You're watching a series, studying or waiting for a page to load, and your hand drifts up to your head on its own. You hunt for a hair that feels different, coarser or thicker than the rest, pull it out and look at it. Maybe you roll it between your fingers or run it across your lips. By the time you notice, there are a few on the keyboard or in your lap, and a thinner patch you'll cover tomorrow with your parting, a cap or a little eyebrow pencil.
If you recognise yourself in that scene, you're not a strange case and you're not short of willpower. It has a name: trichotillomania. In this article I'll explain what trichotillomania is, why it's so hard to stop, how it differs from an ordinary bad habit and which treatment actually works.
What trichotillomania is
Trichotillomania is a repeated, very hard-to-resist urge to pull out the hair on your head or elsewhere on your body, to the point where the loss shows. The person has tried to stop more than once without success, and the whole thing causes distress or gets in the way of daily life. The American Psychological Association includes it in its dictionary of psychology, and the diagnostic manuals place it within the family of obsessive-compulsive and related disorders. Many people simply call it 'trich'. The most widely quoted estimates put it at between 1 and 2% of teenagers and adults: far more common than it seems, but rarely talked about because nearly everyone hides it.
How trichotillomania shows up
Everyone has their own pattern, but some elements come up again and again.
Signs of trichotillomania
- Pulling hair from the scalp, the most common area, but also eyebrows, eyelashes, beard or body hair.
- Bald patches with an irregular shape, often more noticeable on one side of the head than the other.
- Tension that builds before pulling and a sense of relief, even pleasure, straight afterwards.
- Small rituals: feeling for a 'particular' hair, looking at the root, rolling it between the fingers or biting it.
- A lot of effort spent covering it up: careful hairstyles, caps, eyebrow make-up, avoiding swimming pools, wind or the hairdresser.
Pulling your hair without noticing, or on purpose
There are two ways of pulling, and most people do both. One is automatic: it happens while you're doing something else (reading, driving, scrolling, studying) and you only notice once the hair is already in your hand. The other is focused: a strong urge or a hard-to-bear emotion turns up, and pulling is how you calm it down. Telling them apart matters because they're worked on differently. Automatic pulling calls mainly for awareness and barriers; focused pulling calls for learning to handle what you're feeling in that moment.
Why it happens: causes of trichotillomania
There isn't a single cause. Genetics play a part (sometimes more than one person in a family has it), as do the hormonal changes of puberty and, above all, the job the behaviour does. Pulling a hair regulates: it lowers tension, boredom, frustration or anxiety, or gives the body some stimulation when it's under-stimulated. That instant relief is what the brain learns and wants to repeat, and the more you pull, the more you want to keep going. That's why telling yourself 'enough, never again' rarely works: the loop has already become automatic.
Trichotillomania, anxiety and shame
Trichotillomania and anxiety feed each other. Stress increases the urge to pull; afterwards come guilt, the fear that someone will notice and the feeling of being out of control, which set the anxiety off again. Low mood and a battered self-image often come along with it. And there's one ingredient that weighs very heavily: shame. Some people hide it for years from their partner, their family and even their doctor. Often the first step is being able to tell someone without feeling judged.
Is it OCD? Is it self-harm?
These two questions come up almost every time. Trichotillomania belongs to the same family as obsessive-compulsive disorder (OCD), but it isn't the same thing. In OCD there are obsessions, frightening thoughts, and compulsions to neutralise them; in trich there's usually no obsession behind it, and pulling can bring relief. Nor is it generally seen as self-harm in the strict sense, because the aim isn't to cause injury. When someone pulls their hair to punish themselves or to feel pain, that needs to be addressed as such. Trich is one of the body-focused repetitive behaviours, alongside skin picking (excoriation disorder) and nail biting, and they often go together.
