Hair Pulling: Compulsion, Addiction, or Both?

Trichotillomania, commonly referred to as hair pulling or trich, is a body-focused repetitive behavior (BFRB) characterized by compulsive hair pulling that results in significant hair loss, emotional distress, and impaired interpersonal functioning. Originally classified as an impulse control disorder, it is now classified as an Obsessive-Compulsive Related Disorder (OCRD). While it is not the same as Obsessive Compulsive Disorder (OCD), it does share similarities with OCD.

Despite common assumptions, repetitive hair pulling is more than just a “bad habit”. It’s not an attention-seeking behavior. It’s not due to weakness or poor hygiene or a lack of concern for oneself. It is a complex disorder that remains the focus of much debate as to its origins and how best to treat it.

Some experts suggest that hair pulling and other BFRBs like skin picking are more closely related to OCD and should be treated as such. They point to the compulsive nature of hair pulling and its similarities to OCD. Trich is driven by sometimes irresistible urges to pull one’s hair and the inability to stop, even when the person desperately wants to. People living with trich describe feeling compelled to pull their hair out, experiencing growing tension until they do. After pulling their hair out, many describe feeling a sense of relief.

Other evidence suggests that the characteristics of hair pulling and other BFRBs are more closely aligned with behavioral addictions such as gambling. In fact, if you were to look at the diagnostic criteria for hair pulling, OCD, and behavioral addictions like gambling, there is considerable overlap making for a very complicated picture.

• • Continuing the behavior despite the harm it causes
  • The presence of urges
  • Elevated impulsivity
  • Similar responses to treatments including psychotherapy and medications

Addiction or compulsion – does it really matter? Delving deeper into the nuances of hair pulling reveals a stark contrast between addiction and compulsions.

Compulsion vs. Addiction

A compulsion a type of behavior (e.g., hand washing, checking the door locks) or a mental act (e.g., counting, praying) engaged in to reduce anxiety or distress. Typically, the individual feels driven or compelled to perform the compulsion to reduce the distress associated with an obsession or to prevent a dreaded event or situation. It is a repetitive, hard-to-control, and unwanted behavior or urge that when acted upon relieves some kind of internal distress.

Compulsive behaviors are usually performed to:

• Avoid some obsessive fear from happening
• Reduce feelings of distress related to the obsessive thoughts
• Make things look or feel “just right” 

For people with trich, triggers can be mental (thoughts or feelings) or related to physical sensations (e.g., itching, tingling). Some people may experience both. People with trich tend to be very aware of their behavior and even have some insight into why they pull.

Addiction is generally defined as a compulsive, chronic, physiological or psychological need for a substance, behavior, or activity having harmful physical, psychological, or social effects and typically causing well-defined symptoms (such as anxiety, irritability, tremors, or nausea) upon withdrawal or abstinence. Addiction typically revolves around the pursuit of pleasure or relief, driven by the brain's reward system. Whether it's the rush of dopamine from drugs, the thrill of gambling, or the gratification of consuming certain foods, addictive behaviors are often rooted in the anticipation of pleasure.

People with addictions tend to lack awareness that there is a problem or of the harm their behaviors or actions are inflicting on themselves or those around them. Insight usually only comes after extensive damage to both self and social circumstances, often as a result of input from others or from treatment experiences.

So, Is Trichotillomania A Compulsion or An Addiction?

When it comes to defining trich as a compulsion or an addiction, the picture is not clear and opinions vary even among people who live with trich.

On one hand, hair pulling shares quite a few qualities that are found in addictions:

• engaging in something harmful despite being aware of its negativity
• feelings helpless to control the behavior
• the overwhelming urge to engage in the behavior
• pleasurable or relieved feelings that result from engaging in the behavior 
• feelings of intense pleasure followed by feelings of guilt, shame, and embarrassment following the act

On the other hand, trich is classified as an OCRD but the pleasure that comes with pulling is not associated with OCD. The obsessive thoughts that are the hallmark of OCD are generally absent with trich. However, research suggests that the intense pleasure that comes from pulling may be due to the release of endorphins in response to stimulated pain receptors. The pleasure from non-chemical addictions is thought to be related to the release of brain chemicals such as adrenaline or dopamine when engaging in certain behaviors.

It has been suggested that rather than an either/or, trich and other BFRBs may actually represent a unique group of disorders that share some qualities of both OCD and behavioral addiction. 

Treatment and Beyond

Just as they share some characteristics, trich, OCD, and addictions also seem to share similar responses to certain treatment modalities. Although it is clearly not a “perfect fit”, when it comes to treatment, the most important consideration is the person’s experience.

Cognitive-behavioral therapy (CBT) is a cornerstone of treatment for BFRBs like trich as well as for behavioral addictions like gambling. Therapy can help you identify triggers, develop coping strategies, and challenge negative thought patterns that contribute to the problem. Additionally, habit reversal training (HRT) aims to replace hair-pulling with alternative coping strategies, fostering healthier ways of managing stress and anxiety. While there is no single medication used to treat trich, there is some evidence that medications used to treat addictions may hold promise for trich.

While more research is needed to fully understand the dynamics, viewing trich through a broader lens may reveal new treatment options and paths to recovery. Until then, working with your mental health provider can help you to find the treatment options that are right for you.

References

1. Stein, D. J., Kogan, C. S., Atmaca, M., Fineberg, N. A., Fontenelle, L. F., Grant, J. E., Matsunaga, H., Reddy, Y. C. J., Simpson, H. B., Thomsen, P. H., van den Heuvel, O. A., Veale, D., Woods, D. W., & Reed, G. M. (2016). The classification of Obsessive-Compulsive and Related Disorders in the ICD-11. Journal of affective disorders, 190, 663–674. https://pubmed.ncbi.nlm.nih.gov/26590514/

2. Grant, J. E., Odlaug, B. L., & Potenza, M. N. (2007). Addicted to hair pulling? How an alternate model of trichotillomania may improve treatment outcome. Harvard review of psychiatry, 15(2), 80–85. https://doi.org/10.1080/10673220701298407

3. APA Dictionary of Psychology. (n.d.). Compulsion. Retrieved from https://dictionary.apa.org/compulsion

4. APA Dictionary of Psychology. (n.d.). Obsession. Retrieved from https://dictionary.apa.org/obsession

5. Definition of addiction. (2023, September 27). Retrieved from https://www.merriam-webster.com/dictionary/addiction