Why Can’t I Stop Pulling My Hair? What Really Helps Trichotillomania

Draft for review only : not for publication or scheduling

Hair pulling can be incredibly difficult to explain to someone who has never experienced it.

People often say to themselves, “Why can’t I just stop?” They may promise that this will be the last time, hide thinning areas of hair, avoid hairdressers or photographs, or feel ashamed when somebody notices.

Yet trichotillomania is not simply a bad habit or a lack of willpower.

Trichotillomania, sometimes called Hair-Pulling Disorder, is a recognised psychological condition characterised by recurrent pulling of one’s own hair, often despite repeated attempts to reduce or stop it. Hair may be pulled from the scalp, eyebrows, eyelashes or other parts of the body.

For some people, the pulling is deliberate. For others, it happens almost automatically while watching television, reading, studying, working at a computer or lying in bed.

And importantly, it is treatable.

Why do people pull their hair?

There is rarely one simple reason.

Some people describe an increasing sense of tension or an uncomfortable urge before pulling, followed by a feeling of relief afterwards. Others search for a particular hair that feels coarse, uneven or somehow “wrong”.

Emotions can also play a part. Pulling may increase during periods of:

• anxiety

• stress

• boredom

• frustration

• loneliness

• overwhelm

• anger

• tiredness

For other people, the behaviour has become so automatic that they do not realise they are doing it until they notice hair in their hand.

This is why telling somebody to “just stop pulling” rarely works.

As a psychologist, I am much more interested in understanding what happens immediately before the pulling, what the person experiences while they are doing it, and what the pulling provides afterwards.

That gives us something we can actually work with.

What is the best treatment for trichotillomania?

The psychological treatment with the strongest evidence is a behavioural form of Cognitive Behavioural Therapy, or CBT, called Habit Reversal Training, or HRT.

A major 2026 review and meta-analysis of treatments for trichotillomania found particularly strong support for behavioural therapy incorporating Habit Reversal Training and for Acceptance and Commitment Therapy enhanced Habit Reversal Training (Fisak et al., 2026).

In practical terms, HRT usually involves three important areas.

1. Becoming aware of the pulling sequence

The first task is not necessarily to stop the behaviour immediately. It is to become much better at noticing it.

A sequence might look like this:

Stress → hand moves towards hair → fingers begin searching → particular hair is found → urge increases → hair is pulled → brief relief

Treatment helps the person recognise the sequence earlier, ideally before the hair is pulled.

Keeping a simple record can help identify patterns such as where pulling occurs, the time of day, emotions present, the strength of the urge and whether the pulling was conscious or automatic.

This can be particularly important because there are often two broad types of pulling.

Automatic pulling may occur almost outside awareness, perhaps while reading, watching television or scrolling on a phone.

Focused pulling is more deliberate. The person may consciously search for a particular hair, experience mounting tension or feel compelled to remove a hair that feels different from the others.

Many people experience both.

2. Developing a competing response

Once the person recognises the urge or the early hand movement, they practise doing something physically incompatible with pulling.

This might include:

• placing both hands flat on the thighs

• gently clenching the hands

• clasping the hands together

• holding a textured object

• engaging the hands in another activity

The important part is that the alternative behaviour becomes linked to the trigger.

For example:

“When I notice my fingers searching my scalp, I place my hands on my thighs for one minute.”

This sounds simple, but repeated practice gradually changes the habitual behavioural pathway.

3. Changing the environment

Another important part of treatment is called stimulus control.

If someone repeatedly pulls their hair while watching television, for example, we might look at changing what their hands are doing during that particular period.

Hair might be tied back, a textured object might be available, tweezers may be moved out of immediate reach, or the person may change where or how they sit.

This is not about permanently avoiding every trigger.

It is about making unconscious pulling slightly less automatic while new habits are being learned.

Going beyond HRT: understanding what the pulling does for you

One particularly useful development is the Comprehensive Behavioural Model, known as ComB.

ComB looks at the individual function of hair pulling. It asks whether pulling is primarily associated with sensory experiences, particular thoughts, emotions, physical movements or specific environments.

For one person, the main trigger might be anxiety.

For another, it may be searching for a coarse hair.

For somebody else, pulling may happen almost exclusively while scrolling on their phone in bed.

The model examines several areas, including:

• Sensory: What does the person notice about the hair, scalp or texture?

• Cognitive: What thoughts occur? For example, “That hair feels wrong” or “I need to get that one out.”

