The Difference Between OCD and Trichotillomania (Hair Pulling)

Trichotillomania – also known as the ‘hair-pulling’ disorder – is categorized as the repetitive and uncontrollable urge to pull hair from your body. While some confuse it with OCD, it is in fact a separate condition.

While hair can be pulled from any part of your body with this condition the most common areas include the scalp, eyelashes, eyebrows, arms, pubic hair, and armpits.

Hair pulling is a real mental health condition and can lead to feelings of low self-esteem and a lack of self-confidence.

The urge to pull is overpowering and the resulting damage and hair loss can leave the sufferer retreating from social situations and isolating themselves for fear of judgment.

Up to 1 in 3 people may suffer from this disorder within their lifetime, so please do not feel like you are alone in this. It is more common than you might think and a full recovery is possible.

Let’s look at OCD and Trichotillomania together and separately…

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What is OCD?

Obsessive-compulsive disorder is categorized by two main elements; disturbing obsessions and anxiety-reducing compulsions.

Obsessions can arise in the form of unwanted images, thoughts, urges, feelings, or sensations. The context of these obsessions can vary greatly depending on the individual and their specific subtype.

It is the content of these obsessions that creates such distress for the sufferer.

We all experience intrusive thoughts, but for the OCD sufferer, they aren’t easy to shake. Most of us may have intrusive thoughts pop into our head and have a few seconds of thinking that was a bit odd!

But for the OCD sufferer, it leaves them questioning themselves and they can quickly get caught in a loop of rumination and ‘problem-solving’.

This is why OCD is known as the ‘doubting disorder’.

It is the uncertainty surrounding those obsessions that cause such immense torment. Because of this, someone with OCD with then attempt to navigate these uncomfortable feelings by engaging in ritualistic and repetitive behaviors that temporarily ease the feelings of anxiety and help them regain a sense of control, if only for a short while.

Much like obsessions, compulsive behaviors can vary wildly depending on the individual and their specific subtype.

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What is Trichotillomania: The Basics

Trichotillomania (TTM) is commonly known as the ‘hair pulling’ disorder.

We conceptualize trichotillomania as both an obsessive-compulsive spectrum disorder and an impulse control disorder, following feelings of high anxiety or stress the sufferer has an overwhelming urge to pull out their hair.

The most common areas to pull hair from are the scalp, eyelashes, pubic hair, and eyebrows.

This body-focused repetitive behavior (BFRB) of pulling hair from their body is done in order to soothe intense negative emotions.

Pulling episodes can vary in length, from a few minutes to many hours.

Even though the sufferer knows that excessive hair pulling can result in hair loss and damage, they feel compelled to perform the act to either find relief from the anxiety and distress or to numb out difficult emotions that they are experiencing. Despite trying to stop, the impulse to pull their hair is quite irresistible.

To the onlooker, it may appear to be a mild ‘habit’ similar to nail biting. But those with TTM are living with a mental health condition that can cause them a great deal of shame which is why the ritual of hair pulling is typically done in private (where possible) and time is spent making sure they are able to hide their hair loss from others.

Focused vs. Automatic hair-pulling

For those with OCD, their compulsive behaviors are often done on an automatic pilot. It is sometimes the case that these compulsions are done with little awareness as their brain tries to shield them from the agony of obsessions.

Because of this, they may engage in ritualistic behaviors without even realizing they’re doing it.

However, others are fully aware that they are doing the compulsions knowing it will alleviate their uncertainty and anxiety.

Compulsions such as avoidance, reassurance-seeking, and rumination are notoriously difficult to catch but it is possible to raise our awareness and interrupt the behavior.

In the case of hair-pulling, this behavior can be one of two things:

Focused – Some people with TTM are consciously aware of the behavior. They do the ritual knowing that it will offer some form of relief or pleasure from doing so. In this instance, hair pulling can be quite intentional and on occasions, elaborate rituals are made to make the experience even more satisfying.

Automatic – Automatic hair pulling is done in a similar way to those with compulsions in OCD. It is not done intentionally, quite the opposite. It has become an automatic habit that is performed without realizing they are even doing it. Some people even report having no idea that they are engaging in the behavior (and sometimes can even pull their hair in their sleep).

The negative and positive emotions of hair-pulling

Unlike OCD, people with trichotillomania can find some form of positive emotions in their hair-pulling rituals depending on the mood, circumstance, and reason for pulling.

Negative emotions – For most, hair pulling is a coping mechanism for painful and uncomfortable emotions. Feelings of anxiety, stress, boredom, loneliness, or frustration can all trigger hair-pulling episodes in an attempt to find relief.

Positive emotions – To some degree, people with TTM can find an element of satisfaction and positive feelings toward hair pulling as it offers relief and can soothe those negative feelings. As a result, it becomes tempting to continue to pull their hair with the hope of holding on to these positive feelings.

The similarities between OCD and hair-pulling

The main similarity between OCD and hair-pulling lies in the compulsive and ritualistic behaviors.

In OCD, the sufferer is caught in the OCD cycle. Fearful obsessions trigger torturous feelings of uncertainty and anxiety. Compulsions are then performed to relieve them of those unwanted feelings and offer temporary relief.

Most of the time, the OCD sufferer may not even be aware that they have engaged in compulsive behaviors as they happen as an automatic response to the obsessions.

Without realizing it, they maintain the cycle of OCD by engaging in ritualistic behaviors.

In TTM, the act of hair-pulling is usually followed by intense feelings of anxiety, stress, or negative emotion. While the type of compulsions done in the context of OCD can be many, hair pulling is the sole impulsive behavior done in trichotillomania.

