Trichotillomania

Articles


Trichotillomania?
By Fred Penzel, Ph.D.
Whose Hair Is It
Anyway?

By Fred Penzel, Ph.D.
A Stimulus
Regulation Model of
Trichotillomania

By Fred Penzel, Ph.D.

Download the Trichotillomania Fact Sheet

Online resources for trichotillomania:
Trichtillomania Learning Center (www.trich.org)
Madison Institute of Medicine (www.miminc.org)
Hair Loss.Com – not strictly trich but informative (www.hairloss.com)

What is Trichotillomania?

Trichotillomania is also known as compulsive hair pulling. A person can be diagnosed with trichotillomania if:

1. The repeated pulling out of one’s hair results in noticeable hair loss, and

2. There is an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior, and

3. There is pleasure, satisfaction, or relief when pulling out the hair, and

4. The condition is not caused by another mental or medical condition, and

5. The condition causes significant distress or interference in one’s life.

What causes Trichotillomania?
There can be different causes of this condition; however, it is believed that an increased genetic risk, or other biological factors play a significant role.

Are there certain ages that this condition tends to begin?
Most individuals tend to start pulling their hair during childhood or adolescence, but it can start at any age including as an infant or in pre-school.

Where are the common parts of the body that people pull from?
Pulling can occur on any part of the body, however, the most common are:

  • Scalp
  • Eyebrows
  • Eyelashes
  • Beard
  • Pubic area

When do people tend to pull their hair?
Hair pulling can occur at any time, whether sitting in a classroom or at a desk at work. However, the most common times tend to be in downtimes such as the following:

  • Watching TV
  • Laying in bed
  • Sitting at the computer
  • Sitting at a stop light
  • Reading a book

Are there certain people who are more likely to pull their hair?

  • In children, boys and girls are equally affected.
  • In adults, trichotillomania appears to be more common in women than men. It is unclear whether this represents those that are actually affected by the condition, versus those who are seeking treatment.

How can one be sure that the pulling is not caused by another condition?
This could be ruled out by seeing a skin doctor (dermatologist) to ensure that there are no other skin conditions, for example on the scalp, that could be causing the pulling to create relief. It is also important that a primary care doctor is seen to ensure that there are no other conditions that could be causing the pulling.

Are there certain things that make Trichotillomania worse?
Stress can cause hair pulling to get worse. Worries about a pending exam, financial problems, relationships, problems at work, etc. can also make the pulling worse. It is also important to note that while these examples represent what are called “negative” stressors, there can also be “positive” stressors. For example, getting married, buying a home or car, or planning a vacation. These situations can cause anxiety, and consequently stress on the body, resulting in the potential for increased pulling.

What is the treatment for Trichotillomania?
A combination of education, medication, and behavior therapy tend to be the most effective forms of treatment. Each individual will need to be evaluated to determine the best protocol depending on their circumstances. Behavior therapy includes “Habit Reversal Training,” which is designed to increase the person’s awareness into the triggers, and create what are called “competing responses” to interrupt the pulling response.

What are some of the other effects that hair pulling can have?
Depending on the degree of pulling, this condition can cause severe hair loss which may result in the need to cover up bald patches with hats, hair pieces and/or wigs. When one is pulling, there can also be an experience of shame and/or embarrassment, since many of those who have this condition feel out of control in their ability to stop. The act of pulling and the time involved in this behavior itself can also result in being late to work, school, or other social events, leading to feelings of depression and/or isolation.

Does the “mania” part of the word Trichotillomania mean that they are manic, as in a Bipolar Disorder?
No. Bipolar Disorder falls under the category of a mood disorder, and is no way connected to trichotillomania. Trichotillomania falls under the category of an Impulse Control Disorder.

More Information:

The Trichotillomania Learning Center
www.trich.org

Stop Picking.com
www.stoppicking.com

Author: Robin Zasio, Psy.D., LCSW, The Anxiety Treatment Center of Sacramento

Reprinted with permission from the International OCD Foundation (IOCDF), PO Box 961029, Boston, MA 02196, 617.973.5801
http://www.ocfoundation.org


Trichotillomania

By Fred Penzel, Ph.D.
Used with permission of the author.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the OCD Newsletter.

