Review of "Understanding psychocutaneous disease: psychosocial & psychoneuroimmunologic perspectives"

Why is trichotillomania not categorized as cutaneous sensory disorder?

Below is the abstract and I will try to include as much fo the article as possible but you need a subscription to access it fully;

“Abstract: The study of psychocutaneous disease involves a comprehensive understanding of the complex and often neglected psychoneuroimmunologic components and pathways. Patients suffering from the many disorders that blur the interface between the fields of psychiatry and dermatology are often misdiagnosed and mistreated because of the lack of knowledge and awareness of the underlying disease‐causing mechanisms. Individuals with psychodermatologic disease also experience a general lower overall quality of life as it has negative implications on psychosocial, emotional, and cognitive well‐being. Factors like early life interactions, body image dissatisfaction, and societal stigma play a crucial role in the development of psychosocial stress experienced by individuals with visible skin conditions. This heightened level of stress serves as a trigger in the activation of the hypothalamic‐pituitary‐axis (HPA), mediating immune responses that influence cutaneous disease severity and exacerbation. In order to improve the quality of life and treatment outcomes of the patient population impacted by psychodermatologic disease, it is essential to better understand the complex interplay between the various psychosocial factors and pathophysiologic pathways involved.”

When you have trich, you wonder “Am I making this up? Am I crazy? Do I have a psychological problem?”. So having trich is complicated in that way. Doctor’s don’t know what to do with us. After 4 decades of psychologist wanting to tell us what we need to do to “just stop”, maybe they need to see the long-term treatment outcomes of those 40 yrs haven’t helped anyone with trich.

“Various studies indicate that at least 40% of dermatologic patients exhibit a psychiatric comorbidity, calling for a better understanding and awareness of the interplay between the two disciplines”

Model of psychosocial factors implicated in the origin and maintenance of skin‐specific affect/distress, and systemic adaptation response


Figure 1. Model of psychosocial factors implicated in the origin and maintenance of skin‐specific affect/distress, and systemic adaptation response

Sometimes I do find it odd that we blame mothers but not fathers for “pre-disposing factors” listed above. Couldn’t we substitute “parent” instead of “mother”?

Well, looking at the graph it’s no wonder at all why I have trichotillomania but I don’t know if I agree with all of these arrows (the directionality aspect). It has been noted previously that CHRONIC STRESS CAN and DOES dysregulate the immune system response to inflammation (scroll down to another blog post if you want to read it).

Anyways, moving on. There are a few paragraphs about skin conditions leading to personality disorders that I am omitting since it does not interest us since trichotillomania is already classified as a psychological issue. It is not a shocker that having trichotillomania could lead to depression and anxiety.

Although I find this paragraph intriguing;

“Studies examining the mother‐child relationships in atopic dermatitis indicate that the children often faced maternal rejection and feelings that the child was a burden.12 A potential explanation of these feelings may stem from the high levels of stress, ineffective family functioning, and poor psychosocial well‐being and quality of life faced by parents of children with atopic dermatitis.13 These attitudes are not instantaneously formed at the onset of the child’s disease but rather develop over the course of time as the mother's ability to adapt to the chronic stress becomes exhausted and can manifest as alterations in spontaneous response to the child.14

I think this article does suggest that trichotillomania does also impart additional psychological issues that can go unnoticed but are detrimental;

So quick question, do you accept trichotillomania in a “healthy way”? What is a healthy way? (according to them).

So quick question, do you accept trichotillomania in a “healthy way”? What is a healthy way? (according to them).

Psychoneuroimmunology of Skin Disease

“There has been increasing evidence and research identifying the link between stress and cutaneous disorders which is mediated by complex neural integration of immune, endocrine, and autonomic systems. Along with gaining a more comprehensive understanding of the interactions of these systems, the field of psychoneuroimmunology aims to strengthen the “psychosomatic” link of skin disease and stress. Picardi and Abeni23 found promising evidence of the role of stress on the exacerbation of atopic dermatitis, psoriasis, urticaria, and alopecia areata. In addition, Dhabhar24 indicates that stress plays a role in immunoprotection, immunoregulation, and immunopathology in psychocutaneous disease. There is a multifaceted association between psychoneuroimmunologic processes and overall quality of life issues experienced by patients suffering from psychodermatologic disease (Fig. 3).”

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Figure 3. Impact of stress on psychocutaneous disease development.

The stress‐adaptation response & stress‐immune spectrum

Stress consists of an exposure to a stimulus that results in the generation of physiologic and behavioral responses.25 The ability to adapt to stressful situations is mediated through the integrated action of neural, endocrine, and immune mechanisms. The presence of chronic stress or high magnitude acute stress can lead to a disease response because of the exhaustion of normally active adaptive mechanisms. Psychophysiologic resilience plays an important role in returning to a health maintenance equilibrium or allostasis.26 Psychological (early experiences, coping mechanisms, optimism, or social support) resilience and physiologic (neuroendocrine reactivity, sleep, or nutrition) resilience impact the duration and magnitude of stress experienced.2

Skin and sensory perception

When there is internal or external stress, several dermal and epidermal cell populations become activated to mediate proper immune responses. Langerhans cells and dendritic cells migrate to the epidermis and function to present invading foreign antigens to the lymphoid system. Merkel cells are specialized for the sensation and perception of light touch, while Meissner and Pacinian corpuscles are mechanoreceptors responsible for perception of pain, pressure, and temperature.

The secretion of neuropeptides is vital in neurogenic inflammation like vasodilation, plasma exudation, and migration of leukocytes through their action on neuropeptide receptors and specific immune cells.29 Examples of body areas containing a high density of nerve endings include the ends of the fingers, lips, genitalia, and face. Importantly, certain body‐focused repetitive disorders such as skin picking and trichotillomania occur frequently at the face or scalp.

Neuroendocrine and autonomic nervous system's response

Stress response is triggered by the neuroendocrine pathway of the hypothalamic‐pituitary‐axis (HPA) through the secretion of corticotrophin‐releasing hormone (CRH) and arginine vasopressin (AVP).30 These mediators then travel to the anterior pituitary and influence the release of adrenocorticotropin hormone (ACTH) which stimulates the release of cortisol through the adrenal cortex. In turn, through a feedback mechanism, cortisol suppresses the release of ACTH, CRH, and AVP. The concurrent involvement of the autonomic nervous system acts to modulate the activity of the HPA. A summary of the impact and interactions of stress perception, HPA, and health maintenance equilibrium are shown in Figure 4.”

Pay attention to the “pro-inflammatory state if chronic stress induces increased dysregulated cytokine driven responses”

Pay attention to the “pro-inflammatory state if chronic stress induces increased dysregulated cytokine driven responses”


The study of psychocutaneous medicine aims to better understand the disorders that lie at the interface between dermatology and psychiatry. The integrative field encompasses four major fields (psychiatry, psychology, neurology, and dermatology) to address the link between the nervous system, psyche, and skin. Psychoimmunopathologic factors play a crucial role in the exacerbation of preexisting skin disorders and the development of new cutaneous disease. A more comprehensive understanding of psychologic factors and imunopathologic pathways impacting skin disease in early child development, CBI, and relationship satisfaction are needed to better assist the affected patient population. There has been increased interest and findings in the role of emotional stress in the pathogenesis of skin disorders like atopic dermatitis and psoriasis. Recent research aimed to uncover the pathways involved in the effects of stress on the immune system, and skin provides a potential avenue for clinical interventions to reduce stress‐induced exacerbation of cutaneous disease.”

I guess I was hoping this article would tell it us new things. There are some new “terms” worth looking at. I was hoping it would have other treatment implications or reviews on new studies on novel treatments but it did not. It is interesting but lacks steps going forward to me. I am posting bc maybe it has parts that jump out to you.

Emily Kight
Trichotillomania - The Compulsion to Pull Out Hair

What is Trichotillomania (pronounced trik-o-till-o-MAY-ney-uh)?

The word is derived from the Greek thrix, hair; tillein, to pull; and mania, madness or frenzy. The May Clinic defines trichotillomania (also known as trich or hair-pulling disorder) as "a mental disorder that involves recurrent, irresistible urges to pull out hair from your scalp, eyebrows, or other areas of your body, despite trying to stop." In other words, trich is a deep compulsion to pull out one's hair.