Unlike OCD, where these compulsions do not offer any form of pleasure or positive emotions, in some TTM cases, the act of hair pulling can offer feelings of relief or positive emotions.

This is not to say that the sufferer wants to continue the act of hair-pulling.

It is a behavior that can affect their outward appearance and often conjures feelings of shame and embarrassment.

It is simply to say that depending on the degree of awareness involved, the act of pulling hair from their body can feel good in comparison to the negative feelings that caused them to engage in this ritual in the first place.

The differences between OCD and hair-pulling

Even though trichotillomania falls under the classification of obsessive-compulsive disorder, there is one key major difference between the two…

OCD is primarily driven by obsessions

OCD thrives because we give those obsessions (intrusive thoughts, images, urges, feelings, and sensations) more weight, value, and importance than we should.

Intrusive thoughts are unwanted, seemingly appear out of nowhere, and leave us questioning who we are as individuals. This is why we call OCD an ‘egodystonic’ disorder. It goes against the opposite of who we are and what we value.

This is why, when those intrusive thoughts arise, they disturb us.

We find ourselves ruminating:

Why would I think such a thing?

Is that really what I want?

What if that’s true, what does it mean about me?

If I don’t address this thought, what will happen?

These obsessions begin the OCD cycle and always precede those compulsive behaviors.

Trich is a body-focused repetitive behavior

Trichotillomania is not preceded by obsessions.

In the case of hair pulling, individuals might report a variety of reasons why they felt the urge to pull.

This might include:

Sensory triggers, such as the feeling of hair on their scalp or eyelashes, for example.
Emotional triggers, such as feeling anxious, angry, afraid, or bored.
Cognitive triggers, such as thinking about their hair or rigid thinking

Research has shown that there may be a genetic factor involved in the hereditary of TTM, similar to that of OCD.

There are higher numbers found in family members with a relative suffering from trich compared to those without. It is possible that there is a hereditary component involved.

The symptoms of Trichotillomania

What to look out for if you suspect you might be struggling with trichotillomania:

Feeling intense emotions before the urge to pull your hair
Difficulty resisting the urge to pull hair
Bare patches on your scalp, eyebrows, eyelashes, or other areas of your body where the hair has been pulled out
Behaviors include; twirling your hair through your fingers, pulling the hair between your teeth, eating or chewing the hair, and inspecting hair regularly and with precision.
Feelings of embarrassment or shame due to hair pulling
Limiting social interactions for fear of someone noticing bare patches where hair has been pulled out
Liking the texture or hair to be a certain way

Why does hair-pulling feel so good?

The reason could be two-fold…

Each time you pull your hair, the brain releases a small burst of reward hormone which feels good in the body. So, every time you pull, you’re effectively getting a small dose of fell-goods which encourages you to do the behavior again.

It offers a distraction from negative feelings. It may not be that hair-pulling in the context of TTM actually feels good. Rather, it’s a coping mechanism for painful or uncomfortable emotions and offers a worthwhile distraction.

It’s important to note that even if the act of hair-pulling feels good in the moment, those with TTM would still rather they didn’t feel the urge to pull.

Like OCD, hair pulling can have a huge negative impact on quality of life and can severely impact a person’s self-esteem. They do not do this behavior out of choice, it is because the urge and impulse to do so is so strong.

Treatment for OCD

The gold standard treatment for OCD is CBT (cognitive behavioral therapy) with ERP (exposure response prevention).

This combination of treatments has proven to be the most effective in getting fast and long-lasting results.

The reason this works is that this combination of methodologies focuses on helping the sufferer change their relationship and response to their obsessions. It encourages us to place less weight and value on our thoughts and resist the urge to do compulsions.

By doing that, we prove to our brain that we are capable of managing of our anxiety without those ritualistic behaviors, and helps us learn to tolerate the intrusive thoughts which, over time, helps make them less sticky.

For an alternative and accessible option to private therapy, you can join ERP SCHOOL.

Founded and created by top OCD specialist, Kimberley Quinlan, LMFT, ERP SCHOOL will teach you the exact tools and techniques you need to change your relationship and response to your intrusive thoughts and resist the urge to do compulsions.

You will be given the exact steps Kimberley takes with her own private clients, as she guides them through the recovery process.

You can take your life back from OCD! Join ERP SCHOOL here.

Treatment for hair-pulling

A number of therapy types can be utilized to treat trichotillomania effectively.

CBT is as successful in treating OCD as it is TTM, which is why it can be particularly helpful when treating the two disorders in tandem.

Habit reversal training is a behavioral therapy that is typically employed for this particular disorder. You will learn to recognize the circumstances and scenarios that trigger your urge to pull and consider how you can substitute this with other behaviors instead.

Similar to CBT and ERP, you are encouraged to change your response to the trigger and resist the urge to pull.

Can the two be treated together?

Unlike OCD and bipolar disorder or OCD and depression which require separate treatment, OCD and TTM can be effectively and easily treated simultaneously.

With both benefitting greatly from the tools and techniques used in cognitive behavioral therapy, helping one only goes to help the other.

As always, we would highly recommend seeking treatment from a qualified mental health professional who is capable of navigating both disorders.

Our team of clinicians based in California, are qualified and highly experienced in working with both disorders. Under the guidance of top OCD specialist, Kimberley Quinlan, we can help you recover from both disorders using a proven treatment plan.

Please complete an intake form here and we will see if one of our friendly, highly trained clinicians can help you on your road to recovery.