Trichotillomania (TTM) is a disorder in which individuals compulsively pull out their own hair to the point of noticeable hair loss. Hair may be pulled from any area of the body the head, eyebrows, eyelashes, the beard or mustache, the torso, arms or legs, or the pubic area. Specific areas of hair may be pulled to the point of baldness, or pulling may take place over a wide area resulting in a general thinning of the hair. Although hair pulling may start in childhood or adolescence, it is not unusual for it to begin in adulthood. Many sufferers have come to believe that they are the only ones who pull out their own hair, however, it is estimated that about 1% of the population suffers from this problem.

The effects of this disorder upon the lives of sufferers can be quite severe. Those who pull from the scalp or the area of the face have the most conspicuous problems. They may have to resort to wearing wigs, eyeglasses that they don’t need, elaborate hair arrangements, hats, or headscarves. Many of these sufferers avoid much that others take for granted, such as family social events, relationships, school, and even jobs. Simple activities such as going outside on a windy day, riding in a convertible or on a carnival ride, participating in sports, or swimming, can frequently be off limits. Poor self-image and depression are common among those with TTM. Some have gone as far as to resort to alcohol or drugs to relieve their unhappiness. Many confess to feeling like “freaks” or “weirdoes,” and live secret lives. It is bad enough to be missing significant amounts of hair, but it is even worse to know or to have to explain to others that you have done this to yourself. There are sufferers who have gone so far as to tell others that they have cancer and have lost their hair due to chemotherapy.

Pulling may be done deliberately, where the sufferer knowingly stops all activities in order to concentrate upon this activity, or, it can be automatic, where it is done with little awareness while the puller engages in some other activity. This has led some to theorize that there may be two types of hairpulling disorders the deliberate type being more related to Obsessive-Compulsive Disorder, and the automatic type being related to tic disorders such as Tourette’s Syndrome. Activities that are most likely to be accompanied by hairpulling would include talking on the phone, watching TV, working on the computer, reading, sitting in the car in heavy traffic, or lying in bed falling asleep. Sufferers commonly report that hairpulling does not produce pain, and that it actually feels pleasurable.

Hair pulling may actually be done for the purpose of self-regulation. It may serve two different functions, both related to helping individuals regulate the way their nervous systems deal with stimulation. When a sufferer is over-stimulated (stressed, or feeling a strong emotion) it can help to soothe the nervous system and help to achieve a more relaxed state. This happens when pullers focus so tightly on the act of pulling (in an almost trancelike way), that they are able to shut everything else out for a period of time. When they are under-stimulated (bored or inactive) it may provide a type of stimulation that their nervous system requires. Most of the areas where hairs grow most abundantly also tend to be rich in nerve endings, so hair pulling can be quite stimulating.

At the present time, there are two treatments that have been shown to be effective in relieving the symptoms of TTM. They are antidepressant medications, and behavioral therapy. Neither treatment is a cure, as TTM is a chronic problem. The potential for it to become active will always be present. The good news, though, is that with proper help, symptoms can be controlled allowing hair to once again grow to a normal length. Some claims have been made for special diets or hypnosis, but neither approach has ever been scientifically proven, and what little information we do have about them is not particularly convincing or promising. Medications used to treat TTM include such drugs as Prozac, Paxil, Luvox, Zoloft, Celexa, Serzone, Effexor, and Anafranil. Occasionally, these drugs may be augmented with a second medication to help them to work better. Augmenting agent such as Risperdal, Zyprexa, Seroquel, Geodon, and Abilify are frequently used for this purpose. The main limitation of medications is that although they seem to work well for some individuals,not everyone responds well to them. Also, if they are your only treatment and you stop taking them, the pulling behavior will soon return.

