Angela’s Trichotillomania (Hair-Pulling Disorder) and Anxiety

trichotillomania hair pulling

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), trichotillomania, is defined as the compulsive urge to pull out one’s own hair. As such, it is classified as an ‘impulse control disorder’. Trichotillomania is also related to obsessive-compulsive disorder (OCD). The actress, Olivia Munn of HBO’s Newsroom, is probably the most well-known celebrity who suffers from hair-pulling disorder. From interviews, Munn specifically pulls out her eyelashes.

Angela, a woman in her mid forties, was an office secretary. She sought my help because for the past 12 years she had been struggling with anxiety and hair-pulling disorder. Angela’s usual pattern was that she would first feel some tension building up. Then she felt the urge to pull out her hair. She would try to resist the urge but then her anxiety would become unbearable. At this point she would start to pull out some hair. Immediately afterwards she would feel relief with a pleasurable sense of gratification. However, after pulling out some of her hair, she felt guilty and depressed. She realized that she had a bald patch as a result of her compulsive urge and felt ashamed of herself. For several days she would feel angry with herself and commit to try and resist the next urge.

She had taken several steps to solve her problem. Among them, wearing gloves or a hat and putting bandages on her fingers to make it cumbersome to pull out her hair. She had also undertaken psychotherapy. Her psychologist had worked with her so she would learn to calm herself down with relaxation exercises; to challenge anxiety-provoking thoughts and distractions.

For example, she was told to pay attention and notice the first signals of the urge pull her hair. At this point, she had to stop the urge by repeating positive sentences and thoughts to herself. And finally she had to doodle, file her nails or otherwise engage her hands and fingers as a distraction in order to get her mind off pulling her hair. All of these various strategies helped but very little. The urge was so strong that she wasn’t able to stop it, and the more she tried to distract herself, the stronger it became. She was also taking an anti-anxiety medication.

After many years of unsuccessfully struggling with this problem, Angela had developed a few strategies to hide her problem. When she realized that the bald patch on the back of her head was becoming too large, she had started to style her hair in a certain way to cover it up. Then she had started pulling out her hair from the front of her scalp. She had told her hairdresser that her hair had fellen out because of anxiety. She was scared that someone would notice her bald patch. This made her more anxious but she didn’t know what to do.

I pointed out that she followed a very precise pattern:

  1. First she felt the a peculiar tension building up
  2. Then she noticed the urge to pull out her hair
  3. The urge becomes overpowering
  4. She pulls out her hair and immediately feels a rush of pleasure and relief
  5. At the end she feels guilty, ashamed and depressed

Angela nodded her head as I was going through the step-by-step process of her problem. Then I told her that, at times, she had tried to distract herself and not to think about her urge and resist it. However, the urge was so powerful that she would give in to the tremendous power of the temptation. I then told her to think about her problem as a way to seek pleasure.

“Taking into account the step-by-step process you follow to pull your hair”, I said, “what other human urge resembles this process?”

“I don’t know.” she said after a pause.

“Imagine a woman that feels a tension building up in her body. The tension becomes an urge to be satisfied. The more she tries to resist the temptation, the stronger becomes the urge. Finally she gives in, and satisfies the urge feels the pleasure rushing throughout her body. She feels satisfied and relieved but then she feels guilty and ashamed.”

“Do you mean I have a problem with my sex life?” she asked.

“No. That would be conjecture without any scientific basis. I’m talking about the known fact that whenever we repress an urge, prohibit it or try to not to think about it, it becomes overwhelming. The more you run away from it the stronger it becomes.”

I explained to her that all of her strategies made sense logically but they didn’t work. I asked her if she was willing to try something else. Something a bit peculiar. It would be like an experiment she could undertake to see what results, if any, came from it. She agreed.

“Whenever you feel the urge of pulling your hair,” I said, “you can do two things. You can either decide to avoid it completely or you to pull out your hair. But if you decide to pull out your hair, you must pull out 5 single hairs. It must be five. Not four. Not six. Five! In case that you decide to pull out five single hairs, you must proceed in the following fashion. Have several matches handy with a match box. Take out a match and roll it around the first hair you pulled out. Make sure that you do not overlap the hair on the match. Pay attention so that each time the hair curls around the match, it is nicely wound beside the previous one and doesn’t overlap it. Then with the help of your saliva or liquid glue, secure the hair to the match so it won’t unwind. You must then repeat this process with the other four hairs.”

I told instructed her that if she decided to repeat the five-hairs-pulling procedure, she had to set an alarm to go off 30 minutes later. Then after the alarm had gone off, she could decide if she wanted to go through the elaborate procedure. I pointed out to Angela that, the 30-minute break, actually could increase the pleasure she derived from pulling her hair out. The waiting and anticipation would give her more satisfaction and relief when the task was finally done..

I repeated and explained in detail how she had to roll a single hair around a single match. Reminding her that she had to do it with great precision and care. “Make sure you fully enjoy the process”, I told her. Then when that was done, she had to put her rolled up hairs in the match box and bring it to our next session for me to see.

For one week she did as I instructed and brought the match box with all her hair rolled around a match. I had also given her another task for her anxiety. I asked her to continue the tasks for two more weeks.

In our next session, Angela said that at the beginning she was rather enjoying pulling five strands of hair and keeping it in the match box. However, a few days later she began to get tired of it. She had felt less tension as well and fewer urges to pull out her hair.

I saw Angela for three more sessions over the next few months. At the end she was happy that she was free from anxiety and had overcome the urge to pull her hair completely. I had also taught her several new skills to manage her work stress.