Harry Wong
Dec 2017
Vol 14 No 4

Self-Mutilation: Trichotillomania – Compulsive Hair Pulling

By Lisa Bundrick, LMSW

According to Zila and Kiselica (2001), the definition of self-mutilation is not easy to distinguish “because it has not been widely defined as a syndrome and the accompanying signs and symptoms are not uniformly or systematically recorded.”

Examples of self-mutilation include: scratching, biting, burning or cutting various part of the skin, pulling out hair from any part of the body, head banging, breaking bones, limb amputation, castration, eye enucleation (removal of the eye), the intrusion of wound healing, a restriction of breathing or blood flow to body areas, placing items under the skin or into bodily openings, and hitting oneself (with objects or with other parts of the body). Self-mutilation by cutting or burning is most common.

Individuals may self-mutilate out of frustration, depression or due to a lack of coping skills.  Individuals may also self-mutilate due to a lack of communication skills, to seek attention from others, or as a form of retaliation. Additionally those who self-mutilate are suspected to have a low self-esteem. Some who self-mutilate do so to “punish” one’s self, to make a “statement,” or as a part of a “ritual” (Crowe & Bunclark, 2000; Favazza & Rosenthal, 1990; Favazza & Rosenthal, 1993; Favazza, 1998; Timofeyev, Sharff, Burns, & Outterson, 2002; Zila & Kiselica, 2001).

The purpose of this article is to give the reader insight into a particular form of self-mutilation, Trichotillomania.

According to DSM-IV-TR, Trichotillomania is an impulse control disorder. Trichotillomania symptoms have been linked to the symptoms of Obsessive-Compulsive Disorder (OCD), due to the similarities amongst hair pulling and other compulsive symptoms. The crucial feature of Trichotillomania is the persistent “pulling out of one’s own hair that results in noticeable hair loss” (APA, 2000). Hair can be pulled from any place on the body, but the most common places are the scalp, eyebrows and eyelashes. Often the individual will make an effort to conceal or deny this behavior (APA, 2000; Diefenbach, Reitman, & Williamson, 2000; Favazza, 1998; Friman, Finney, & Christophersen, 1984; Penzel, 2003; Watson & Winter, 2000).

According to the National Mental Health Association (2010), compulsive hair pulling usually begins when an individual is approximately 12-13 years old. However, it can begin at an earlier or later age. The symptoms for Trichotillomania must be present for several months before a diagnosis can be made. Additional symptoms of Trichotillomania include:

  • “An increasing sense of tension immediately before pulling out the hair or when resisting the behavior.
  • Pleasure, gratification, or relief when pulling out the hair.
  • The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (i.e., dermatological condition).
  • The disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2000, p. 677; National Mental Health Association, 2010).

Additionally, some individuals may have the desire to pull hair from other people, pets, dolls and other fibrous materials. There are no definite causes for one to develop Trichotillomania. However, its onset can be linked to stressful events that an individual may experience, like changing schools, puberty or an increase in tension (APA, 2000, Diefenbach, Reitman, & Williamson, 2000; National Mental Health Association, 2010; Penzel, 2002; Walsh & McDougle, 2001).

The following interventions are suggested, once one has received a diagnosis of Trichotillomania:

1. Learn about Trichotillomania. The following webpages may be of use:

2. Identify Triggers to Hair Pulling (Penzel, 2003; Gluhoski, 1995). Help the individual to identify what he/she was doing before pulling hair.

3. Self-monitoring (Diefenbach, Reitman, & Williamson, 2000; Gluhoski, 1995; Friman, Finney, & Christophersen, 1984). The individual should keep track of how he/she felt before, during and after pulling hair, through the use of a journal. This should also include the individual’s “emotional responses to people, situations, or events that induce stress or anxiety or result in problematic behavior” (Reid, 2000, p. 274). The amount of time spent pulling hair and how much hair was pulled should also be recorded. This will help to create awareness about hair pulling.

4. Identify social support networks (Friman, Finney, & Christophersen, 1984). The individual should create a list of those who he/she can turn to for support to help stop pulling hair and to relieve stress.

5. Create a list of beliefs, advantages and disadvantages to hair pulling (Gluhoski, 1995). The individual will explain what his/her beliefs are about hair pulling.

6. Design personalized goals to prevent hair pulling and modify one’s schedules, routines and circumstance that may contribute to hair pulling (Penzel, 2003; Friman, Finney, & Christophersen, 1984).

7. Self-reinforcement (Friman, Finney, & Christophersen, 1984). The individual should create a reward system for his/ herself to not pull hair. This system can be tangible rewards or positive self-statements (Reid, 2000).