One main type of behavioral therapy used to treat TTM is known as Habit Reversal Training (HRT), a treatment developed back in 1973 by Dr. Nathan Azrin. It is composed of four steps:

1. Awareness training keeping detailed records of all pulling episodes and their surrounding circumstances.

2. Relaxation training learning to calm one’s nervous system and to focus and center oneself.

3. Breathing retraining learning to breathe from the diaphragm to increase relaxation and focus.

4. Competing response training a method of tensing the forearms and hands that is incompatible with pulling.

Steps 2 through 4 make up the actual HRT response that is practiced whenever the sufferer gets the urge to pull. Other additional techniques designed to provide or relieve stimulation may also be incorporated along with HRT. Learning to use HRT can involve much work and practice, and involves a good deal of effort. It can also be used with children as young as eight or nine years old, but would probably be too difficult and frustrating to those who are younger.

TTM is a very complex problem with many inputs, and while HRT is a valuable technique, it is not comprehensive enough to accomplish the task of recovery on its own. For this reason, an approach known as Stimulus Control (SC) should also be employed. SC is a behavioral treatment that seeks to help sufferers identify, and then eliminate, avoid, or change particular activities, environmental factors, emotional states, or circumstances that trigger pulling. It is used to help sufferers consciously control these triggers, and then create new conncections between urges to pull and new, non-destructive behaviors. Using the records that are kept for HRT, information is gathered about these triggers, and then used to modify them, one step at a time. SC and HRT together would appear to make a very effective combination, and seem to be the most effective all-around approach.

The cause of TTM is unknown at this time. Some have theorized that it may be part of the Obsessive-Compulsive Spectrum of disorders, or that it may be an ancient grooming program that resides in the brain, and which has become inappropriately activated. Its basis may be genetic, but this, too, remains to be scientifically studied. Other problems that may be related to TTM include severe skinpicking and nailbiting. There is much that we have yet to learn about this disorder. Only further research will reveal the answers.

If you would like to read more of Dr. Penzel’s writings on Trichotillomania, take a look at his self-help book, “The Hair-Pulling Problem: A Complete Guide to Trichotillomania,” ) Oxford University Press, 2003. You can find out more about it at

www.trichbook.com


Whose Hair is it Anyway?

By Fred Penzel, Ph.D.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the OCD Newsletter.

Case 1: “Mrs. R___,” I began, “Your daughter Marcie (nine years old) just isn’t making the progress in her therapy that we had hoped she would. She hasn’t been doing her homework, and it just seems that her heart isn’t in it. I think she’s just going through the motions, and is only coming here because she doesn’t want you to get upset with her. This really doesn’t seem important to her at this time. I think the best thing would be for us to take a break for now. Marcie’s mother agreed. “Whenever I ask, she says she isn’t pulling, but I have actually seen her doing it a few times lately. When I ask her about it, she totally denies everything, but I can see for myself that nothing is growing back.”

Case 2: “My fourteen year-old daughter pulls her hair,” said the woman on the other end of the phone. “I want to bring her in for treatment, but she doesn’t seem to care about it. Part of the hair on the top of her head is missing, and so are her eyelashes, but when I talk to her about going for help to do something about it, she says it doesn’t really matter and that she doesn’t care. She says it’s just a bad habit, it isn’t that bad, and that she really can control it. If I try harder to get her to talk about it, she just gets angry and storms out of the room. Is there some way we can make her care about it and go for help? Doesn’t it bother her that she looks this way?”

The two case scenarios above are typical of children who are not prepared to begin working on a recovery from their trichotillomania (or compulsive hair pulling, as it is also known). I have encountered situations like these quite a number of times over the years. Our first case depicts a child who is simply too young, and our second shows an adolescent who has not yet accepted that she has a problem. One of my old college professors once told me “You can sum up most of child psychology in one word readiness.” Neither child is ready.

There is a percentage of younger children who have pulled out head hair, eyebrows, or eyelashes who appear indifferent to what they have done. If asked, they will acknowledge that they have pulled out the hair, and even acknowledge that it looks unsightly. What they may not show is concern or distress over the fact. This can be extremely perplexing to parents, who ask, “Why doesn’t it bother my child? Can’t she (or he) see how bad it makes them look?” Parents also worry about whether or not their child will be teased or ostracized as being “different” by the other children, or else regarded as some kind of “freak.”