As many as 4 percent of people may have trichotillomania, according to the National Institutes of Health.  The compulsion to pull hair out seems to be more common in women, but this could be because women are more likely to seek treatment or medical advice. Experts think the numbers could be higher because many people never speak of this disorder or seek treatment. The thought of being misunderstood by society has many suffering from trichotillomania taking great strides to keep their illness secret.

Trich is characterized by the chronic compulsion of pulling out one's own hair.

  • An impulse control disorder along with kleptomania, pyromania, and pathologic gambling.

  • Classified as part of the obsessive-compulsive spectrum according to the Diagnostic and Statistical Manual of Mental Disorders (DSM).


People with these types of disorders cannot control the urge even though they are aware they may cause damage to themselves. Some pull out their hair when they are stressed as a way to attempt to soothe themselves. In many cases, trich can lead to bald spots and even skin irritation.

Symptoms and results of trichotillomania may lead some suffering from the disorder to isolate themselves.

DSM criteria or symptoms for compulsive hair pulling:

  • Recurrent pulling out of one's hair resulting in noticeable hair loss

  • An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior

  • Pleasure, gratification, or relief when pulling out the hair

  • The disturbance is not better accounted for by another mental disorder and is not due to general medical conditions (e.g., a dermatologic condition)

  • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

For people with trichotillomania, hair pulling can be:  

  • Focused - Intentional to relieve tension or stress and sometimes creating elaborate rituals for pulling hair, such as finding the "right one" or biting pulled hairs.

  • Automatic - Pulling hair without even realizing it when bored, reading or watching TV.

Some people may demonstrate both focus and automatic tendencies of compulsive hair pulling depending on the situation or mood.

Etiology - Causes

According to the Mayo Clinic "the cause of trichotillomania is unclear. But like many complex disorders, trichotillomania probably results from a combination of genetic and environmental factors."

·         Family history - genetics may play a role in the disorder.

·         Age - usually develops just before or during early teens.

·         Other disorders - people with trich may have other disorders.

·         Stress - severely stressful situations may be a trigger for some.

If you are dealing with trich, there is are others dealing with the same disorder. You are not alone. 

If you are looking for ways to help with the compulsion for hair pulling, read our article from December 2017 titled "What Can Help Trichotillomania?".


Kaitlyn Blair
Stress-Immune Response & Trichotillomania (TTM)

I have been reading a lot of interesting literature on the immune system and psychological disorders. For example, studies have described onset of tics and OCD following infection from strep, or fever in childhood. Another study suggests that early early-onset forms of TS and OCD may be causally related to streptococcal infections and immune abnormalities.

I actually got strep bad when I was 8 or so. I remember my aunt Windy saying I lost weight and I felt surprised by her concern because I always assumed my parents were “on top of it”. (I think I was just a skinny kid though it had nothing to do with the viral infection itself honestly). I have some weird memories of a horrible fever I got at summer camp too 7-10. The camp called my mom but she couldn’t or wouldn’t get me ( I’m sure campy ain’t cheap and I wasn’t going to die from strep/fever). So they left me alone in a cottage in the woods away from the other kids for 5 days. Someone brought me food and would check-in of course. I remember going to this pool filled with cold murky pond water and swimming in it and then getting afraid there were monsters in it. Not sure they should have left me alone thinking about the bacteria in that pool when I was fighting an infection but that’s how the 90’s childhood was and it was great.

Anyway, I did end up getting TTM shortly there after. Of course I started when a kid told me if an eye lash fell out, you could make a wish and it would come true. So I went to the bathroom to strategically make wishes and “fix” the whole world. That could have been the end of it but it wasn’t. I stopped wishing but kept pulling. I do remember having OCD thoughts/impulses. If I moved my toe in a shoe, I would have to move the other. I also developed a stutter. I could not say “lemonade” well. Words starting with “L” were hard for me. It didn’t last long though. I haven’t had a stutter since age 9 or so.

So for me reading about the viral infections leading to higher incidence of OCD/TS (Tourettes) and the relationship of those disorders with TTM, I can’t help but wonder how the pathways (muscle memory, brain circuitry, skin immune response) could have been heavily influenced to be more ingrained by a virus that dysregulated my immune response to stress to allow TTM to take the shape it has.

Some interesting aspects to this.

1.) “Broadly, the immune system comprises cells, proteins, organs, and tissues that work together to provide protection against bodily disease and damage (see Box for explanations of relevant immunological parameters). Several facets of the human immune system have been empirically associated with stress. During acute stress lasting a matter of minutes, certain kinds of cells are mobilized into the bloodstream, potentially preparing the body for injury or infection during “fight or flight” [1]. Acute stress also increases blood levels of pro-inflammatory cytokines [2]. Chronic stress lasting from days to years, like acute stress, is associated with higher levels of pro-inflammatory cytokines, but with potentially different health consequences [3]. Inflammation is a necessary short-term response for eliminating pathogens and initiating healing, but chronic, systemic inflammation represents dysregulation of the immune system and increases risk for chronic diseases, including atherosclerosis and frailty [4]. Another consequence of chronic stress is activation of latent viruses. Latent virus activation can reflect the loss of immunological control over the virus, and frequent activation can cause wear-and-tear on the immune system [5].

Interestingly, these responses may not be the same for everyone. Those who have experienced early adversity, for example, may be more likely to exhibit exaggerated immune reactions to stress [67]. Currently, the field is moving toward a greater understanding of who might be most at risk for chronic inflammation and other forms of immunological dysregulation, and why. This question is important not only for health, but also for longevity, as evidence suggests that the immunological effects of chronic stress can advance cellular aging and shorten telomere length [8]. “


Thoughts: Does this mean that stress in childhood could dysregulated my immune response making me more susceptible to TTM? Maybe.

“Stress that occurs early in development (e.g., maltreatment, poverty, and other adverse experiences) has immunological consequences that can be observed both in the near and long term after the stressor occurs. Early life stress (ELS) in children associates with immunological dysregulation, including low basal levels of cytokines that control immune responses [10]. When immune cells were stimulated in vitro (e.g., with tetanus toxoid), those cells from children who experienced ELS produced more pro-inflammatory cytokines [10].”

Ok, why aren’t we looking at this TTM populations? FINALLY, someone did do an interesting study on TTM “Salivary Inflammatory Markers in Trichotillomania: A Pilot Study


Background: Immune dysregulation has been hypothesized to be important in the development and pathophysiology of compulsive disorders such as obsessive compulsive disorder (OCD), which has a high comorbid overlap with trichotillomania (both are OC-related disorders). The role of inflammation in the pathophysiology of trichotillomania has garnered little research to date.”

BTW, This was published August 2018 so its NEW new stuff. Exciting!

“There are several lines of evidence to suggest a role for immune-mediated pathophysiology in a variety of psychiatric conditions, including OCD, a disorder with phenomenological and possibly biological links to trichotillomania [4]. Studies measuring plasma cytokine levels have demonstrated a significant reduction in interleukin-1β (IL-1β) levels in OCD subjects compared with controls, but no significant differences in plasma levels of IL-6 and tumor necrosis factor-α (TNF-α) have been shown [5]. A recent case-control study of 20 adults with OCD who underwent PET imaging, however, found that translocator protein distribution volume (translocator protein density increases when microglia are activated during neuroinflammation and the distribution volume is an index of translocator protein density) was significantly elevated in the dorsal caudate, orbitofrontal cortex, thalamus, ventral striatum, and dorsal putamen [6] demonstrating inflammation within the neurocircuitry of OCD. The only study which included subjects with trichotillomania examined cerebrospinal fluid and found that the mean cerebrospinal fluid IL-6 levels did not differ between OCD patients (n = 26) and controls or between trichotillomania patients (n = 9) and their matched controls [7].

