H2O Under the Bridge: A Case of Trichotillomania

H2O Under the Bridge: A Case of Trichotillomania

by Elias Aboujaoude
Dr. Aboujaode provides an engaging and informative account of hair-pulling, in this exclusive excerpt from his book, Compulsive Acts: A Psychiatrist's Tales of Ritual and Obsession.


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The Concerned Hairdresser

As a psychiatrist, I am used to receiving referrals from internists and primary care providers, from other psychiatrists or specialists seeking a "second opinion," and of course, from concerned family members who sometimes have to force loved ones into my office for an evaluation against their will. But imagine my surprise at receiving a consultation request one morning from a worried...hairdresser!
"Dr. A., I'm so glad I caught you," a soft, earnest voice said. "This is Sebastian from Sebastian's Guild Salon in San Francisco."
"Do I know you?" I asked.
"No, we've never met before," Sebastian said, "but I understand you specialize in trichotillomania."
Sebastian's precise and deliberate pronunciation of the difficult word indicated perhaps a more than casual level of familiarity with the disease. "Have you been diagnosed with trichotillomania?" I asked.
"God, no!" he exclaimed, "unless you consider baldness a natural form of trichotillomania..."
"No, baldness is quite different," I said, appreciating the caller's attempt at levity.
Then, injecting a good dose of drama into every superlative, Sebastian added, "Well, if I still had my hair, the very last thing I would do is compulsively pull it out! I simply love and respect hair too much...This is not about me, Doctor, but about my dearest friend—who is also a top client of mine. She has the worst case of trichotillomania you have ever seen. I've worked with her for almost ten years now, but as creative as I am with hair—and I'm pretty good at what I do!—I've finally run out of tricks to cover up her bald spots. They're bigger than ever now, and I have less of her hair to work with, so I am officially giving up and asking for your intervention."
"Why doesn't she come in for a consultation?" I asked.
"She won't come in alone," Sebastian answered. "She needs me for moral support, she says, even though she might change her mind if she spoke to you. You seem very nice and, umm, quite friendly for a shrink. Forgive my prejudice, Doctor, but I've had some awful experiences with your profession in my day. This is not about me, so I won't go into how I was restrained against my will and given medications intramuscularly—intramuscularly!—or how I was court-ordered to get shock therapy—shock therapy! But, thankfully, all that is behind me now. H2O under the bridge...So, going back to my friend Pat, I really do think you would find me quite helpful if I came in with her. I don't know if you know this, but hairdressers are their clients' confidants, and I can give you quite a bit of important information about Pat that she may have forgotten—or that she may not even know about herself!"
Although quite worried about what I was agreeing to, and about the considerable additional baggage Sebastian was sure to add to the mix, I could not create obstacles to Pat's first visit when she seemed to be in such great need of help. "If Pat is OK with your accompanying her, I am OK with it, too," I said. "Let's all meet and go from there."
"Sounds good," Sebastian said. Then, taking on an even more theatrical air, he added, "I do have one last question, Doctor. It's for my own personal peace of mind, really. Do you think I've been enabling Pat's behavior all these years by doing such a good job covering up her bald spots? I'm so very guilt-ridden by that thought! It just breaks my heart to think I may have been part of the problem instead of being part of the solution. To think that, for years, I jokingly called her Loulou, even giving her a parrot for Christmas one year, instead of pushing her into treatment, causes me intractable insomnia. Please, Doctor, tell me that I have not contributed to my best friend's devastating problem..."
Sebastian was referring to Loulou, the world's best example of trichotillomania across species, a parrot from a French novella by Flaubert with "his front blue, and his throat golden," who displayed a "tiresome mania" of compulsively plucking his own feathers. As delivered by Sebastian, however, this obscure literary reference came across as more show-offish than cultured. His penchant for high drama, combined with his feeling of victimization by psychiatry, made for an intriguing but potentially combustible personality mix that left me both very curious and very nervous. Despite reminding myself that I would not be his doctor, I was already concerned about what role Sebastian would play in his best friend's treatment.
"I believe you wanted to help Pat the best way you knew," I said, trying to reassure him. "It's not unusual for patients with trichotillomania to go for many years before seeking professional help, and most of them don't have talented hairdressers helping them out! I doubt that Pat would have come to see me much sooner if you had not been involved all these years, though I cannot say that with complete certainty. I'm glad, however, that you have now decided to help her get psychiatric care. It's absolutely the right thing to do."