When trichotillomania starts
It usually begins around the start of adolescence, typically between the ages of 10 and 13, although it can appear at any age. When it shows up in very young children, before the age of 6, it may be temporary and go away without treatment, as MedlinePlus, the medical encyclopaedia of the US National Library of Medicine, points out. In childhood the difference between boys and girls is small; in adulthood, by contrast, it's diagnosed far more often in women. Without treatment it tends to come and go for years, with better and worse spells depending on stress.
When to ask for help
It's worth seeing a professional if:
- You have visible bald patches or rely on tricks to hide them.
- You've tried to stop several times and can't.
- It takes up a lot of your time or affects your work, studies or social life.
- You avoid swimming pools, the hairdresser or intimacy for fear it will show.
- You feel guilty or ashamed every time it happens.
Two more things. If you swallow the hair (known as trichophagia), mention it to your doctor soon, because hairballs can form in the stomach. And before assuming it's trichotillomania, it's a good idea for a doctor or dermatologist to rule out other causes of hair loss, such as a scalp infection or alopecia areata.
How trichotillomania is treated
The treatment with the strongest evidence is psychological: a form of cognitive behavioural therapy called habit reversal training (HRT). The UK's National Health Service (NHS) describes it as the usual treatment. It has several parts:
- Awareness: noting when, where and in what mood the urges appear, until you can catch them before your hand reaches your head.
- Spotting triggers: places (the bathroom, your bed, the sofa), activities, times of day and emotions.
- Competing response: when the urge comes, doing something that makes pulling impossible, such as clenching your fist and tensing your arm or squeezing a ball, until the urge eases.
- Stimulus control: making it harder, with tweezers out of reach or less time in front of the mirror.
- Support: someone you trust who encourages you and notices your progress, without policing or scolding you.
Therapists often add work on emotional regulation or elements of acceptance-based therapies, especially when pulling is focused and acts as a safety valve. Medication isn't the first-line treatment; if it's needed, a doctor should assess it.
What you can do starting today
Some things help from day one, whether you're starting therapy or still thinking about it. None of them works miracles on its own; what works is combining them.
Strategies to curb trichotillomania
- Keep a simple log for two weeks: time, place, what you were doing and what you were feeling. You'll find patterns you can't see right now.
- Put barriers in place: plasters on your fingertips, thin gloves while you watch TV, a bandana or a snug beanie, or shorter hair.
- Keep your hands busy at high-risk moments with a stress ball or something to fiddle with.
- When you feel the urge, clench your fist and wait. Urges rise, peak and fall, even if you do nothing.
- Change your surroundings: less direct light on the bathroom mirror, tweezers out of sight, your phone away from the bed.
- Look after the background stress: move, sleep enough, have a warm bath, breathe slowly.
- Tell someone you trust. Keeping it secret often makes the anxiety grow.
And when you slip up, which you will, talk to yourself the way you'd talk to a friend. Scolding yourself raises the tension, and tension is exactly what feeds the urge.
If it's your child who pulls their hair
If you notice it in a child or teenager, the way the adults react matters a great deal. Telling them off, punishing them or saying 'stop touching your hair!' every five minutes usually makes it worse: it raises the tension and pushes the pulling into hiding. It works better to talk about it calmly, notice when it happens (homework, screens, bedtime) and offer them something else to do with their hands. With teenagers, shame weighs even more; if you're worried about how they're doing in general, this guide to teen mental health may help. If it lasts for weeks or there are already bald patches, it's worth seeing a professional who specialises in child therapy and can work with your child and with the family.
How therapy helps
In therapy, stopping the pulling is the goal, but the way there involves understanding what it does for you and finding other ways to soothe whatever lies underneath. We work on logging and catching the urges early, alternative responses, the stress and emotions that trigger them, and also the shame and self-esteem that trich has worn down. I do this as a health psychologist, in person in Igualada or through online therapy, in Spanish or Catalan. If you'd like to know how I work with this family of disorders, you can read about online OCD therapy.
If you've been hiding bald patches and fighting the urges alone for a while, you don't have to carry on like that. Get in touch for a first assessment with no obligation. Trichotillomania can be treated and, once the pulling stops, hair usually grows back.