8. Learn relaxation techniques (Penzel, 2003; Gluhoski, 1995). Relaxation techniques (progressive relaxation or diaphragmatic breathing) should help the individual relax and resist the urge to pull hair.

9. Schedule an appointment with a psychiatrist or physician to learn about risks and benefits of taking medication. If medication is taken, continue taking it as planned and make sure to remain in contact with psychiatrist or physician.


American Psychiatric Association (2000). (4th ed., rev.) Diagnostic and Statistical Manual of Mental Disorders -IV-TR. Washington DC.

Crowe, Michael and Bunclark, Jane (2000). Repeated self-injury and its management. International Review of Psychiatry. Volume 12, Issue 1. Retrieved August 18, 2003: EBSCO.

Diefenbach Gretchen J., Reitman David and Williamson Donald A. (2000). Trichotillomania: A challenge to research and practice. Clinical Psychology Review. Volume 20, Issue 3, Pages 289-309. Retrieved October 17, 2003: Science Direct

Favazza Aromando R., and Rosenthal Richard J. (1990). Varieties of pathological self-mutilation. Behavioral Neurology. 3, Pages 77-85.

Favazza Aromando R, and Rosenthal, Richard J. (1993). Diagnostic issues in self-mutilation. Hospital and Community Psychiatry. Volume 44, Issue 2, Pages 134-40.

Favazza Aromando R. (1998).The coming of age of self-mutilation. Journal of Nervous and Mental Disease. Volume 186, Number 5, Pages 259-68.

Friman, Patrick C., Finney, Jack W. and Christophersen, Edward R. (1984). Behavioral treatment of Trichotillomania: An evaluative review. Behavior Therapy. 15, Pages, 249-265.

Gluhoski, Vicki L., 1995. A cognitive approach for treating Trichotillomania. Journal of Psychotherapy Practice and Research. 4, Pages 277-285.

National Mental Health Association (2010). Other Mental Illnesses Trichotillomania.  Retrieved March 28, 2010, from World Wide Web:

Penzel, Frederick I. (2002). Trichotillomania: Recognition and Treatment. Retrieved March 28, 2010, from World Wide Web:

Penzel, Frederick I. (2003). Cognitive-Behavioral Treatment of Trichotillomania. [Online]. Retrieved March 28, 2010, from World Wide Web:

Reid, William J.(2000). The Task Planner: An Intervention Resource for Human Service Professionals. Columbia University Press: New York.

Timofeyev, Alexander V., Sharff, Katie, Burns, Nora, and Outterson, Rachel (2002). Self-mutilation. Retrieved October 19, 2003, from World Wide Web:

Walsh, Kelda H., and  McDougle, Christopher J. (2001). Trichotillomania. Presentation, etiology, diagnosis and therapy.  American Journal of Clinical Dermatology. Volume 2, Issue 5.  Retrieved July 1, 2003: EBSCO.

Watson, Sue and Winter, David A. (2000).  What works for whom but shouldn’t and what doesn’t work for whom but should? A case study of two clients with Trichotillomania. European Journal of Psychotherapy, Counseling & Health. Volume 3, Issue 2. Retrieved July 1, 2003: EBSCO.

Zila, Laurie MacAniff and Kiselica, Mark S. (2001). Understanding and counseling self-mutilation in female adolescents and young adults. Journal of Counseling & Development.  Volume 79, Issue 1. Retrieved September 12, 2003. Available: EBSCO.


About the author

Lisa Bundrick has a Master’s Degree in Social Work from the University at Albany, State University of New York, a Bachelor’s Degree in Sociology from Plattsburgh State University of New York and an Associate’s Degree in Liberal Arts from Adirondack Community College. She holds her New York State permanent certification as a School Social Worker for grades K-12 and her license in New York State as a Licensed Master Social Worker (LMSW). Lisa also received a Certificate of Completion in Field Instruction for social work field instructors from the University at Albany, State University of New York.

Her career related experiences in the field of education include working with students and staff in charter and public schools as well as in a community college. As a school social worker, she works with students in individual, small group and classroom settings assisting them in developing skills and knowledge to enable their success in both academic and social settings.

In addition to her counseling experience, she has experience with crisis intervention, developing functional behavior assessments and behavior intervention plans, academic advisement, career planning, and cover letter and resume writing. She has also been the field instructor of an undergraduate and graduate social worker intern assisting them in developing beginning social work skills. She is currently employed as an elementary school social worker in a public school district.

Also by Lisa Bundrick:




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This entry was posted on Saturday, May 1st, 2010 and is filed under *ISSUES, Lisa Bundrick, May 2010. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.
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