The Ritual of Pulling - Focused vs Automatic Pulling

Trichotillomania is a diagnosis based on a set of clearly defined characteristics as set out by the American Psychiatric Association (APA) Diagnostic and Statistic Manual (DSM5). It describes individuals with trichotillomania as engaging in recurrent hair pulling following the experience of an increasing sense of tension prior to or when trying to resist pulling. However some experts in the field have questioned this description as a diagnostic characteristic as it could discount the type of pulling known as "automatic pulling".

Pulling in auto-pilot

Automatic pulling is pulling that the individual engages in without realising it. This often occurs in contexts where the person is engaged in passive activities such as reading, studying or watching television. Behavioral therapy for disorders such as trichotillomania often helps the person identify behaviors or strategies to either distract from the urge to pull, or offers an alternate behavior that makes it difficult to pull. The problem with this strategy is that is requires you to implement your chosen strategies prior to picking, This then poses a problem for the individuals whose pulling is predominantly automatic, because it would often be only after a few minutes into pulling that the person realises they had been doing it, by which time it is too late to implement behavioral strategies. It is for this reason that a critical part of an effective cognitive behavioral therapy program for BFRBs like trichotillomania is to first develop an understanding and awareness of pulling patterns.

Focused pulling

Developing an understanding and awareness of ones pulling patterns can transform automatic pulling into focused pulling. While this can be overhwhelming, it is an important first step toward managing your pulling. Focused pulling is characterized by an overt experience of the urge to pull. In focused pulling the person is aware of the build of tension as described by the DSM5 and craves the feeling of pulling as a way to relieve that tension. For many it may seem counter-intuitive to want to become more aware of these feelings, but is is only when you are able to identify the signs that you are about to pull that you will be able to implement effective strategies to prevent it.

Becoming more aware

So how does one become more aware of the urge to pull? One of the methods used in CBT is to maintain a log of the unwanted behavior. This entails recording details of your pulling each time you become aware that you doing it. Information to record includes:

• Date
• Time of day
• Place / environment
• What you were doing prior to pulling
• what you were thinking about or feeling prior to pulling
• Whether you were in the presence of others or not
• How long you think you were pulling before you realised you were doing it

It can be quite challenging to remember to record all this information each time you pull. Some patients report that they either forget because they are not able to record immediately at the time of pulling, or that they do not always have a pen and paper handy to diligently record all this information. If you are using pen and paper journaling it may help to create a template table with the above as headings that you can complete each time you pull. Alternatively if you are like most people in today's day and age that always has a smartphone nearby, it may be worthwhile using one of the many free notetaking applications available for both android and iOS. For some patients the very exercise of keeping a pulling log has resulted in pulling frequency decreasing. It allows you to identify triggers you may not have even been aware were there, which then allows you to avoid or address these proactively to prevent the urge to pull from even occuring. As the old adage goes: "prevention is better than cure".