Why do I pull my hair out as a form of self punishment?

Dear Me, 

Recurrent, irresistible urges to pull out hair from your scalp, eyebrows, or other areas of your body, despite trying to stop, are symptoms of a condition called trichotillomania. Trichotillomania is categorized as a body-focused repetitive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). People with trichotillomania describe experiencing mounting tension before pulling out their hair, and gratification or relief after pulling it out. It’s a chronic condition that spans genders and ages. Your question alludes to trichotillomania commonly coexisting with other illnesses, such as eating disorders and other psychiatric conditions. It may be interesting to know that psychiatrists have even found evidence to support a relationship between trichotillomania, body-focused repetitive behaviors (BFRBs), and eating disorders. 

Both BFRBs and eating disorders are often used as methods to cope with distressing emotional experiences (e.g. stress, depression, anxiety) because they may provide temporary relief once the behavior is performed. Individuals experiencing either or both of these conditions may struggle to effectively regulate their emotions using safer, more sustainable approaches, leading them to resort to these actions for a sense of comfort or control. They may also lack the ability to control their behaviors while in distress, which is why BFRBs and eating disorders often share an impulsive element. You mentioned that you consider trichotillomania a “shameful habit”, which isn't an uncommon feeling. However, these feelings can create a cycle of shame or “self-punishment,” in which individuals engage in BFRBs to cope with their feelings of shame related to their eating disorder, or vice versa. Acting on these thoughts of shame by actually performing these behaviors may cause more feelings of shame, which further perpetuates the cycle. 

Scheduling an appointment to meet with a health care provider or mental health professional may be the first step in getting you a conclusive diagnosis. Given the intersections of these (and other) diagnoses, you may consider providing the health professional with a thorough explanation of the symptoms and feelings you experience so they may determine the most appropriate treatment plan. To prepare for a conversation with a professional, consider the following questions: 

• When did the hair-pulling and bulimia start? Did they start at the same time or one before the other? 
• What do you believe are the triggers of these behaviors? 
• What do you think would happen or what did happen when you’ve tried to stop? 

Contrary to what you’ve seen on television, no specific medications have been approved by the Food and Drug Administration (FDA) to cure trichotillomania (although medications do treat symptoms of some coexisting disorders). There is, however, evidence to suggest that the following therapies can help treat this condition: 

• Habit reversal training: This therapy involves learning how to recognize situations where you're likely to pull your hair and how to substitute other behaviors instead. 
• Cognitive therapy: This therapy can help you identify and examine distorted beliefs you may have about hair pulling. 
• Acceptance and commitment therapy: This therapy can help you learn to accept your hair-pulling urges without acting on them. 

List adapted from the Mayo Clinic 

A health care provider or mental health professional may also prescribe medications to manage certain symptoms, such as an antidepressant. Studies also indicate potential advantages of taking N-acetylcysteine, an amino acid that affects neurotransmitters associated with mood, and olanzapine (Zyprexa), an antipsychotic, to manage symptoms. Support groups for BFRBs may also be helpful and can be found at organizations, such as the TLC Foundation for Body-Focused Repetitive Behaviors. Hope this information was helpful and best of luck in your search for information.