The answers to these questions are not very mysterious. Preadolescents frequently seem untroubled by their altered appearance, even if eyebrows are missing, eyelashes are gone, or patches of hair are missing from their heads. When this occurs it is most likely due to a lack of social maturity and awareness on their part. They haven’t yet become conscious of their appearance or the notion of “fitting in” socially. As long as their behavior doesn’t immediately interfere with school or play activities, it is of no importance to them. Their playmates may not be that conscious of it either, or may take notice of it, but not really care. Where younger children do seem extremely bothered by their lack of hair, it is either because they are socially precocious, or they are reflecting their parent’s distress over the problem. That is, they are upset because their parents are upset, but not because it is upsetting to them directly.

When some younger children are brought for treatment, as in our first case scenario, they tend to be generally unmotivated and uninterested. Their reaction is that this time could be better spent playing, watching TV, or getting their schoolwork done. Getting impatient or angry at them is really useless. Trying to change a child’s behavior in this way will only create more stress, and one of the reasons people pull, of course, is to relieve stress. A child may also react to this pressure by being more secretive about their pulling, denying that they are doing it, or by pulling more to express frustration and anger at their parent’s behavior. You wouldn’t get angry at a young child who wasn’t ready to be toilet trained yet (or at least I hope not). Children do things when they are ready, not when we are ready for them to do them. Even if they are ready, at any given moment, they don’t have to want what we want. A parent may not like this fact, but they may have to accept it as something they have no control over.

If parents truly want to be helpful, and avoid creating paradoxical situations, they have to work on controlling their own upsets in cases like this. Sometimes the message that gets communicated is not “I don’t like your behavior,” but instead, “I don’t like you as much as I used to because of the way you look.” More than anything else, children want our unconditional love. If they feel that they cannot get this, they can react angrily, trying to get us to change. The result may be the pulling of even more hair, just to send a message. There are things our children do that we simply cannot control, and when it comes to certain things, they hold the trump card.

Of course, no one likes to have a child who is different, or who doesn’t look or act like other people’s children. You don’t ever have to like it. Acceptance doesn’t mean liking something. It simply means acknowledging the reality of things as they are and what can be done. Accepting is not something that you just get through all at once. It is something that you will have to work on every day. It may also help to try to put things in perspective. This is the child you love, with or without hair. He or she is still who they were before they began pulling, and still has feelings, too. There are many worse things that can happen to your child, many of them untreatable. Having this problem doesn’t make them any less of a person, and it is something that they can recover from, even though it may not be right now.

In the case of our teenager in Case 2, it is not unusual for someone of this age to not want to admit to a problem that they know full well exists. Unlike preadolescents, many teenagers are extremely self-conscious, and very sensitive about their image, as they are still trying to figure out who they are. They tend to examine themselves under a microscope a lot of the time. A teenager’s angry or sullen denial of a problem such as in our case is admittedly not a very good way of dealing with things, but to someone who is still not fully mature (even if they have an adult-sized body) it may be the only way they can cope and preserve some kind of positive self-image. The harder a parent pushes, the angrier the teen’s response may become. The strength of their denial will also increase, as may their pulling.

So what can parents and therapists do when a child or adolescent seems disinterested or unmotivated? As a therapist, I do not jump directly into treatment. I like to make a careful assessment of the symptoms, the situation, the person, and what that person brings or doesn’t bring with them to therapy. I am very careful in the first session to find out whose idea it was to come for help. I will typically ask a child or adolescent, “Whose idea was it to come here today?” I routinely follow this up with “Do you really want to be here?” When faced with someone who is not very unenthusiastic about treatment, and who would rather not be there, I have a policy I have evolved over the years. It applies whether the reluctant sufferer is at their first session, or at their tenth. My overall guiding philosophy here, is that you cannot want someone to get better more than they do. I would rather leave someone with a good feeling about having seen a therapist, than make everything connected with the experience unpleasant. If we have at least been able to accomplish this much, then we have still achieved something important.

