Written by Hannah Sommer Garza, Ph.D.
As a trichotillomania (trick-o-till-o-may-nee-uh; TTM or “trich”) treatment provider, I have come across many myths and misconceptions about trichotillomania (hair-pulling disorder) from new clients, family members of new clients, other people in my social network, and even other medical and psychological treatment providers. “That’s where people believe there are bugs in their hair, so they pull to get them out, right?” I’m telling you, I feel like I’ve heard it all!
While I happily dispel myths and provide more accurate information in those situations, I have come to realize how little most people know about trichotillomania in general. I also think that the existence of these misconceptions can lead to individuals with trich feeling stigmatized at home, with friends, at school/work, and with their doctors/hairstylists/coaches (fill in the blank). I’m hopeful that by sharing up-to-date information, we can decrease stigma associated with trichotillomania and the pursuit of trichotillomania treatment. I believe that knowledge is power, and I hope that this post gives more power to individuals with trichotillomania.
What is Trichotillomania?
Trichotillomania, also known as hair-pulling disorder, is the repetitive pulling out of one’s hair. Pulling sites vary from one individual to the next with trich, and they can be from anywhere on the body where hair exists (e.g. scalp, eyebrows, eyelashes, arms, legs, pubic area, chest, stomach). Trichotillomania is considered a diagnostic mental health disorder, and it is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an Obsessive-Compulsive and Related Disorder. Trich is also considered a body-focused repetitive behavior (BFRB) http://www.bfrb.org/learn-about-bfrbs alongside excoriation (skin-picking), and onychophagia (nail-biting).
According to the DSM-5, diagnostic criteria for Trichotillomania are:
- Recurrent pulling out of one’s hair, resulting in hair loss
- Repeated attempts to decrease or stop pulling
- The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The hair pulling or hair loss is not attributable to another medical condition (e.g. a dermatological condition)
- The hair pulling is not better explained by the symptoms of another mental disorder
Now that we’ve covered the basics, let’s get to the myths and misconceptions.
Myth: Trichotillomania is Rare
Nope. Research shows that about 1 or 2 in 50 people have trichotillomania at some point during their lifetime. That means that of the approximate 325 million people in the United States (according to the U.S. Census Bureau), around 6.5 million to 13 million (MILLION!) people will meet diagnostic criteria for trichotillomania at some point during their lifetime. As an anecdote, since talking openly with family and friends about treating trichotillomania and other BFRBs, I have had people come out of the woodwork to tell me that they have trich, have a relative with trich, or know someone with trich. It’s a lot more common than you might think.
One reason trichotillomania may seem to be a rare problem is that many individuals with trich feel shame, embarrassment, or other undesirable emotions related to disclosing their trich to others. Social and cultural messages about hair, beauty, and mental strength can contribute to this too. Many individuals with trichotillomania go through great lengths to hide it, and may do so by wearing makeup, hairpins, hats, headwraps, or other concealing clothing. It is also common for individuals with trichotillomania to avoid doing certain activities that may lead to them being “discovered” such as attending sleepovers, going outside on a windy day, going swimming, going to the hair salon, etc. Taken together, the pressure to stay silent about trich due to stigma and people’s savvy with concealment make trichotillomania seem more rare than it really is.
Myth: Only Girls Have Trichotillomania
Boys can definitely have trichotillomania. In fact, rates of trichotillomania are similar for boys and girls during childhood. They become much more skewed toward girls (80-90% of cases) in adulthood. It is suspected that women/girls are much more likely to seek professional help for trichotillomania compared to men/boys. A study found similar rates between men and women in the community (i.e. not treatment-seeking) and higher rates of women with trichotillomania in clinical settings (i.e. treatment-seeking). One theory is that men are better able to conceal their trichotillomania by shaving their face or head. In the U.S., people may not think twice about seeing a man with a shaved head, but a woman with a shaved head may get all kinds of odd looks or questions. “Do you have cancer?” Thus, societal norms about hair and hair loss may influence women to seek treatment more compared to men. The jury is still out, though, and more research is needed to give us a definitive answer about reasons for gender differences seen in epidemiological studies. Regardless of differences in rates, studies generally show that trichotillomania presentation is similar for men and women and response to treatment is similar for men and women.