Cytokines are small, soluble proteins secreted by cells to influence the behavior of other cells via regulation of cellular immunity and inflammatory response. Pro-inflammatory cytokines include IL-1β, IL-6, and TNF-α, which are produced both peripherally and in the central nervous system. TNF-α stimulates vagal afferents and is produced by neurons and glial cells in an activity-dependent manner [89]. IL-6 and IL-1 are also produced in the brain, where they mediate neuroinflammation and response to injury [910]. Interestingly, IL-1β, IL-6, and TNF-α also mediate neuroprotection to excitotoxicity [11]. IL-8 is associated with inflammation and is increased by oxidant stress, which in a vicious cycle causes the recruitment of inflammatory cells and induces an increase in oxidant stress mediators. While poorly understood, it is increasingly recognized that there is important cross-talk between the peripheral immune system and central nervous system functioning, whereby inflammation may influence psychiatric symptoms and cognition [1213].

Although some studies shed some light on the topic of possible role inflammation in compulsive disorders, many questions remain unanswered. Understanding the role of cytokines in compulsive behaviors such as trichotillomania may allow for a greater understanding of the pathophysiology underlying this disorder and related disorders. Based on the extant literature, we hypothesized that salivary cytokine levels would be abnormal in trichotillomania. By examining the relationship between salivary cytokines and trichotillomania, we hope to determine a possible biological signal supportive of follow-up work using blood samples (which may more accurately capture central inflammatory pathways than saliva).”


“Inflammatory dysfunction has been implicated in other mental health disorders such as OCD and schizophrenia [412], but has received scant study in the context of trichotillomania. The current study examined a range of salivary inflammatory markers (IL-1β, IL-6, IL-8, and TNF-α) in a sample of patients with trichotillomania, and whether inflammation related to symptom severity and other clinical measures. The key finding was that patients overall had relatively low level of salivary inflammatory markers compared to externally published norms. Reduced autonomic response to painful stimulation, measured using the cold pressor task, has previously been reported in trichotillomania [23] and in skin picking disorder [24]. Many patients with trichotillomania report that hair pulling is not painful, especially after the habit has developed [25]. In the general population, cold pressor task pain perception was positively correlated with higher inflammation as indexed by C-reactive protein [26]. Acute inflammation in healthy volunteers, such as induced by an endotoxin model, increases pain response on the Cold Pressor test [27]. Therefore, 1 intriguing possibility raised by the present data is that inflammatory pathways are dampened in trichotillomania; and that this in turn may contribute to persistence of hair pulling due to reduced pain response. Thus, the current findings may indicate common reduction of IL-1β across OCD and trichotillomania, but that trichotillomania is linked with a broader range of inflammatory changes.”

HOLY MOLY. The treatment implications to this are totally untapped.

Other fun reading;

1. Camila d'Angelo LS, Eagle DM, Grant JE, Fineberg NA, Robbins TW, Chamberlain SR. Animal models of obsessive-compulsive spectrum disorders. CNS Spectr. 2014;19:28–49. [PubMed]

2. Mitchell RH, Goldstein BI. Inflammation in children and adolescents with neuropsychiatric disorders: a systematic review. J Am Acad Child Adolesc Psychiatry. 2014;53:274–296. [PubMed]

3. Gray SM, Bloch MH. Systematic review of proinflammatory cytokines in obsessive-compulsive disorder. Curr Psychiatry Rep. 2012;14:220–228.[PMC free article] [PubMed]

4. Attwells S, Setiawan E, Wilson AA, Rusjan PM, Mizrahi R, Miler L, Xu C, Richter MA, Kahn A, Kish SJ, Houle S, Ravindran L, Meyer JH. Inflammation in the ­neurocircuitry of obsessive-compulsive ­disorder. JAMA Psychiatry. 2017;74:833–840. [PMC free article] [PubMed]

5. Carpenter LL, Heninger GR, McDougle CG, Tyrka AR, Epperson CN, Price LH. Cerebrospinal fluid interleukin-6 in obsessive-compulsive disorder and trichotillomania. Psychiatry Res. 2002;112:257–262. [PubMed]

Emily Kight
" An Interactive, Self-Help Program for Trichotillomania" Research Study is “an internet-based treatment programs for both trichotillomania and skin picking by Dr. Keuthen, Dr. Suzanne Mouton-Odum, and Dr. Melinda Stanley.” (TLC website). Dr. Keuthen is the author of the popular book Help for Hair Pullers which is available on Amazon. “ was developed by leading experts in the field of trichotillomania. The program is based upon years of clinical practice and empirical research”.

The research article I am reviewing “ An Interactive, Self-Help Program for Trichotillomania” is a study done by some of the people who made it. It sounds interesting to me!

Reasons for an internet based treatment program; “Despite the widespread nature of this disorder, relatively few mental health professionals are educated about cognitive behavioral treatment for TTM, leaving sufferers frustrated and oftentimes misinformed. Further, when treatment is available, it is sometimes cost prohibitive.”

True dat! I never actually met a specialist in TTM so the few therapist I saw gave helpful tips but were not experts. Even if one was in my area, not sure I could have afforded it so I definitely see an online program being able to close this gap. My laptop is rarely farther than a few feet from me at any moment.

Also, other disorders have utilized this tool as well. With the shame associated with TTM, it’s likely to be helpful stepping stone for a lot of people.

Author writes “A computer-based strategy also minimizes cost and provides a more interactive, individualized self-help strategy than bibliotherapy. More immediate feedback and reinforcement are available with a computer-based approach, and there is the possibility of greater maintenance of improvements. However, no such strategy has been developed heretofore for trichotillomania. This paper describes the development and two phases of program evaluation for, an on-line, interactive, self-help approach for TTM based on empirically supported cognitive behavioral treatment for this disorder. The ultimate goal of this work is to enhance dissemination of empirically supported approaches to manage repetitive hair pulling for people who otherwise would not have access and to provide expert and nonexpert clinicians with a potentially useful adjunct to in-person treatment. However, it is important to note that is not meant to serve as a substitute for more comprehensive care that allows for attention to a broader array of symptoms and coexistent problems in the context of an ongoing interpersonal therapeutic relationship.”


Program Development

“The primary goals in developing were to create a program for adults and adolescents with TTM that was affordable, accessible, and confidential.1 Key components include interactive behavioral programs that: (a) assess and increase awareness of precipitating and maintaining factors associated with hair pulling; (b) teach a range of coping skills to reduce the frequency and severity of symptoms; and (c) provide an avenue for maintaining treatment gains.

At program start-up, participants are queried about associated symptoms (e.g., major depression, psychotic processes, suicidality, obsessive-compulsive disorder, severe anxiety, and substance abuse). If any of these symptoms are endorsed, participants are encouraged to seek alternate help before initiating the program. Referral sources are offered at this time.

The program includes three modules: assessment, intervention, and maintenance. The assessment module focuses on gathering information about behavioral sequences surrounding hair pulling and identifying unique cues and reinforcers for each person. Following the empirical literature about common precipitating cues and consequences (e.g., Diefenbach et al., 2002Mansueto et al., 1999), participants are asked to record situations, precipitating behaviors, and thoughts and feelings experienced before, during, and after pulling. Participants are asked to enter information on a daily record every time they pull or have an urge to pull a hair (see Figure 1). “

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And my question, is sometimes hairpulling has nothing to do with my emotions. Sometimes I just feel nothing and pull. This is a whole other aspect to trich/TTM that seems to get neglected in research articles. For example, on a normal day, how do you know exactly how you feel? I feel ok. Nothing bad, nothing good. Why am I pulling? No one seems to be able to understand this outside of the pullers mind.

At any rate logging the number of hairs, where, how often is very good technique. Keeping bags of the hair after you pulled really gets you motivated to stop.

“The number of hairs pulled each day is presented to the user in graphic form to facilitate visual tracking of progress.” That sounds pretty cool. Probably helps motivate you to keep up the good work!

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“Five subsections of the assessment module ask for progressively more detailed information, including preceding motor behaviors (e.g., stroking the hair or searching for a certain hair); physical sensations associated with pulling (e.g., itching, burning); feelings experienced before, during, and after hair pulling; thoughts associated with pulling; and postpulling behaviors (e.g., biting the root off of the hair or simply discarding the hair). The assessment module takes approximately 2 to 5 weeks to complete, depending on the frequency of data entry. At the end of the assessment module, each user is presented with an individualized behavioral Personal Analysis, which is a summary of all relevant data previously entered (see Figure 2). This analysis provides the foundation for the selection of coping skills to be presented during the intervention phase. All data are recorded for the user and summarized in graphic form on My Page (see Figure 3). In addition to the graph, subscribers may view their entries, edit past entries, and navigate through the program via My Page.”