• Affective: What emotions are present, such as anxiety, boredom or frustration?

• Motor: What physical movement or sequence has become habitual?

• Place: Where and when does pulling usually happen?

Research by Carlson and colleagues (2021) found that a 12-session ComB intervention produced significant reductions in trichotillomania symptoms compared with a control condition.

The advantage of this approach is that treatment becomes individualised rather than assuming everybody pulls their hair for the same reason.

When ADHD and Hair Pulling Overlap: The Body-Focused Repetitive Behaviour Connection

There is another piece of the picture that is particularly important for people with ADHD.

Trichotillomania belongs to a group of behaviours often described as body-focused repetitive behaviours, or BFRBs. These include hair pulling, skin picking and other repetitive behaviours directed towards the body.

ADHD and trichotillomania can occur together.

In a study of 308 adults with trichotillomania, Chesivoir, Valle and Grant (2022) found that 15.3% met the clinical threshold for ADHD. Those with both conditions also showed significantly higher levels of attentional, motor and non-planning impulsivity.

This matters because hair pulling in somebody with ADHD may not always be driven primarily by anxiety.

For some people, it may be connected with:

• impulsivity, where the hand reaches for the hair before conscious thought catches up

• sensory seeking, particularly searching for a particular texture or sensation

• under-stimulation or boredom, such as pulling while watching television, studying or scrolling

• self-regulation, where repetitive sensory activity provides temporary stimulation or calming

• difficulty shifting attention away from an urge once it has been noticed

This does not mean that everybody with ADHD will develop trichotillomania, nor does it mean that hair pulling automatically indicates ADHD.

It does mean that when the two occur together, treatment needs to take the ADHD into account.

For example, simply asking a person to “notice the urge and stop” may be much harder if they have reduced awareness of what their hands are doing during periods of hyperfocus or under-stimulation.

An ADHD-informed treatment plan might therefore involve making competing responses immediately available, increasing sensory alternatives, creating environmental prompts, reducing unstructured high-risk periods and making strategies simple enough to use without relying heavily on working memory.

Someone who pulls while studying might keep a tactile object permanently beside their laptop rather than expecting themselves to remember to fetch one once the urge has already started.

Similarly, if boredom is a major trigger, treatment may need to address stimulation as well as restraint.

Recent genetic research is also beginning to explore the biological relationship between body-focused repetitive behaviours and other psychiatric and neurodevelopmental conditions.

Greenspun and colleagues (2026) examined families affected by trichotillomania and/or excoriation disorder. Their findings pointed towards genetic factors involving obsessive-compulsive and neurodevelopmental pathways. The study did not find a statistically significant over-transmission of ADHD-related polygenic risk, so it would be premature to suggest a direct genetic ADHD-trichotillomania connection. However, it adds to a growing understanding that BFRBs are complex conditions with biological as well as psychological and behavioural influences.

This is one reason why I would avoid treating hair pulling purely as a “bad habit”.

Particularly where ADHD is present, the better question may be:

“What is this behaviour doing for the person’s brain at that moment?”

Once we understand whether the pulling is providing stimulation, sensory input, emotional regulation, relief or simply occurring automatically, treatment can become far more targeted.

Where does ACT fit?

I often find Acceptance and Commitment Therapy, or ACT, particularly helpful alongside behavioural treatment.

People with trichotillomania can become trapped in a battle with their urges.

They may think:

“I must not pull.”

The urge appears, they desperately try to suppress it, tension increases, they eventually pull and then feel disappointed or ashamed.

ACT takes a different approach.

Instead of trying to make every uncomfortable urge disappear, we help someone learn:

“I can experience an urge without having to act on it.”

Techniques may include urge surfing, mindfulness, acceptance and cognitive defusion.

Instead of thinking:

“I need to pull this hair.”

we might practise:

“I’m noticing that I’m having the thought that I need to pull this hair.”

That small shift can create psychological space between the urge and the behaviour.

In a randomised clinical trial, Woods and colleagues (2022) found that Acceptance-Enhanced Behaviour Therapy produced significantly greater improvement than psychoeducation and supportive therapy. At the end of treatment, 64% of people receiving the acceptance-enhanced behavioural treatment were classified as clinical responders compared with 38% receiving the comparison treatment.

What about EMDR?

I am often asked whether EMDR can treat trichotillomania.

EMDR can be an excellent treatment for trauma and PTSD, but it is not currently regarded as the primary evidence-based treatment for trichotillomania itself.