I tell disinterested or reluctant children and adolescents:

“It’s really okay if you don’t want to do this right now. I don’t want you to feel so uncomfortable that you have to not tell the truth or make excuses to avoid coming here. I only want you to come here to work with me if this is truly where you want to be. I won’t be mad at you, and actually, I really appreciate your being honest with me. Maybe some day in the future, you will want to do something about this problem, and if you do, I will always be glad to work with you. So why don’t we take a break. You can go home and think about what you would like to do. Here is my card. You can keep it or give it to your Mom or Dad. All you have to do is call me or have them call me any time if you would like to come back. Even if you decide to come back a year from now, I will still be happy to help you.” I also tell them “Don’t worry about what your Mom or Dad will say, either. I will talk to them and explain the way things are. I will tell them to leave it up to you, and to trust that you will know when the time is right. I will ask them to not mention your hair to you, until you want to talk about it.”

In this way, we can part on good terms, not having created some kind of senseless test of wills that the parents and I cannot possibly win. We have left the door open, and put the responsibility and sense of control in the hands of the person with the problem. I have had a number of children, who when left to face their situation themselves, have later returned to successfully work on recovering from their hair pulling.

I am a great believer in encouraging the development of personal responsibility in both my child and adult patients. The well-known psychologist Rollo May once said,”People only change when it becomes too dangerous to stay the way they are.” Only the sufferer can tell when they have reached this point. Once there, they must be relied upon to do what must be done, if it is ever going to happen. Even if we could stay on top of a child or adolescent and force them to go through the motions and follow treatment instructions, they will have learned nothing. As soon as they are out from under a parent’s watchful eye, they will quickly let it all go.

My advice to parents is that sometimes doing nothing is really doing something. Don’t nag, pressure, annoy, criticize, threaten, yell at, or punish your child for not wanting to participate in treatment. Threatening them or taking away privileges will only create more resentment and resistance, lead to more pulling, and will finally put the entire subject of hair pulling beyond discussion of any kind. When your child finally comes to you and says “Mom and Dad, I need some help,” they have finally gotten to where you want them to be. They are ready. Something positive can now happen.

Whose hair is it, anyway?

If you would like to read more about what Dr. Penzel has to say about Trichotillomania, take a look at his self-help book, “The Hair-Pulling Problem: A Complete Guide to Trichotillomania,” (Oxford University Press, 2003). You can learn more about it at

www.trichbook.com


A Stimulus Regulation Model of Trichotillomania

By Fred Penzel, Ph.D.

Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the OCD Newsletter.

Recently, I looked back over the article I wrote on CBT for TTM a decade ago (The Cognitive-Behavioral Treatment of Trichotillomania) in the Spring 1992 issue of In Touch. As I looked it over, I couldn’t help notice how much my understanding of the disorder has changed since then. I realize now how much more complicated it has turned out to be, and at the same time how much more we need to learn. The good news, however, is that we do have more insight into the behavioral aspects of TTM, and have more sophisticated medications, so there is also a lot more we can do in terms of treatment. Back in 1992 when I wrote my article, the only real behavioral approach we had for TTM was Habit Reversal Training (also known as HRT), and the only medications we had were Anafranil and Prozac. While HRT is still considered a very useful tool in treating TTM, it is by no means the only one we have.

Over the last ten years, I have gained two very important understandings about TTM. One is that TTM is a complicated problem with many inputs and triggers, and that if it is to be treated successfully, they must all be identified and dealt with. I have Dr. Charles Mansueto, an expert clinical psychologist and noted TTM theorist to thank for this perspective. His “Comprehensive Model” of TTM, which he has been evolving over the years, caused me to take a fresh look at the disorder. In the early 1990’s, while many of us were initially trying to get a handle on the phenomenon that is TTM, Dr. Mansueto focused on the complexity of the disorder as an explanation of why attempts to come up with effective treatments had generally been unsuccessful. He concluded that hair pullers have many individual differences, and that no one model truly explains TTM. Instead, he believed that we would be able to deliver treatments that are more effective by identifying and accounting for all the various inputs that fed into TTM. By doing this, we could then tailor treatment packages that would meet the needs of each individual patient. According to Dr. Mansueto, there are both internal and external factors that affect hair pulling. Dr. Mansueto identifies five modalities that act as both cues and sources of feedback that work together to maintain pulling. The first four of these modalities are said to be internal to the sufferer. They are Cognitive (the individual’s thoughts and beliefs), Affective (the individual’s emotional state), Motoric (physical actions), Sensory (sight, touch, etc.), and External (environmental). To fully understand TTM, Dr. Mansueto believes that all of these modalities must be considered in the various ways in which they interact with each other.