“The goal of the maintenance module is to maintain gains made during active treatment. TTM has a high relapse rate, and continued monitoring of behavior and reminders to use coping skills may serve to prevent relapse and promote recovery. During the maintenance module, participants continue to record all urges/episodes on the daily record. If situational correlates change and new high-risk situations are noted, the program incorporates the changes into the Personal Analysis and additional coping strategies may be offered. Users continue to rate the strength of their urges before and after use of coping strategies, and they continue to set weekly goals. If goals are not met for 4 consecutive weeks, the program considers this a relapse and the user is directed to return to the intervention module to review coping strategies and reevaluate high-risk situations. During the maintenance module, users are presented with weekly activities intended to assist with recovery and relapse prevention. These activities include specific exercises to aid users in defining for themselves what recovery means, how to accept urges without responding to them, and long-term approaches to affective and sensory regulation (e.g., how to reinforce oneself for positive changes; how to continue to remind oneself to use coping strategies, etc.).”

Participants who tried it out

“Participants were 265 users of, who signed on between January 1, 2003, and December 31, 2003, and had at least 2 weeks of data available for outcome analyses.2 Demographic data were available for 190 to 192 of the 265 participants. The majority of these individuals were women (95.3%; n = 181). Age distribution was as follows: 2.1% under 12 years (n = 4); 19.3% 12–18 years (n = 37); 9.9% 19–24 years (n = 19); 22.4% 25–30 years (n = 43); 27.6% 31–40 years (n = 53); 14.6% 41–50 years (n = 28); 3.6% 51–60 years (n = 7); 0.5% 61–70 years (n = 1). Most participants were Caucasian.”

Duration of program use

“On average, participants used for 11.7 weeks (SD = 11.36; n = 265). Duration of program use correlated significantly and positively with hair-pulling frequency at baseline (r = .25, p < .001), suggesting that participants who reported more hairs pulled per week at program initiation were more likely to use for a longer period of time.”

Active versus inactive users

“At the time of data analyses, 126 users were actively using and 139 users had discontinued program use. “ So 53% people stopped using it. Who knows why though. Maybe it didn’t work for their subtype. Maybe it was hard to keep up with. It costs $30 a month so maybe some people just didn’t feel like spending more money on it.

Outcome Analyses

Baseline versus final ratings

“Mean scores at baseline and final rating on each outcome for participants with at least two data points are reported in Table 2. Analyses of covariance demonstrated a main effect of time on MGH scores, F(1, 266) = 7.01, p < .009, eta2 = .03, with means indicating a significant (although modest) reduction in symptoms from baseline to final rating. The Time × Weeks interaction was not significant, F(1, 266) = 1.88, p > .17, suggesting that improvement on this measure occurred independently of program duration. Hair-pulling frequency also demonstrated improvement over time, but in this case, only the Time × Weeks interaction was significant, F(1, 262) = 22.96, p < .001, eta2 = .08, indicating that duration of program use accounted for the moderate changes from baseline to final ratings. Unexpectedly, urge severity increased somewhat from baseline to final rating, F(1, 262) = 4.49, p < .04, eta2 = .02.”

So essentially, some things did improve and then shockingly, urge intensity increased but not my too much. Maybe it makes sense that your urge intensity would “seem” to increase since you aren’t pulling your hair as much? But the frequency (hair loss) went down so that’s the most important part for some of us.

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“Data from 265 users with at least 2 weeks of outcomes suggested significant, albeit modest, reductions in overall severity and frequency of hair pulling. Ratings of overall severity improved regardless of duration of program use, although there was some evidence that significant improvement on this global measure occurred only during the assessment phase, with maintenance of gains during intervention. Reductions in frequency of hair pulling, on the other hand, appeared related to duration of program use, suggesting that longer use of resulted in greater reductions in the numbers of hairs pulled. On this outcome measure, the majority of improvement occurred during the intervention phase, although significant variability in reported hair-pulling frequency likely precluded identification of statistically significant findings. Unexpectedly, self-reported urges to pull increased over time. It is possible that stronger urges resulted from decreases in actual pulling behavior, but it is important to note that the size of this effect was quite small and therefore not clinically meaningful.”

How does this stack up against traditional methods?

“Although response rates (defined according to MGH scores) were lower than those reported on comparable measures at posttreatment following more intensive CBT for TTM in academic clinical trials (86%, Lerner et al., 1998; 64%, van Minnen et al., 2003), rates were comparable to those reported at long-term follow-up after more intense CBT (31%; Lerner et al., 1998). Because rates of relapse are high across all treatment for TTM (Keuthen et al., 2001Lerner et al., 1998), the rate of improvement here is particularly notable given the self-help nature of the approach. “


“ is an easily accessible and private self-help option that may produce improvement comparable to long-term outcomes following intensive CBT. As such, may be useful as a stand-alone approach to be used by patients without access to treatment providers or as an adjunctive approach to be used by patients currently in treatment with an expert or nonexpert provider. 

It is unlikely that will be of optimal value to all individuals who suffer from repetitive hair pulling. However, the data overall suggest that may provide a potentially useful self-help alternative or adjunctive approach for reducing repetitive hair pulling. Nevertheless, it is important to note that is not an Internet-based therapy that allows for interactive work with a treatment provider. Rather, it is an entirely self-help format, and users receive feedback derived via a computer algorithm that summarizes data input by the user him- or herself.”

So, it’s self-driven and affordable and convenient. If you can’t make it to an TTM expert, or your therapist isn’t one, this could be helpful.

If you can’t afford a therapist, I’d look into DBT workbook and doing this online program. At the end of the day, only you know how to help yourself.

Emily Kight
Acceptance and Commitment Therapy for Trichotillomania (2018 study)

On researchgate you can actually download the entire article written by university of Utah researchers who did the study here in August 2018.

Question for you; How willing are you to experience the urge of pulling without doing anything but experience it?

Essentially, HRT (Habit reversal therapy) has been the “go to” method for treating trich (TTM) but it still seem to fail to address issues underlying TTM;

“However, HRT does not account for emotional and cognitive difficulties that usually occur within trichotillomania and are a major component of focused pulling (Flessner, Penzel, & Keuthen, 2010; Franklin, Zagrabbe, & Benavides, 2011; Lootens & Nelson-Gray, 2016). Further, following through with a behavioral response (in automatic or focused pulling) is challenging when faced with intense bodily sensations and thoughts about needing to pull.

One thing I enjoy is someone finally put into words that although there are two types of pulling in TTM (focused vs automatic), it appears they both exist in some degree in all individuals with TTM.

“Trials combining DBT with HRT have demonstrated reduction in trichotillomania severity with adults and adolescents (Keuthen et al., 2011; Keuthen et al., 2012; Keuthen et al., 2010; Keuthen & Sprich, 2012; Welch & Kim, 2012). For example, Keuthen et al, 2012 reported a statistically significant 42.7% decrease in hair pulling severity scores in treatment completers at post-treatment. Another trial demonstrated a statistically significant 48.6% decrease in hair pulling severity in nine treatment completers at a six-month follow-up (Keuthen et al., 2011). Additionally, trials combining ACT with HRT have shown promising results, reducing trichotillomania severity with adults and adolescents (Crosby, Dehlin, Mitchell, & Twohig, 2012; Fine et al., 2012; Twohig & Woods, 2004; Woods et al., 2006).”

So essentially making the case the HRT and DBT do help in reducing severity of TTM. Also, we do note that these are not big studies. We can also note that a 6 month follow-up may not guarantee long term progress but it’s good anyway. I’ll take it. TTM is a lot about getting back on the wagon anyway. Maybe the ride gets longer each time.

“There is mounting evidence that ACT enhanced HRT (ACT/HRT) is able to effectively target automatic and focused pulling. “ So They give some pilot studies that show reduction in severity of TTM too. What is meant by ACT enhanced, I wonder? Both DBT and ACT are suppose to target the emotional regulation in relation to hair pulling. Both seem to help in smaller studies. Small studies to me is under 30 people.

