When Anxiety Has You (Literally) Pulling Your Hair Out

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Photo: Jurek Wyszynski/Ocean/Corbis

It’s an ancient human habit, and yet it’s one psychiatrists are still struggling to understand: compulsive hair-pulling. The behavior can be caused by anxiety or stress, boredom, or seemingly nothing at all, explained psychologist Ali M. Mattu, who spoke about the history of the disorder yesterday on Columbia University Medical Center’s biweekly podcast.           

He explained that hair-pulling is now lumped together in the latest edition of the Diagnostic and Statistical Manual, the DSM-V, with other “body-focused repetitive behaviors” like skin-picking or nail-biting. But it stood as its own diagnosis for a long time, previously known as trichotillomania, and so there are a few things researchers have pinpointed that are specific to this disorder. Here are some of the highlights from the podcast.

How common is hair-pulling?
It used to be thought of as relatively rare, Mattu said, but now psychiatrists know that it’s actually pretty common. About 1 in 50 adults struggles with the compulsion, and though it didn’t make its first medical journal appearance until 1889, there’s evidence that some ancient Greeks and Egyptians were hair-pullers, he said. Hair-pulling tends to start around puberty, and women are more likely to do it than men — though, Mattu said, it could actually be that women are simply more likely to seek treatment, and that men blame self-inflicted hair loss on baldness.

What’s behind the hair-pulling urge?
For some people, it’s a method of stress relief. “They come home; they had a hard day, and want to pull that hair,” Mattu said. “For a lot of people, it helps them regulate the way they’re feeling.” When they’re overanxious, it can be a way to calm the nervous system down; when they’re bored, it helps pick them up, he explained.

That doesn’t apply to everyone, though, and there are more complicated answers as well. Plenty of people pull their hair without even realizing they’re doing so. Mattu said it can come down to genetics, environment, or some amalgamation of the two. “It used to be this idea that you’d feel tension before and release after,” Mattu said. “What we know now is that’s not true for everyone.”

Are there any treatments?
Psychiatrists have struggled to find effective treatments, Mattu said, likely because there are “no two people with hair-pulling that are exactly the same.” So far, the most thoroughly tested medication has been fluoxetine — Prozac – but the results were inconclusive.  

But for people who pull their hair out while barely registering that they’re doing so, habit-reversal training can help. This has been used to treat other disorders that cause tics, like Tourette’s, and it seems like the same mechanisms are at work in hair-pulling. Psychiatrists work with hair-pullers to help them get an increased awareness and understanding of everything that might lead them to the behavior. “What’s happening in your arm?” Mattu said. “What is the first sensation, the first warning sign, that you are about to pull your hair?” He has his patients practice clasping their hands until the urge subsides.

This doesn’t work so well for the people who pull their hair out intentionally. These people “want to pull their hair,” he said. Practicing mindfulness and simply keeping their hands busy, helps a bit, he said. But often, this comes down to treating an underlying mood disorder; in fact, about half of hair-pullers also suffer from anxiety or depression, he said. But most people do respond to treatment, he said. “At the end of the day, I think this is normal grooming behavior that has gone awry.” Really, though, the entire podcast is fascinating, and worth a listen