I have found Dr. Mansueto’s insights to be true, and vital to delivering proper treatment to my TTM patients. However, I also tend to believe that they may actually be a part of a much larger picture. To truly understand hair pulling (along with such things as skin picking and nail biting), we need to move up to the next level to come up with an overall theory that plausibly explains why TTM exists at all, and at the same time, accounts for what all of the various other explanations of the disorder are telling us. This leads to my second understanding.

After years of observation, clinical treatment of TTM, and discussion with colleagues, I have evolved my own theory of how hair pulling and related behaviors are done for a particular and important underlying reason. Remember, this is only a theory and remains to be tested. It is my belief that in those who suffer from TTM and similar behaviors, the mechanisms that are supposed to balance internal levels of stress within the nervous system do not appear to be working properly. This is most likely the result of an underlying genetic predisposition, and one that acts through the serotonin and sometimes the dopamine systems of the brain. It has always been my observation that people pull when they are either overstimulated (due to stress or either positive or negative excitement) or understimulated (due to being bored or physically inactive). It would appear that pulling might therefore be an external attempt on the part of a genetically prone individual to regulate an internal state of sensory imbalance. It is truly ironic that something like TTM could satisfy a biological need and yet be so destructive at the same time. I call this the Stimulus Regulation (SR) Model of TTM.

In order to be able to function normally, the human body must maintain a number of different systems in states of balance that exist within certain limits. These systems must remain balanced within themselves, and also relative to each other. This happens via a dynamic, ongoing internal process that is known as homeostasis. This process stabilizes our internal states in many ways in response to constantly changing conditions, and without our being aware of them. Homeostasis is utilized by body systems that regulate such basic things as body temperature, blood pressure, heart rate, respiration, etc. The mechanism I am theorizing about is another form of homeostasis; one that normally maintains internal levels of stimulation without our being aware of it. All human beings are constantly receiving stimulation to their nervous systems from a constantly changing environment. If this stimulation is too great, it results in stress. If it is too low, the individual falls into a state of sensory deprivation. There is scientific evidence suggesting that in order to function at an optimum level, we all need a certain level of stimulation that is neither too high nor too low. As I have said, I believe that certain people experience difficulty with the way their nervous systems regulate these levels of stimulation. That is to say, they are exposed to the same levels of stimulation from the environment that others are, but their nervous systems seem unable to easily manage these levels. In disorders such as TTM, while this mechanism may not be working properly, the individual is forced to try to find a way to manage it externally. It is as if the person is standing in the center of a seesaw, or on a high-wire, with overstimulation on one side, and understimulation on the other, and must lean in either direction (by pulling) at different times, to remain balanced.

In seeking sensory stimulation, people tend to go to the sites where the nerve endings are. Grooming-type behaviors would seem to be a likely choice when it comes to reducing or producing stimulation. Any one of a number of different grooming-like behaviors could be pressed into service to perform this balancing function externally. Hair pulling, skin picking, nail biting, blemish squeezing, cheek biting, nose picking, etc., are only a few of a whole group of behaviors that already exist in the repertoires of all human beings that can be put to this use. Although I would agree with the part of Drs. Judith Rapoport and Susan Swedo’s well-known theory that these behaviors are perhaps parts of ancient grooming programs present in the brain, I would tend to disagree that they have been inappropriately released (as this theory also states). Grooming behaviors are something all human beings already engage in on a daily basis. The difference is that those people, whose behaviors have become extreme versus those who are doing them at a low level, are having difficulty regulating their internal levels of stimulation, and are putting the behaviors to another use.