“Theoretically, ACT aims to increase psychological flexibility, which can be defined as the ability to engage in meaningful, values-directed behavior without any particular regard for inner experiences (i.e., thoughts, emotions, sensations). Psychological flexibility has been shown to be associated with lower levels of hair pulling severity, less frequent and intense urges to pull, and lower levels of distress related to pulling (Begotka, Woods, & Wetterneck, 2004; Bluett, Homan, Morrison, Levin, & Twohig, 2014; Twohig, Morrison, & Bluett, 2014).

For example, in the treatment of trichotillomania, an ACT therapist would demonstrate the futility of attempting to change or control the client’s urge to pull, instead focusing on increasing the client’s willingness to experience the urge to pull as it is. This would allow the client to better experience urges as simply bodily sensations and internal thoughts that do not need to be removed before engaging in meaningful life actions.”

“The purpose of the current study is to examine ACT alone as a treatment for trichotillomania in a randomized controlled trial of adults and adolescents. We chose to allow adolescents and adults into the study because the research question (“does ACT work without HRT?”) can be answered across age groups, and recruitment of participants with a diagnosis of trichotillomania is difficult. Moreover, the study will examine the role of psychological flexibility in treatment outcomes.

Hypothesis: “We predict that ACT alone as a treatment for trichotillomania would demonstrate significant reductions in hair pulling symptoms and psychological inflexibility compared to a waitlist control condition. We hope to gain a better understanding the contributions that ACT provides to the treatment of trichotillomania.”

Results: “The results indicate that some, but not all, adults and adolescents respond to ACT alone as a treatment for trichotillomania with adolescents demonstrating overall less improvement than adults.”

Take home? Doing ACT will likely help, and doing ACT or DBT with HRT will likely help more. To what extent, it would vary.

You might still be wondering what in the world is ACT too. I feel a little deprived of the details but;

“Contacting the present moment in ACT emphasizes awareness and openness to experiences and often includes describing thoughts, urges, and sensations without attempts to change or control them while engaging in valued behavior. This process is similar to awareness training found in HRT that attempts to bring greater attention to urges to reduce automatic pulling.”


“ACT alone and ACT/HRT appear to be quality treatments for at least a significant portion of individuals with trichotillomania. It is likely that both share some processes of change and target the major components of trichotillomania. This may also be the case for other treatments, such as DBT, that have produced similar results. Therefore, it may not matter which treatment is used, so long as the automatic and focused elements of the pulling behavior are addressed. However, this small trial is the only examination of ACT alone for trichotillomania and these results should be interpreted with caution. It appears that ACT alone is potentially comparable to ACT/HRT; however, ACT/HRT has substantially more evidence for its efficacy at this time.

The findings provide additional evidence for the utility of ACT as a component of trichotillomania treatment, especially in adults. Moreover, the findings indicate that ACT alone is a potentially viable treatment, with or without explicit HRT components. For adults it appears that the specific methods of trichotillomania treatment are less important than the processes they target, so long as the automatic and focused components of hair pulling behavior are properly addressed. “

Emily Kight
Review: "Tourette's syndrome, trichotillomania, and obsessive–compulsive disorder: How closely are they related?"
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I’d like to look at a Review from 2009 titled: “Tourette's syndrome, trichotillomania, and obsessive–compulsive disorder: How closely are they related?”. The link is here. Though if you can’t find access through a library you may be limited. A review is different from research because a review is written by a researcher who is referencing dozens or more studies to make generalizations. So they typically tend to be “newbie” friendly. It’s compiling conclusions of dozens of studies to tell us something from each that make a case for or against an idea.

The question of whether Tourette's syndrome (TS) and trichotillomania (TTM) are best conceptualized as obsessive–compulsive spectrum disorders has been raised by family studies on the close relationship between TS and obsessive–compulsive disorder (OCD). These disorders are characterized by repetitive behaviors and may have a number of phenomenological intersections as depicted in Fig. 1

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Figure 1. Obsessive–compulsive disorderTourette syndrome and trichotillomania. Legend: A—automatic trichotillomania; B—tic-like compulsion, complex tic (“compulsion-like” tic) and sensory phenomena; C—focused trichotillomania or hair focused obsessions or compulsions (“grooming-like” obsessive–compulsive symptoms) and sensory phenomena; D—complex repetitive behavior disorder.

I think this picture is nice because it demonstrates the subtypes hair pullers in relation to similarities to tics and OCD. I find myself appearing more like “B” where I have a compulsion like tic and sensory phenomena. That is not to say I am not on a “gradient” on don’t have features of “A” (automatic) or “C” "(Hair focused obsession pulling) or “D” (complex repetitive behavior disorder). Probably some parts of the day I am in “C” phase and other times, in “A” phase or in “D”.

So the researchers/readers might benefit from adding a color gradient to this idea. It would be neat if a motion tracking company like habit aware could team up with other type of pullers (non-automatic) to see if their technology actually can categorize these phases and get long term data. You could introduce new therapeutics and see from the tracking, how it impacts their TTM.

Anyway, might be nice if we had some clear definitions of what the researchers meant;

“Tourette's syndrome and OCD

2.1. Phenomenology

The main phenomenological differences between TS and OCD are presented in Table 1. In OCD, compulsions are typically performed in response to obsessive thoughts, images, or impulses. In contrast, in TS tics are not commonly preceded by obsessions. In addition, tics are sometimes performed involuntarily, whereas compulsions are always performed intentionally. Tics that are performed voluntarily and compulsions not preceded by obsessions represent an area of overlap between OCD and TS.” (So the area B-D) on figure 1.

The Tourette's Syndrome Classification Study Group (1993) describes tics as an “involuntary” (i.e., completely unintentional) response to either an urge or an unpleasant sensation (i.e., sensory phenomena), perceived as “voluntary”. Nevertheless, as indicated above, there are areas of overlap between complex motor tics and compulsions. For instance, repetitive behaviors such as touching or eye blinking may result from a need to relieve an urge or an unpleasant sensation, or to neutralize a superstitious fear.”

The term “intentional repetitive behavior” may have the advantage of encompassing various presentations of stereotyped repetitive behaviors reported in TS and OCD patients (as well as a number of other disorders, such as trichotillomania and stereotypic movement disorder), while at the same time allowing a clear differentiation from unintentional or involuntary tic phenomena (e.g., simple tics) (Miguel et al., 1995). The intentional repetitive behaviors of both TS and OCD can be conceptualized as responses to unpleasant internal cues.

So to summarize this, tourette’s is distinct in that the tic movement is described as “involuntary” but they do see overlapping, its not clear if tourette’s may also take a more intentional form or if that is distinct from TS and would be an OCD tic instead. If the tics is on the intentional side, it can be due to unpleasant internal cues. Not enough detail for my taste on what these “cues” mean exactly.

Moving on;

“2.1.2. OCD with tics

On a theoretical continuum of tics and compulsions, it can be hypothesized that a nodal point exists where the shift from “unintentional” to “intentional” repetitive behaviors takes place. Subjective experiences that precede these behaviors may be helpful in defining this demarcation (Miguel et al., 1995), and may be particularly useful to investigate in the subgroup of OCD with tics. OCD patients with tics often report compulsions not preceded by obsessions, and instead usually perform their repetitive behaviors to relieve sensory phenomena (i.e., bodily sensations, general feelings), or to reach a specific sensation or feeling “just-right”


“Studies have reported that patients with tic-related OCD present higher rates of trichotillomania, body dysmorphic disorder (BDD), mood disorderssocial phobia, other anxiety disorders and attention deficit hyperactivity disorder when compared with patients with non-tic-related OCD.”

And here we pause, and consider that the intersection of so many other disorders could be having a synergistic effect on your hair pulling. It would be rare to just have one disorder. It would be rare to just have TTM.

Immune function

“Seminal research has described a subgroup of childhood-onset OCD or tic disorder patients with onset and subsequent exacerbations of their symptoms following infections with group A beta-hemolytic streptococci. This subgroup was designated by the acronym PANDAS: pediatric auto-immune neuropsychiatric disorders associated with streptococcal infections (Swedo et al., 1997). It is hypothesized that PANDAS may arise when antibodies directed against invading bacteria cross-react with basal ganglia structures, resulting in exacerbations of OCD or tic disorders (Swedo et al., 1993; Mell et al., 2005).”

