Tweezing, Tugging, Twirling: The many faces of Trichotillomania

By: Suzanne Feinstein, PhD

Trichotillomania, often referred to as hair-pulling disorder, is a complex condition characterized by an irresistible urge to pull out one’s hair. This disorder can affect individuals of any age and can lead to noticeable hair loss, distress, and social or functional impairment.

 The act of pulling hair can be focused and intentional, or it can be automatic and done without full awareness.

Understanding Trichotillomania

Trichotillomania is classified as an impulse control disorder, where the individual experiences an increasing sense of tension before pulling the hair and pleasure, gratification, or relief when pulling the hair out. It can be associated with other psychiatric conditions such as anxiety, depression, and obsessive-compulsive disorder (OCD).

Here are some specific behaviors associated with trichotillomania:

  1. Tweezing or Pulling: Individuals with trichotillomania often pull out specific types of hair, such as scalp hair, eyelashes, eyebrows, facial hair or pubic region. They may use tweezers or their fingers to do so.

  2. Eating Hair (Trichophagia): Some people with trichotillomania engage in a behavior called trichophagia, where they bite, chew, or even swallow the hair they’ve pulled out. This behavior can have negative effects on their daily lives.

  3. Tugging and Twirling: Trichotillomania may involve repetitive tugging or twirling of hair. This can be a way to soothe anxiety or provide sensory stimulation.

  4. Pulling off Split Ends: Individuals may excessively cut or pull off their split ends, causing more damage to their hair. This behavior can be very time consuming and result in eye strain, back pain or other types of discomfort.

The Psychological Aspect

The psychological underpinnings of trichotillomania are multifaceted. For some, it serves as a coping mechanism to relieve stress, anxiety or boredom. For others, it may be a form of self-expression or a way to exert control over one’s body when other areas of life feel uncontrollable.

Despite efforts, people find it challenging to stop or decrease hair-pulling due to the rewarding, tension relieving or gratifying nature of the behavior. The behavior leads to clinically significant distress or impairment, affecting social, academic, or occupational functioning.

Hair pulling is compulsive in nature. It can be performed with varying degrees of awareness, or without any conscious thought, causing significant hair loss and distress. Trichotillomania can cause severe emotional distress. Individuals who struggle with trichotillomania often deal with shame, anxiety, depression, or embarrassment. They may use scarves, wigs, or makeup to cover affected areas.

In addition, people with hair pulling struggle to find family or friends or even clinicians who can understand their condition. This can contribute to avoidance of close relationships. They may refrain from social events or activities that expose hair loss, engage in secrecy to keep hair pulling hidden, and avoid speaking about their struggles due to a lack of sensitivity or understanding from others.

Physical Manifestations

The physical consequences of trichotillomania are not just limited to thinning hair or bald patches. Repeated pulling can damage the hair follicles, leading to permanent hair loss. Additionally, individuals can cause damage to skin tissue if they dig for hair under the skin. This may lead to infections, especially if sharp objects are used for hair pulling.

Sometimes as a post-pull ritual, an individual might closely examine the follicle, which can cause subsequent eye strain and vision problems. And if the person ingests the pulled hair (trichophagia), it can lead to stomach pain, or even worse, gastrointestinal blockages.

The repetitive arm and hand movements involved in trichotillomania can cause carpal tunnel syndrome, neck pain, back pain and other muscular problems.

The Science Behind Trichotillomania 

Trichotillomania likely results from a combination of genetic and learned factors. Family history and an imbalance in certain neurotransmitters increase the risk of having this disorder. 

Serotonin, a chemical that carries signals between the brain and body, is thought to play a role in trichotillomania since it is involved in impulse control. Glutamate, another chemical compound in the central nervous system, is important for mood regulation and cognition, and may contribute to trichotillomania. 

Treatment Approaches

Diagnosis is based on symptoms and psychological examination. Seeking professional help is crucial for managing trichotillomania and reducing its impact on daily life.

Treatment for trichotillomania often includes cognitive-behavioral therapy (CBT), particularly a technique known as habit reversal and stimulus control treatment. Medications, such as selective serotonin reuptake inhibitors (SSRIs), have also been used to treat the disorder, although behavioral therapy remains the cornerstone of treatment.

The Role of Support

Support from family, friends, and support groups can be crucial for individuals dealing with trichotillomania. Understanding and patience are key, as the journey to overcoming the disorder can be challenging and fraught with setbacks. Unfortunately, many people have a poor understanding of this disorder and thus, struggle to provide the necessary support and sensitivity to help their loved ones.


Trichotillomania is a disorder that wears many faces, from a psychological coping mechanism to a physical manifestation of stress. It’s a condition that requires a compassionate understanding and a multi-faceted approach to treatment. With the right support and intervention, individuals with trichotillomania can learn to manage their impulses and lead fulfilling lives.

Advanced Behavioral Health, LLP helps people tackle their BFRB symptoms using scientifically–proven CBT techniques

Call 646-345-3010 or email Dr. Suzanne Feinstein at for a free 15 minute consultation to see if you qualify for treatment.

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