilt increase, so does tension; as tension increases, the urge to pull grows stronger.
Within the family, the following attitudes can be supportive:
- Talk in a calm and curious way: "I've noticed some bare patches in your hair. Would you like to talk about it? I'm not angry; I want to understand."
- Don't see the behaviour as defining your teenager: They are not "someone who pulls their hair" but someone who has a behaviour they are struggling with.
- Avoid constant reminders: Saying "Again?" every time they touch their hair makes the young person feel watched and leads them to hide the behaviour more. Decide together with your teenager how reminders will be given, if they are to be given at all.
- Avoid systems based on punishment or reward: Giving a reward for a day without pulling and a punishment for a day with it ignores the emotional load behind the behaviour and increases pressure.
- Take their concern about appearance seriously: Requests such as wearing a beanie, changing their hairstyle or filling in their eyebrows can help them feel more comfortable. It is important to see these not as "hiding" but as a way of protecting themselves.
- Manage comments from relatives and others: Preventing comments about the young person's hair during religious holiday visits or family gatherings, and if necessary closing the subject with a short, general explanation, lightens their load.
What helps a teenager who pulls their hair most is not voices telling them to "stop", but a calm closeness that tries to understand why they are struggling.
Supportive Steps You Can Take at Home
Although professional support is important, a young person can also take some steps at home with the family's support. These steps need to be applied with the young person's own choice and consent.
- Awareness: Noticing the times, places and feelings when pulling happens most is the first step. The young person can keep short notes to answer the questions "When, where, and what was I feeling?"
- Alternatives for the hands: Objects that keep the hands busy, such as a stress ball, a soft piece of fabric, modelling clay, a small fidget toy or knitting, can reduce automatic pulling.
- Small barriers: Measures such as tying the hair back while studying, wearing thin gloves or plasters on the fingers, or wearing a beanie make it harder to reach for the hair and increase awareness.
- Adjusting high-risk situations: The settings where pulling happens most, such as looking at the phone in bed or spending a long time in front of the bathroom mirror, can be identified and changed.
- Ways of coping with tension: Breathing exercises, short walks, physical activity and enjoyable activities help release tension in ways other than pulling.
Each of these steps may seem small, but when applied regularly they support one another. Remembering that setbacks, meaning the behaviour increasing again after a period of decline, are ordinary reduces disappointment for both the young person and the family.
Hair Pulling at School and Among Friends
A young person spends much of the day at school, and hair pulling often increases in class, especially in long lessons, exams or mock exams. Fear of being noticed at school can lead them to avoid joining in lessons, going up to the board or close contact with friends.
At this point, cooperation with the school can be helpful. With the young person's consent, giving brief information to the school counsellor can mean they are allowed to use a small object to keep their hands busy in class, or that wearing a beanie is not made an issue. However, deciding together with the young person who will be told and how much is important in respecting their privacy.
Thinking in advance about what to say when a friend notices a gap in their hair and asks about it also helps the young person feel safer. A short, calm answer such as "I play with my hair when I'm stressed; I'm working on it" can close the subject without making a big deal of it. Many young people living with trichotillomania find that when they tell a close friend, they meet a far more understanding response than they expected.
When Should You Seek Professional Support?
When hair pulling is noticed, it is generally helpful to talk to a professional. Getting support is especially important in the following situations:
- Loss of hair, eyebrows or eyelashes has become noticeable
- The young person wants to stop but cannot
- Because of shame, they are withdrawing from school, friends or social activities
- The behaviour is accompanied by anxiety, depressive symptoms, obsessions or other body-focused behaviours, such as skin picking
- Pulled hair is being swallowed; as this can lead to stomach and bowel problems, an assessment by a doctor is essential
- The young person expresses intense anger towards themselves, worthlessness or hopelessness
In some cases, an assessment by a dermatologist or a psychiatrist may also be part of the process. If the young person talks about thoughts of harming themselves or ending their life, seek support without delay; in an emergency, call 112 (emergency services).
How Is Trichotillomania Addressed in Therapy?
Trichotillomania is a condition that can be worked on with suitable approaches. In counselling for teenagers, the most commonly used methods are based on Cognitive Behavioural Therapy.
Habit reversal training: In this approach, the young person first learns to notice in detail when, where and with what feelings the behaviour arises. Then a "competing response" is developed that cannot be done at the same time as pulling when the urge comes; for example, making fists and holding them for a few minutes, or squeezing an object in their hand.
Stimulus control: The settings and situations that make pulling easier are identified, and practical adjustments are made to change them.
Emotional regulation skills: Skills for coping in healthier ways with the tension, anxiety or boredom behind the behaviour are worked on. Acceptance- and mindfulness-based techniques can teach them to notice the urge and let it pass rather than fighting it.
Work on shame and self-worth: The young person's self-critical thoughts are addressed. The thought "I'm broken" can give way to the view "There is a behaviour I struggle with, and I'm working on it."
Working with the family: With parents, the conversation covers creating a supportive environment at home, deciding how reminders and comments will be made, and being able to stay calm in the face of setbacks.
Frequently Asked Questions
Does trichotillomania go away on its own?
In some young people the behaviour may lessen over time; but in many, without support, it can continue for a long time or increase again during stressful periods. Getting support early helps prevent the behaviour from becoming entrenched.
Will the pulled hair grow back?
In most cases, hair grows back once pulling decreases. However, pulling from the same area for many years can damage hair follicles in some people. An assessment by a dermatologist will be informative on this.
Should I tell my teenager every time I see them pulling their hair?
Constant reminders usually increase tension and shame. Instead, it is more helpful to agree together with your teenager whether they want reminders and, if so, how they should be given, for example with a pre-arranged silent signal.
Is hair pulling a form of self-harm?
Trichotillomania is generally not intended as self-harm; it is more often linked to reducing tension or a sensory need. But every young person's situation is different, and any accompanying emotional difficulties should be assessed by a professional.
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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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