The Roots of Distress: The Relationship Between Trichotillomania and Anxiety Disorders

Anita worked at a fast food restaurant. She was 17 years old, months from graduating high school, and any waking moment that wasn’t devoted to school or sleep she spent at the drive-thru window, handing out milkshakes and hamburgers, converting the hours to dollars in her head. While her friends spent their money on clothes, concert tickets, books, movies, and meals out with friends, Anita squirreled away every penny she earned. It wasn’t that she was thrifty or a naturally good saver; when she was younger she had spent every bit of babysitting money she’d ever laid her hands on, every birthday check from her grandparents, every $20 bill her mom gave her to “go have fun.” But now Anita had bigger concerns than the perfect jeans or seeing her favorite band. “All I wanted was to buy a wig,” she tells me.

The previous year, Anita had become consumed by the unstoppable desire to pull out her own hair. At first it was slow, just a few strands at a time, but soon she devoted hours to the meticulous plucking of individual hairs, quickly leaving her head covered in bald patches. She had taken the minimum wage job at the restaurant in hopes of paying for a high-end wig that would allow her to enter college looking like a “normal” 18-year-old. There were better-paying jobs out there, but she had chosen this one specifically because the uniform included wearing a hat with which she could cover her bare scalp and keep her disorder hidden.

Trichotillomania was the deciding factor in most things at that time. I wore elaborate head coverings and never had a boyfriend because there was a risk someone might try to run their fingers through my hair. I was so deeply ashamed and so good at disguising myself that even my parents didn’t know that I was nearly bald. But college presented a whole new set of concerns and I lived in absolute terror of having to live with strangers and share showers and be constantly watched. Hiding wouldn’t be as easy there.

She did end up buying the wig and, through meticulous planning, successfully kept her trichotillomania hidden for several more years, even as she sank deeper into distress. “I tried to stop pulling many times. I joined online support groups for people with trich and even went to counseling for a brief time, but I always started again,” she says. “It wasn’t until I was diagnosed with anxiety while in grad school that things really started to fall into place.”

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What is Trichotillomania?

Trichotillomania is an impulse control disorder in which you feel compelled to pull out your hair. The most common hair pulling site is the scalp, but some pull out eyelashes, eyebrows, pubic hair, or any other body hair. For some, the pulling is contained to one location, while others pull out hair from multiple body parts. Once thought to be rare, trichotillomania now affects an estimated 2-4% of the population and typically emerges in childhood; the disorder is seven times more common in children than in adults, although many continue pulling throughout their lives. Symptoms include:

  • Noticeable self-induced hair loss
  • Increasing feelings of tension prior to pulling
  • Feelings of pleasure or relief while pulling hair
  • Close examination of pulled hair, such as inspecting the roots
  • Specific hair-pulling preferences or patterns of pulling behavior
  • Playing with, biting, chewing, or eating hair

For many people with trichotillomania, hair pulling is a deliberate, enjoyable, and ritualistic process, for others, the pulling is unconscious, and some engage in both intentional and unintentional pulling. Despite the emotional distress and functional impairment that commonly arise as the result of the hair loss, the satisfying nature of hair pulling often keeps you trapped in a cycle of buildup, release, and regret that mirrors other forms of addiction. Mackensie Freeman, who started pulling out her eyebrows in the fifth grade, told Cosmopolitan Magazine, “I like pulling hair and it’s a big barrier to overcome the pleasure of doing it. It’s calming. In the moment, I act on it, it feels good, but then I regret later.”

The exact cause of trichotillomania is not known. In fact, the disorder may have no singular genesis, but, rather, a collection of potential triggers, both nebulous and concrete. What is known is that trichotillomania often develops in concert with anxiety disorders and many experts now understand trich as a maladaptive attempt to cope with overwhelming psychological distress. In 2012, Alexandra Heather Foss, an abuse survivor who suffered from crippling anxiety, wrote a stirring personal essay for The New York Times about her own history of hair pulling:

The way I coped with circumstances outside my control was to grab onto something — my body, more specifically, my hair. I tried to marginalize my pain and dissatisfaction by uprooting the bad things that were making me anxious with tweezers, my fingers, nail clippers, safety pins, whatever tools were available during the desperate hours of my suffering. I would pull and pick and the destructive vortex of emotion that was threatening inside to sweep me away from life would stall, would recede, and for a while I could be calm, safe, even though that safety came at a painful price.

In moments of acute emotional pain, the sense of calmness imbued by hair pulling can be profoundly relieving and offer a path out of the suffering. Foss even credits her trichotillomania with saving her life in times when she had no other escape from her pain. However, this relief is short-lived; not only does the urge to pull return and often grow stronger with time, but your behavior and altered physical appearance can further fuel your anxiety and impair your ability to live a healthy and productive life. Often, trichotillomania creates new and specific sources of fearfulness that augment your pre-existing emotional pain; you may feel so ashamed of how you look that you self-isolate, withdrawing from family and friends, and it can impede your ability to attend school or work, removing you from the vital social supports you need to heal. For some, this can lead to the development of depression, as you are left vulnerable to ever-deepening emotional instability.

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Recovering Through Co-Occurring Treatment

If you suffer from trichotillomania and a co-occurring anxiety disorder, concurrent treatment of both disorders is critical to alleviating psychological suffering and creating long-term behavioral health. Without addressing the underlying causes of your trichotillomania, it is unlikely that you will be able to stop the compulsive urge to pull, as the trigger remains present. Anita knows this all too well. “My hair pulling was a symptom,” she says. “The techniques I learned to stop pulling were completely ineffectual as long as that layer of anxiety was still there. I needed to learn how to heal myself from within and create positive change. That goes beyond just stopping ‘bad’ behavior.”

Anxiety disorders and trichotillomania share much in common when it comes to treatment, and both benefit from a holistic, interdisciplinary approach that allows you to explore both your conscious and subconscious thoughts, beliefs, and experiences while giving you concrete skills to replace damaging coping mechanisms with healthy alternatives. However, for many who struggle with these disorders, recovery requires not just clinically sound care, but immersion in a nurturing environment that supports your whole self. “We want nourishment, not only for our bodies but for our souls,” Foss writes. “That is what we need to flourish, to feel less anxious. Environments that are safe, loving, relationships that are honest and nurturing.”

At Bridges to Recovery, we create a warm, inviting community of compassion, love, and acceptance that gives you the strength to move forward with inner tranquility, confidence, and purpose. Our experienced, multidisciplinary clinical team offers a diverse array of therapeutic modalities that help people find true and lasting relief from the psychological pain of anxiety and trichotillomania, including intensive psychodynamic therapy, Cognitive Behavioral Therapy, specialized therapy groups, and holistic therapies that invite your mind, body, and spirit to engage in a process of profound healing. With the support of our expert clinicians and empathetic peers, you can find real escape from psychological pain and create a brighter, more joyful future.

Bridges to Recovery offers comprehensive residential mental health treatment for people living with trichotillomania, anxiety disorders, and other co-occurring psychiatric disorders. Contact us to learn more about how we can help you or your loved one experience relief from suffering and start the journey toward recovery.

Image Source: Unsplash user Christopher Campbell