Some hair pullers are now wondering if strep preceded hair pulling or not. Interesting as we have seen more and more research about the gut being the “second brain”. Additionally, some hair pullers found relief from taking NAC which works with the gut in some way. It does take 8 weeks to show results so hang in there if you are trying it. It is interesting to think a virus can “trigger” TS or OCD and possibly TTM as well.

 Deep brain stimulation

Several case reports in TS have described successful results with placement of electrodes in various sites, mainly in the anterior internal capsule, in the medial thalamus and in the globus pallidus internus (Vandewalle et al., 1999Dell'Osso et al., 2005Flaherty et al., 2005Diederich et al., 2005Houeto et al., 2005Ackermans et al., 2006). Different brain areas have been targeted in OCD, with effective results after the stimulation of areas such the anterior limb of the internal capsule (Greenberg et al., 2006).

What is “deep brain stimulation”? Deep brain stimulation involves implanting electrodes within certain areas of your brain. These electrodes produce electrical impulses that regulate abnormal impulses. Or the electrical impulses can affect certain cells and chemicals within the brain. The amount of stimulation in deep brain stimulation is controlled by a pacemaker-like device placed under the skin in your upper chest. A wire that travels under your skin connects this device to the electrodes in your brain.Link to info here.

Anyway, the reviewers not that its not clear is TTM is OCD class of disorder or something else because some studies showed positive effects on a medication that helps with OCD for people with TTM. There has always been discussion on how to class TTM. So no wonder we have poor treatment options.

Repetitive behaviors

“As mentioned earlier, OCD is typically characterized by the presence of both obsessions and compulsions, and often these cover a number of different areas (e.g., checking, washing). In contrast, trichotillomania is typically characterized with a focus solely on hair-pulling. However, there may be some overlap with the phenomenology of OCD; hair-pulling may be triggered by concerns about symmetry, hair-pulling is often performed in a repetitive and ritualistic fashion, and hair-pulling may be preceded by an increase in anxiety and followed by a decrease in anxiety.

On the other hand, functional analysis of hair-pulling, compulsions, and tics often indicates important differences between these symptoms. Tics frequently involve abrupt movements of one or more muscle groups and occur in response to a sensory urge, whereas hair-pulling always involves many muscle groups, resulting in a series of complex movements, with a very specific ‘grooming’ purpose. Similarly, the cognitive mechanisms, such as thought–action fusion, inflated sense of responsibility and the need for control over thoughts, that operate in OCD are not particularly characteristic of either TS or TTM.

One hypothesis has been that hair-pulling occurs in two different forms — focused and automatic. The focused form of hair-pulling is redolent of OCD insofar as it is preceded by anxiety, and results in a decrease in anxiety. However, the automatic form of hair-pulling is rather different; it is somewhat reminiscent of a trance state in that patients are only minimally aware of their behavior at the time that they are doing it, and in that it may be associated with dissociative symptoms. Nevertheless, there has been only some clinical or psychobiological validation of this distinction to date (Woods et al., 2005).”

So it’s interesting they say “We think there are two forms of TTM” meanwhile they presented a figure that had 4 forms that overlapped. So if you are rigid in a “two type of puller” dogma, you miss the complexity and dynamic nature of TTM.


“How similar are TS and TTM to OCD? It seems clear from data on phenomenology, psychobiology, and treatment that TS and TTM are not simply variants of OCD. Nevertheless, some genetic (Pauls et al., 1996) and imaging (Moriarty et al., 1997) data indicate that TS and OCD may have significant overlap in their underlying mechanisms, and TS is arguably the disorder most closely related to OCD. In the case of TTM, there is less information available on underlying psychobiological mechanisms, but there are some data to support an argument that hair-pulling can be conceptualized primarily as a stereotypic disorder, along with conditions such as repetitive skin-picking, which are currently neglected in DSM-IV. Any discussion of the psychobiological validation of a spectrum between TS, TTM, and TTM must, however, be tempered by the admission that our knowledge of the psychobiology of any one of these disorders is currently only partial.

Even in the absence of a full understanding of psychobiology, is there a rationale for conceptualizing OCD, TS, and stereotypic disorders as lying on a spectrum? We would argue that with respect to TTM and stereotypic disorders, the OC spectrum concept has significant conceptual and clinical utility. At a conceptual level, the idea of a spectrum provides a useful framework for integrating data on overlaps as well as differences in the phenomenology, psychobiology, and treatment across these disorders. Thus, for example, work on cortico-striatal-thalamic-cortical circuitry in TS and OCD may shed light on why both disorders are characterized by impulse dyscontrol, but also on why TS is characterized predominantly by motoric symptoms. From a clinical perspective there may be significant utility in emphasizing the different relationships between TS, TTM, and OCD: this reminds clinicians to screen for these otherwise neglected disorders (e.g. stereotypies are typically omitted in screening for common mental disorders), to evaluate important comorbidities (e.g. determining the presence of tics in OCD), and to consider particular treatment options (e.g. although antipsychotics are one of the first line treatments of TS, they may be useful in the augmentation therapy of OCD and TTM). Nevertheless, we are also mindful of the possibility that such an approach may be disadvantageous insofar as TS, TTM, and OCD each require a unique conceptual and clinical framework involving non-overlapping assessment measures and treatment options.”

I didn’t include chunks of the article because some of it was outside the focus of what I was interested in. A review article in itself looks ideas presented by decades of research which vary considerably in how good the data is. For example, they talked at length about how people with TTM compared to a control group to look at “response flexibility” and “spatial thinking” impairments. “Results” showed TTM patients performed worse on every measure practically but only 20 people with TTM were tested. So to me that wasn’t really a good study. I also skipped the animal models because they compared hair pulling to “whisker trimming” behaviors in mice and I just can’t for the life of me find much value in that comparison. Mice models have their value but even in biology, there are limits. You would be surprised how much money a drug company may pump into something that cures something in mice, but fails to do so in humans. So in terms of psychology, I’m not even going to waste my time reading those studies right now. If they were an animal model of “parrot pulling feathers out” studies, then I would be interested in reading that since the comparison is more closely related.

I did find it interesting when they talked about the “spectrum” of OCD, TS and TTM. Considering the picture (figure 1), this suggests the overlaps are representations of a spectrum with specific intersections. This idea is something that could use more work in studying. As a puller, I can identify with the obsessive nature of a pokey hair or wiry hair, but I can also identify with the “trance” state of an automatic puller. So while it may some purpose to categorize some as automatic or focused, we may want to elaborate on the full picture that the binary system misses. If you can track/record a trance, a compulsive pulling episode, a obsessive compulsive “the hair” must be pulled episodes, and a complex assortment of all 3, we might get able to find the internal and external triggers for each type.

Also, realizing you are on a gradient and vulnerable to different types of TTM episodes, could help dictate which treatment you would use and when.

Emily Kight
"Trichotillomania has correlation to sensory overstimulation disorder", ok and?
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I have wanted to write more about research on trichotillomania. No product out there is a going to "cure" anyone and I wonder if it's something that should be cured sometimes. I understand the shame aspect but I also now understand the freedom to say "This is me. If you think I am weird because I don't have perfect hair, that's a short coming on YOUR part". I don't feel like I owe anyone perfect hair or beauty. I don’t expect anyone to look perfect so why should anyone expect me to? So I understand acceptance but I also want to know why. Why do I do this? It’s ok that I do pull, but why? How come I don’t smoke cigs instead? Oh I know why, I can’t stand the smell. It makes me gag. But why can’t I stand the smell? This study could explain why.

What does it means on a deeper level to have this physiological urge that others don't have? What does it mean to experience the world this way? Those are questions I would like to explore more fully. The research out there isn't perfect and working in research enables me to suss out errors/weakness in studies more than a non-research person. For example, this study suggests, that people with Trichotillomania, have intense feelings and responses to sensory experiences. This could mean that smells or sounds and touch can bother/excite us more. That is to say, we experience the sensory part of the world differently.

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Sensory over-responsivity (SOR) has been described as a disproportionately intense, prolonged, or heightened reaction to ordinary sensory stimuli, such as tactile and auditory sensations (e.g., sound of people chewing, feeling of specific clothing textures) that leads to functional impairment Rogers and Luby, 2011). Recent research has begun to examine relationships between sensory triggers, perfectionism, and OC-related disorders, and in particular how these may be related to SOR.