Myth: Trichotillomania is the Result of Trauma
There is no clear evidence to support this myth. About 50% of people with trichotillomania report some sort of negative event or trauma occurring in their lives around the time they started pulling…BUT those events include common occurrences such as changing schools, moving to a new city, or parents divorcing. The other 50% deny experiencing ANY negative events when they started pulling. If trichotillomania was truly the result of trauma, trauma would be reported in much higher numbers. Additionally, many people experience negative events throughout their lives and do not go on to develop trichotillomania. Similarly, many people have trichotillomania without previously experiencing significant negative events. Ultimately, the research shows that there’s just not a clear link of trauma predicting trichotillomania. The causes of trichotillomania are still being researched, but the explanation appears to be much more complicated than one root cause. Furthermore, research suggests that there may be a related genetic component. Many BFRBs and Obsessive-Compulsive Related Disorders and sub-clinical features of these issues tend to cluster together within families.
Myth: Trichotillomania is OCD
I hear this one a lot, so let’s set the record straight. Trichotillomania is in the Obsessive-Compulsive and Related Disorder section of DSM-5 because there are some noteworthy similarities among disorders in that section. The main similarities are that both people with trich and those with OCD report having compulsive urges and repetitive behaviors. Otherwise, contextual and functional subtleties differentiate the two.
OCD obsessions are intrusive thoughts or images that are distressing. “Obsessions” about pulling in trichotillomania are more likely to be associated with focused pulling, or purposeful pulling within the individual’s awareness. For instance, thoughts associated with urges like “this kinky hair needs to go” or “I will only pull one more” may precede pulling behaviors. These “obsessions” in trichotillomania would only relate to hair-pulling. If someone has “obsessions” about hair pulling AND another topic (e.g. germs), then it is possible that they meet diagnostic criteria for both trichotillomania and OCD. Studies have found approximately 6.5%-10.7% of individuals with trichotillomania to have a comorbid diagnosis of OCD.
An OCD compulsion is a repetitive mental act or behavior used in response to an obsession. For example, washing one’s hands extensively or repetitively (compulsion) in response to the fear of becoming ill (obsession). For these reasons, it is understandable why many people might get confused that repeated attempts to pull out one’s own hair is a “compulsion.” However, there are some noteworthy differences. With trichotillomania, there is an element of sensory self-soothing. Many people with trichotillomania report having an enjoyable feeling or feeling of relief during pulling (and often feelings of regret after pulling). In contrast, people with OCD are distressed by their obsessions and compulsions. Ultimately, it is important to understand the content of “obsessions” and the functions of pulling behaviors and other possible “compulsions” to differentiate between trichotillomania and OCD.
Researchers continue to explore features of trichotillomania in order to clarify some of the existing myths and misconceptions, and to find the best ways to treat trichotillomania and other BFRBs. There is a major multi-state study trying to do just that. If you’re interested in learning more or getting involved with the research initiative, check out the BPM Research Initiative http://bfrb.org/research-programs-news/bpm.
Now that you know a little more of the truth about trichotillomania, you can help to spread the word and spread the knowledge. Let’s work together to reduce trichotillomania stigma. Look for our next post on more myths and misconceptions about trichotillomania, especially related to the reasons for pulling and treatment/recovery options. For more information about trichotillomania, check out the Trichotillomania Learning Center (TLC) Foundation for BFRBs http://bfrb.org/ .
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th Ed.; DSM-5). Washington, DC.
Grant, J. E., Stein, D. J., Woods, D. W., Keuthen, N. J. (2012). Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors. Washington, DC, London, England: American Psychiatric Publishing Inc.
Mouton-Odum, S., Goldfinger Golomb, R. (2013). A Parent Guide to Hair Pulling Disorder: Effective Parenting Strategies for Children with Trichotillomania. Goldum Publishing.