That does not mean it is never appropriate.

If hair pulling began following a traumatic experience, or if trauma memories and associated emotional states clearly trigger episodes of pulling, EMDR may be useful in treating the underlying trauma while Habit Reversal Training or another behavioural intervention is used to treat the hair pulling itself.

In simple terms:

EMDR may treat the trauma trigger. HRT treats the hair-pulling behaviour.

The distinction is important.

Emotional regulation matters too

For some people, hair pulling is strongly connected with difficult emotions.

Where this is the case, I may incorporate emotional-regulation strategies drawn from CBT, ACT, mindfulness or Dialectical Behaviour Therapy, or DBT.

Research into DBT-enhanced CBT has also shown promising reductions in both hair-pulling severity and difficulties with emotional regulation (Keuthen et al., 2012, 2015).

For example, rather than:

Stress → urge → pulling

we might work towards:

Stress → notice urge → pause → competing response → regulate emotion → return to activity

Treatment is therefore rarely about one technique.

Good therapy asks:

What is maintaining this behaviour for this particular person?

That formulation then guides treatment.

There is a way forward

Perhaps the most important message is that trichotillomania should not be reduced to “bad behaviour”, vanity or poor self-control.

Hair pulling can become a powerful learned cycle involving sensations, emotions, thoughts, environmental cues and relief.

For people with ADHD, we may also need to consider impulsivity, sensory needs, stimulation, attention and self-regulation.

And learned cycles can be changed.

For most people, I would begin with a CBT-based behavioural approach incorporating Habit Reversal Training and stimulus control, potentially strengthened by ComB and ACT.

Where ADHD is present, these approaches can be adapted to work with the person’s attention, executive functioning and sensory profile rather than expecting them simply to “try harder” to resist an urge.

Where emotional regulation or trauma plays an important role, treatment can then be extended to address those needs.

One hair-pulling episode does not mean somebody has failed treatment.

It tells us something about the trigger, the urge and what we need to work on next.

That is information, not failure.

Dr Danielle Baillieu Chartered Counselling Psychologist, London UK Tel: 07903936379 email: dr.danielle@lifechanges4good.com https://www.lifechanges4good.com/category/all-products

References

Carlson, E. J., Malloy, E. J., Brauer, L., Golomb, R. G., Grant, J. E., Mansueto, C. S., & Haaga, D. A. F. (2021). Comprehensive behavioral (ComB) treatment of trichotillomania: A randomized clinical trial. Behavior Therapy, 52(6), 1543–1557. https://doi.org/10.1016/j.beth.2021.05.007

Chesivoir, E. K., Valle, S., & Grant, J. E. (2022). Comorbid trichotillomania and attention-deficit hyperactivity disorder in adults. Comprehensive Psychiatry, 116, 152317. https://doi.org/10.1016/j.comppsych.2022.152317

Fisak, B., Shorb, C., Patel, D., & Ezcurra, V. (2026). The efficacy of psychotherapeutic and pharmacological interventions for trichotillomania: A review and meta-analysis. Journal of Psychiatric Research, 197, 264–274. https://doi.org/10.1016/j.jpsychires.2026.02.029

Greenspun, S. R., Milanes, I., Farhat, L. C., Abdallah, S., Bok, D., Chen, D., Liu, W., Teefe, E., Bloch, M. H., Fernandez, T. V., et al. (2026). A genomic study of trichotillomania and excoriation disorder in families. Translational Psychiatry, 16, 432. https://doi.org/10.1038/s41398-026-04164-6

Keuthen, N. J., Rothbaum, B. O., Fama, J., Altenburger, E., Falkenstein, M. J., Sprich, S. E., Kearns, M., Meunier, S., Jenike, M. A., & Welch, S. S. (2012). DBT-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial. Journal of Behavioral Addictions, 1(3), 106–114.

Woods, D. W., Ely, L. J., Bauer, C. C., Twohig, M. P., Saunders, S. M., Compton, S. N., Espil, F. M., Neal-Barnett, A., Alexander, J. R., Walther, M. R., Cahill, S. P., Deckersbach, T., & Franklin, M. E. (2022). Acceptance-enhanced behavior therapy for trichotillomania in adults: A randomized clinical trial. Behaviour Research and Therapy, 158, 104187. https://doi.org/10.1016/j.brat.2022.104187

Website: lifechanges4good.com | Email: dr.danielle@lifechanges4good.com