There is wide variation among individuals with TTM in symptom presentation, and little is known about subtypes or endophenotypic variants, which could relate to treatment outcome, prognosis, and underlying genetic and neural vulnerabilities. Subtypes, or “styles,” of pulling have been proposed based on the degree to which an individual is aware of engaging in the pulling (e.g., Christenson and Mackenzie, 1994Flessner et al., 2008) and the extent to which pulling is related to emotion regulation processes (e.g., Alexander et al., 2016Diefenbach et al., 2008). 

So what does that mean? The authors jump to the conclusion that it means we have emotional regulation issues. Now I don't doubt I have those but I don't know if experiences sounds/smells more intensely = emotional regulation issues.

First the authors present that there appear to be two types of pulling

1) Automatic - characterized as a behavior that occurs outside of the puller's awareness.

2) Focused- occur within conscious awareness and to function more as an emotion regulation strategy.

I have always felt it would have been great to just be an automatic puller so I could buy an awareness device and be over it already. I know it’s not that simple though as there appears to be some overlap of both types for people so it’s probably more accurate to consider how much of your pulling style is automatic vs focused. An awareness device should be in your tool box if you have a lot of automatic pulling that you want to inhibit.

“Focused” pulling has garnered particular attention in the treatment development literature (e.g., Keuthen et al., 2012Woods et al., 2006) given that it may be less responsive to traditional habit reversal therapy (Azrin and Nunn, 1973). “Focused” pulling can often involve sensory triggers including tactile or visual sensations such as coarse hair, or the urge to pull hair to satisfy a need for symmetry, for example removing an eyebrow hair that seems out of place (e.g., Christenson and Mackenzie, 1994;), or with by-proxy urges to pull hair from other people that appear out of place (Falkenstein and Haaga, 2016). By-proxy urges have been associated with “focused” pulling and also perfectionism (Falkenstein and Haaga, 2016). Many hair pullers struggle with perfectionism as a trigger for pulling, and it has been found to be a useful treatment target for some (Mansueto et al., 1999Pélissier and O’Connor, 2004).

Whether “focused” pulling, SOR, and perfectionism are associated constructs in a sample with TTM remains unexamined.

Have you considered how much “perfectionism” plays into your trichotillomania? I hadn’t really until I read this carefully. I do exhibit the classic “that pokey hair is out of place and needs to be removed!” feeling intensely. Is it perfectionism? Is it an emotional regulation issue? Is it both?

So how did they study if people with trich had perfectionism and how did they define perfectionism? They recruited people online and with surveys they could classify someone as perfectionistic or not. The survey for perfectionism used a specific scale;

Frost Multidimensional Perfectionism Scale (FMPS; Frost et al., 1990)

This self-report measure assesses the following 6 dimensions of perfectionism across 35 items: concern about making mistakes, setting high personal standards, perceived parental expectations, parental criticism, doubts about actions, and the tendency to be organized (the organization subscale is not in the total score). Each item is rated on a 5-point Likert scale. This scale has been found to have adequate reliability and validity (Frost et al., 1990).

So they also used a similar scale to examine SOR and anxiety and depression. It remains to be known how accurate it is for someone taking a survey to be objective about themselves. It would be useful if patients had their therapists also complete the survey and that way the person could have a score that was averaged between to offset personal bias about yourself. But who has that kind of funding and resources? It’s just not feasible probably.

Results showed people with TTM were more sensitive/responsive to sounds and tactile sensations. I sleep with a sound machine every night and without it, I feel anxiety so I definitely can’t argue against that result. I hate sounds when I am trying to sleep. But who doesn’t? Apparently we hate it MORE than your non-puller type.

Participants also described experiences with auditory over-responsivity, including, “I cannot fall asleep if I hear a clock ticking, or a tap leaking. I have to shout louder than the sound the dishes make when I'm arranging them in the cupboard. I scream or cover my ears if a truck or a bus passes by me.” And another participant stated, “When there is fire alarm testing at work, I have to leave for the day or I get almost zero work done if I stay.”

“Symptoms of SOR were very common in a large sample of adults with self-reported hair pulling: 77% endorsed at least mild tactile symptoms and 73% at least mild auditory SOR (in contrast with the non-affected comparison group: 59% endorsed at least mild tactile symptoms, and 61% at least mild auditory).”

Conclusion: We feel sounds, smells, and tactile sensations more intensely.

“It is also possible that SOR symptoms contribute to high levels of emotional arousal, which in turn increases the likelihood of engaging in hair pulling as an emotion regulation strategy. SOR symptoms may also be more directly functionally related to pulling, as is illustrated by our participants’ qualitative descriptions of sensory stimuli that elicit the urge to pull. Finally, it may be the case that a shared underlying neuropathology underlies both TTM and SOR; abnormalities in cortico-subcortical circuitry involved in emotion regulationemotional processinginhibitory control, and memory processing have been implicated in both conditions (Odlaug et al., 2014Koziol et al., 2011).”

And here we are back to emotional regulation issues. lol

“There are currently no empirically supported treatments for SOR, and it is unclear which techniques may be most useful. Interventions reported in case studies have utilized exposure (e.g., McGuire et al., 2015Reid et al., 2016), but if SOR is indeed related to emotion regulation deficits, other viable candidate treatments could be interventions targeting distress tolerance/emotion regulation. Future research should focus on clarifying the role of SOR in TTM and more broadly, the role of SOR within OC-related disorders as a whole, with the ultimate goal of improving conceptualization and treatment options for these impairing phenomena.”

Well, so bad news first, there is no treatment for SOR. Good news maybe by treating SOR it would help with TTM? If you are considering how your emotional regulation (of lack thereof) is affecting your trich, I would suggest looking at DBT.

However, if we do assume their one idea that SOR increases pulling behavior, we could try to inhibit our sensitivity to sounds and tactile sensations somehow which would lessen urges to pull. Something to consider. How would we experience sounds and tactile sensations less? That’s a good point they don’t address very fully, they just cite “exposure therapy”.

Maybe keeping sound machines on all day everyday? Maybe wearing gloves so you feel less? What do you think? What would make you experience sounds and tactile sensations less? Greater exposure to them maybe? Or less exposure to them? Maybe emotionally regulating the experience of sounds and tactile sensations?

I guess this study was interesting but not sure what to do with this info (they don’t know either lol). I already knew I didn’t like loud sounds and tight clothes. When I asked my partner if he thought I responded more to sounds, smells, and tactile sensations, he was like “Oh yea”. So what do I do with this information? Maybe just keeping it in mind will help me understand myself more. Maybe I should be asking myself if I am tolerating something as a non-puller vs puller? Would a non-puller mind this as much? I think that’s an interesting thought. Something to consider.

Emily Kight
Why did trichotillomania evolve in humans?

Recently I read a chapter from a book about how depression could have been advantageous 150,000 years ago because it provided a human with rest to recuperate while also withdrawing from the tribe to prevent disease spread within. Could trichotillomania have been an advantage 150,000 years ago too? If so, what was the advantage?

150,000 years ago humans lived in tribes and life expectancy was in the 20’s. Many women died in childbirth and many men died hunting and fighting. Still natural selection occured to pass down traits we still have today.

If you did live in a tribe, you presumably shared things or were in close quarters … caves.

A millennial human photographing humble beginnings and then hashtagging “woke”.

A millennial human photographing humble beginnings and then hashtagging “woke”.

I keep thinking what would happen if you woke up infested with lice or mites or some of the sort. It would be an issue to have hair. Lice would cause itching and sleep loss. Sleep loss would put you at risk for not reacting quickly to lethal threats. Not to mention lots of scratching could lead to infection which without medical treatment could eventually lead to further issues. Head lice have been around for a long time.

Genetic studies suggest that lice developed about 1.68 million years before homo sapiens emerged, and that they started their relationships with humans about the same time human evolution separated from chimpanzee evolution.

Could obsessive hair removal been an evolutionary advantage then? Lice was probably common and bald patches would have limited the area lice could thrive. No hair = no lice.

Having no eyelashes would have been one of the only ways to get rid of lice living on your lashes 150,000 years ago. Think about that for a second…….lice can happily live on your lashes!

