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BFRB: Compulsive hair pulling

WASHINGTON (THE WASHINGTON POST) – According to the National Institutes of Health, trichotillomania, the official name for compulsive hair pulling, may affect as much as 4 per cent of the US population. It is also more likely to involve women than men, according to NIH. Last year, the comedian Amy Schumer shared that she has suffered from trichotillomania since childhood, and included aspects of her story in the Hulu show “Life & Beth.” “And it’s not that I used to have this problem and now I don’t,” she told the Hollywood Reporter. “It’s still something that I struggle with.”

More broadly, hair pulling falls under the umbrella of body-focused repetitive behaviours (BFRB), “repetitive self-grooming behaviour that involves biting, pulling, picking, or scraping one’s own hair, skin, or nails that results in damage to the body,” according to the TLC Foundation for BFRBs, a nonprofit group.

Despite how they may appear to others, BFRBs are not forms of self-injury. “Individuals aren’t trying to hurt themselves or damage their bodies,” said psychologist John Piacentini, president of the TLC board of directors. “Picking or pulling often feels soothing, relaxing or positive.” Which can make it very difficult for people to stop. Urges feel overpowering, and the behavior is gratifying. For many, it relieves anxiety. Some have little awareness when they’re picking, pulling or biting. Fighting urges is like trying to resist scratching a mosquito bite.

Trichotillomania can have serious physical consequences. A minority of hair pullers ingest their hair, which may cause life-threatening digestive tract blockages. But the most common side effects are emotional. Many feel embarrassment about their behaviours and avoid social events, career opportunities and dating. Trichotillomania is also highly correlated with depression, anxiety and substance abuse.

“We see a lot of poor self-esteem or self-hatred because of the inability to stop these behaviours,” Piacentini said. “It can lead to very complex outcomes psychologically, physically and socially.”

Cognitive behavioural therapy (CBT) is the first-line treatment for trichotillomania. Comprehensive behavioural treatment, a type of CBT, involves assessing the unique profile of a person’s hair pulling, including triggers in their thoughts, feelings and environment. For instance, an urge might be triggered by an itch on their scalp or an unusually coarse hair. While antidepressants are sometimes prescribed, studies suggest they generally are no better than placebo, though they may help those who also have anxiety, depression or obsessive-compulsive disorder.

BFRBs often serve a self-regulatory function. Fred Penzel, a licensed psychologist who has studied BFRBs for over 40 years, said: “They regulate levels of stimulation within the nervous system. People engage in these behaviours either when they’re overstimulated (anxious or overexcited) or when they’re understimulated (bored or inactive).”


Understanding each individual’s triggers allows psychologists to develop personalized interventions. For example, one psychologist asked me to track my pulling episodes in a notebook, so I could gain awareness of the situations when I was most likely to pluck. As a result, I learned to keep “fidget toys” like Koosh Balls and Silly Putty nearby while I was doing homework or feeling anxious. These interventions helped, but they didn’t stymie my pulling long-term.

Some recent research, however, suggests possible help for hair pullers like me.

A study published in JAMA Dermatology in July showed modest success among 268 people with BFRBs for a self-help treatment called habit replacement. The study looked at people who pulled their hair, picked their skin, or bit their nails or the inside of their cheeks. An experimental group learned a habit replacement technique involving self-soothing touch, what lead author Steffen Moritz, a clinical neuropsychologist, described as “a simple, repetitive movement that does not inflict any harm.” This might involve lightly touching an arm or rubbing the fingertips together.

After six weeks, just over half of the experimental group reported improvement, compared with 20 per cent of the control group. Nail biters experienced the most benefit.

The study had limitations, however. Piacentini pointed out that participants were recruited online and that “the measures were all self-report, so we have no objective measure of the severity of the sample and no objective or clinical reports of how well the study worked.” There was also no follow-up with participants.

And research published in February showed that memantine, an Alzheimer’s drug, may help reduce hair pulling and skin picking. New studies suggest therapies like acceptance and commitment therapy (ACT) and dialectical behaviour therapy (DBT) can effectively manage BFRBs.

Experts feel encouraged by these developments.

But, Penzel said, BFRBs are complex and require nuanced, multifaceted interventions. “The reality is that solving these kinds of problems takes more than a single solution,” he said. Still, self-help strategies like habit replacement can be useful, especially for those without access to therapy. Working with a psychologist knowledgeable about BFRBs is the ideal scenario. “It’s hard to do treatment without a lot of support and instruction,” Piacentini said. Psychologists trained in BFRBs can help motivate patients, while also addressing the cognitive, emotional and sensory components of these behaviours.