The behaviors seen in TTM would seem to provide a number of different types of stimulation to tactile, visual, and oral processing areas of the brain. The types of activities that can provide stimulation include:

Tactile Stimulation

  • Touching or stroking hair
  • Tugging at hair
  • Pulling out a hair
  • Handling and manipulating a hair once it has been pulled
  • Separating the hair bulb from the hair shaft
  • Playing with the hair bulb once it has been separated from the hair
  • Stroking the pulled hair across the cheek or lips

Visual Stimulation

  • Watching a hair as it is being pulled out, either directly or in the mirror
  • Examining a hair that has already been pulled
  • Examining the hair bulb, either on the hair, or once it has been separated from the hair (checking its size, color, the presence of blood, etc.)

Oral stimulation

  • Chewing pulled hairs
  • Biting pulled hairs
  • Biting the hair bulb
  • Pulling hairs between the teeth
  • Swallowing hairs

The question is, why would people resort to these particular behaviors to accomplish this task, and why hair pulling in particular? There are, I believe, several good reasons:

  • These behaviors are always available; hair, for instance, is always within easy reach and plentiful (at least at first).
  • The areas where most people pull from would seem to be rich in sensory nerve endings that would be a natural source of stimulation.
  • Hair can be very stimulating and interesting to touch and manipulate, and as such appears to be extremely effective in either providing or reducing stimulation.
  • Because of a possible genetic basis, these behaviors are perhaps already present in the brain as parts of old grooming programs that can be performed almost automatically and without thinking.

These behaviors can be performed when the person is alone, and also can be done discreetly, without attracting attention and social disapproval (usually), even when others happen to be present.

Some people might ask how hair pulling can satisfy both over- and understimulation as part of the SR Model. Wouldn’t they represent two entirely different phenomena? I believe that each type represents the opposite pole on a continuum of sensory stimulation levels. Obviously, when an individual is understimulated, pulling out a hair can provide immediate tactile stimulation to nerves in the surrounding skin. Depending upon where hair is pulled from, the sensation can be quite intense, and extremely pleasurable for some. As mentioned previously, visual and oral stimulation are also generated by this activity. The reason a hair puller would experience pleasure from something that would cause the average person pain, is because the intensity of the sensation is also able to provide an intense level of relief when the sufferer is understimulated. On the other hand, if an individual is overstimulated, the act of pulling and the intensity of the sensation that it provides can be so absorbing and distracting that it enables them to focus upon it very tightly, shutting everything else out, and bringing on the almost trancelike and self-absorbed state associated with automatic pulling.

Another factor in favor of the SR Model is that it does not fall into the trap of oversimplifying TTM by reducing it to a single factor, nor does it indicate that that a single type of treatment can remedy it. There are certainly many possible inputs that can lead to over- or understimulation. Dr. Mansueto has rightly pointed out that TTM is a very complex problem with many components.

The SR Model not only provides an explanation as to the causes of TTM, it also has implications for treatment. It must be understood that even if this model is correct, we still have no cure at the present time. Because the problem is complex, it would appear to require a combination of approaches. I believe that this interfaces nicely with Dr. Mansueto’s comprehensive approach. Therefore, we must work with the various biological, behavioral, and cognitive tools are available to us to help sufferers to make recoveries that they can maintain. If we are seeking to quell hair pulling and its self-destructive results, it would make sense to recognize that we need to find better ways for an individual to regulate him or herself. This means both finding other equally satisfying and less destructive sources of stimulation when understimulated, as well as effective ways of reducing overstimulation through lifestyle, environmental, and psychological changes. In addition, we cannot also ignore the part habit plays in TTM. This means also finding ways to anticipate, block, and replace behaviors that have become strongly learned by sufferers. Further, because TTM appears to have biological components, we need to make more effective use of current psychiatric medications and other compounds, and consider new developments and what they may be able to contribute.

I hope this can all explain why I have moved beyond the simple use of Habit Reversal in treating TTM. It was a place to start in years past, but by itself, does not now seem adequate. Only when we begin to see TTM in all its complexity, and move beyond single treatment approaches, will we start to see an increase in the type of recoveries that practitioners and sufferers hope for.

If you would like to read more of Dr. Penzel’s writings on Trichotillomania, take a look at his self-help book, “The Hair-Pulling Problem: A Complete Guide to Trichotillomania,” ) Oxford University Press, 2003. You can find out more about it at

www.trichbook.com