Perhaps, this "urge" or "itch" we feel to pull, is an old physiological response to pre-emptively protect us from a possible lice infestation in our eyes and scalp. Perhaps this trigger is stress related since meeting new tribes or moving locations would have been stressful which are also common ways to get lice.

The problem is our genes don't evolve as quick as technology. While hair pulling could be useful then, it does not serve as much of a purpose now (assuming it did at all).

Millennial humans reach more tribes than their ancestors with the advent of social media.

Millennial humans reach more tribes than their ancestors with the advent of social media.

These are just thoughts of course but maybe if you are a hair puller, you are just born in the wrong century to appreciate it?

If you are wondering how mental disorders could have evolved in humans, check out this article from 2017 in Scientific american;

“Another team, lead by human geneticist Renato Polimanti at Yale University in New Haven, Connecticut, is trying to tease out links between environmental factors, mental illnesses and behavioural traits. Polimanti and his colleagues looked at 2,455 DNA samples from individuals at 23 sites across Europe and quantified each person’s overall genetic risk for mental disorders, such as autism, and personality traits, such as extraversion. They then calculated whether that risk was associated with certain environmental factors, such as rainfall, winter temperatures or the prevalence of infectious disease—exploring the idea that these factors might have been involved in selecting for the human traits.

People who live in European regions with relatively lower winter temperatures, they found, were slightly more genetically prone to schizophrenia. Polimanti suggests that if genes that helped people tolerate cold were located close to variants that promote schizophrenia in the genome, then the latter could have been inadvertently carried along during evolution as a “fellow traveller”.

Emily Kight
Make your own grape seed extract hair growth tonic!

Here are some quick tips to get you started on making your own hair growth tonic!

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First you will need to buy a gallon of distilled water, Grape Seed Extract (95% Proanthocyanidins) powder, and a container for everyday use. You can also buy a preservative to stop mold growth or you can leave it in the fridge. If you are making a large batch like this, might be safer to do both!

For preservative you just need a drop of phenoxyethanol-SA which contains caprylyl glycol and sorbic acid. It will protect against, yeast, bacteria and mold. Only need 0.75-1.5%. Can be used in both hair and skin products. Where to buy one? Here at Making Cosmetics!

For buying your grape seed extract, you don’t want cheap. It’s also imperative you use products that say specifically “95% Proanthocyanidins” or you are probably wasting your time.

What evidence is there that it will help grow hair? Academic article Here!

So this is a good product to have if you want something to keep in after you get out of the shower. The problem with other growth products is that you have to wash them out but this is just water and extract so its lightweight. Towel dry your hair and ad a few dabs and go on about the day!

Step 1) Get 1/4-1/2 teaspoon of Grape seed powder and put into beaker/jug

Step 2) Fill beaker/jug up with distilled water until you don’t see powder particles drifting around. You want it to go into solution.

Step 3) (Optional) Pour the beaker into the distilled water jug to further dilute the solution

Step 4) Pour some into second container for everyday use. Then apply half drop of preservative to it. You want it to be around 1% of the entire container solution so you don’t need much.

Step 5) (Optional) Add 1%-5% follicle booster. So again prob just another drop to your secondary container. Mix thoroughly.

Note* Be sure to use a secondary container the size of the one picture or larger. If you use a small container, you need to use even less of the preservative and follicle booster…..which is hard without a pipette.

PLEASE remember to keep out of the light. Store somewhere light will not reach it.

This is how much just a 1/4-1/2 teaspoon makes up! Can you believe it?

This is how much just a 1/4-1/2 teaspoon makes up! Can you believe it?

Nice part about this extract power is that its edible. People use it as a mix in drinks.

Nice part about this extract power is that its edible. People use it as a mix in drinks.

Emily Kight
Neural Pathway Disruption

My goal in creating a cooling in-leave conditioner was to create a new habit. Pulling can be like an automatic movement that becomes almost irresistible to urges. It may start from anxiety and stress, but over time the neural pathways become ingrained and it’s just what feels right to do.

The goal in making Prohibere was never to be a quick fix or a “cure”. The goal was just to disrupt the behavior and with a lot of work, and make the pulling more infrequent and less uncontrollable.

Habit Reversal Therapy has helped some people but it’s so easy to backslide. Traditionally, patients were trained to “fist clench” instead of pull hair. I tried this but it didn’t work for me. So I decided to make something that would still generate a sensation since I wondered if the sensation of hair being pulled drove the behavior (for me atleast).

How do we fix a neural pathway behavior? Practice. Have you ever learned a movement and years later still know how to do it? It’s because the neural pathways are ingrained. Is this the issue with trich?

Path of Least Resistance

Most people live on autopilot most of the time. This is because our neural pathways operate under the law of least effort, or the path of least resistance. The most worn path is the strongest and easiest to travel. It’s like traveling down a super highway. It allows you to conserve mental energy and respond quickly to your life experiences. This type of automatic conditioning can be seen in the body memory of professional athletes or top piano players. It can also be seen the last time you drove home from work yet didn’t recall the entire trip.

What can you do instead of pull? Is it possible to step away and do something you like? Not always.


Visualization is almost as powerful as the real thing given your brain cannot tell the difference between something real or imagined. Research shows that anytime you are thinking, you are engaging and thus conditioning neural pathways. Consequently, whether you are reminiscing about the past, thinking about the present or anticipating the future you are strengthening the neural networks associated with whatever you are thinking about. 

What about visualizing stopping before you have to stop? Will you imagine feeling the strength and power? Intensity of emotion and feeling is required to take an experience and make it a solidified habit. The more emotion you engage, the more neurons you activate to form well-worn pathways.

Repetition and Practice

Neural pathways are strengthened into habits through the repetition and practice of thinking, feeling and acting.

You can do this without buying anything if you are limited on funds. Putting lotion on your hands the first time you pull and repeating it for every attempt after that may suffice. What also will help? Practice in the mirror. It sounds stupid but reaching up to a hair as if you were to pull and then grabbing your lotion or Prohibere, 20 times in a row can strengthen the neural pathway. Repeat this each day.

Don’t want to use a product? Practice moving your hand up to pull and with the other hand, swatting it away. Repeat 25-30 times. Every time you go to the bathroom you fit in a “work out”. See if you can condition your body to start swatting the hand away when you start to pull on it own.


How do we know practicing stopping could help? Police are trained to disarm a suspect in a specific way at the academy where they usually give the gun back to the person they trained with. They repeat this movement quickly and many times. They do this so much in training that in real life, they also disarm and then return the gun back to suspects! It became a real problem that needed to be addressed in training.

What if I practice but I still fall into a pulling episode? RECORD the time, place, and activity. Rate how much you wanted to pull, how many hairs pulled, how many times you pulled and if you were able to stop. Bag the hair to hold yourself accountable. If each time you pulled you had to record it and then put it in a bag, you would start to find it harder to pull because you would be looking at the “work” to do after pulling. The trick is forcing yourself to record EACH time.

Ok, great but what if I still can’t stop pulling?!?!

I get it. All this stuff is great in theory but sometimes life get hard and so stressful. Sometimes you can’t do it all. Some days trich wins. Can you step away and meditate? Can you ask yourself why you might be pulling? Did something trigger you? Were you watching a movie for too long and your body got restless? Do you feel anxious about something? Can you take a hot shower? Can you look at something online real quick to make you laugh?


The true masters of manifesting meditate daily. When you meditate you slow down the nonsense, ungrounded chatter of the busy mind and access the calm abiding wisdom of your inner awareness and the skill of laser focus. Meditation is the process of relaxing the body and quieting the mind. In order to tap into the benefits of neural plasticity you have to disengage the stress response and stimulate the relaxation response. When you are stressed your brain rigidly defers to the strongest neural pathways out of survival and the path of least resistance. Consequently, during stress you do not have access to newly formed neural networks because they have not been tried and proven yet. Most people live in a perpetual state of stress believing feeling tense, time pressured or overwhelmed is the norm. This is simply not true and is the result of an undisciplined mind and body.

Headspace is free! Practice in the mirror is free! I believe you can make steps to lessen the grip trich holds on your life. It may never be 100% gone but it can be disempowered. The fact that you read this and can consider trying something new is a good start to changing your trich. Keep creating a new neural pathway! Good luck!

Emily Kight