Trichotillomania: An Impulse Control Disorder

Literature beat medicine to a description of what would eventually be called trichotillomania when Flaubert's novella A Simple Heart, featuring the parrot Loulou, came out in 1876. It was later, in 1889, that Flaubert's compatriot, Dr. François Henri Hallopeau, a French dermatologist, coined a new term, trichotillomania, by combining the Greek roots for hair (thrix), pulling out (tillein), and madness (mania). More than a century later, dermatologists still see people with trichotillomania more than psychiatrists do, despite the psychological basis for the disorder and the absence of any dermatological interventions that can stop the behavior. (Dermatologists can, however, be very helpful in treating the damage that results from trichotillomania, such as skin irritation and infection of hair follicles.)
Although the usual course of trichotillomania has been well described, much is still unknown about its causes and treatments. It is estimated to affect around 1 percent of the population, with women being more at risk, although women may also be more likely to be included in the statistics because of a greater willingness to seek treatment, whether from a psychiatrist or a dermatologist.
Diagnostic Criteria for Trichotillomania:
A. Recurrent pulling out of one's hair, resulting in hair loss.
B. Increased tension immediately before pulling or when trying to resist the urge to pull.
C. Pleasure or relief while pulling and immediately following.
D. The pulling is not better explained by a skin condition or other medical or psychiatric illness.
E. The pulling causes significant distress or disability.
The overwhelming anxiety people feel before the behavior and the relief that comes with the behavior are shared by other impulse control disorders as well, including kleptomania, pathological gambling disorder, and compulsive sexuality (although the last is not formally included in the DSM-IV). In all these conditions, the pathological behavior varies, but a thrilling sensation is present, which distinguishes them from OCD, where the patient rarely derives any pleasure from the compulsion. So, whether it is the hair pulling in trichotillomania, the shoplifting in kleptomania, the betting in pathological gambling, or the repetitive cruising for sex in compulsive sexuality, these behaviors are experienced as pleasurable, although the patient is also guilt-ridden and tortured by them and is usually well aware of their negative consequences and the long-term damage they cause.
The pleasurable aspect of impulse control disorders can make them more difficult to treat than OCD, because patients are being asked to relinquish an action that, although problematic, is also enjoyable on some level. Another consequence is that patients miss these behaviors and the thrill that accompanies them when they cut back, and they may feel restless and irritable as a result. This withdrawal-like state has been likened to the physiological withdrawal from addictive substances like alcohol and is, in part, why impulse control disorders have also been referred to as behavioral addictions. In fact, Laurie, a forty-year-old nurse I treat for trichotillomania, describes the struggle to resist her pulling urges as "getting the shakes" and compares this state to what her husband, a recovering alcoholic, felt when he abruptly stopped drinking.
Another feature that distinguishes impulse control disorders from OCD is that the behaviors seen in impulse control disorders are often acted out without awareness, almost unconsciously. Laurie, for instance, would often tell me, "I didn't catch myself pulling until it was too late," or, "By the time I realized I was doing it, I had a bald spot already." Similarly, patients with impulse control disorders like kleptomania, pathological gambling disorder, or compulsive sexuality can feel so disconnected from reality and so out of touch with the risks they are running that they can momentarily justify the stealing, betting, or promiscuous behavior, minimizing what is at stake. In contrast, patients with OCD are usually very conscious of their behaviors and often keep detailed mental or written lists of the compulsions performed and the time spent performing them.
Yet similarities with OCD do exist, leading some experts to refer to impulse control disorders as obsessive-compulsive spectrum conditions. The spectrum concept has been championed by Dr. Eric Hollander, a psychiatrist and researcher at Mt. Sinai Medical Center in New York, who has detailed important parallels among these disorders. For instance, in both OCD and impulse control disorders, people experience bothersome, intrusive thoughts. In someone with OCD, the intrusive thought may be an irrational contamination fear after shaking hands with a stranger. In someone with trichotillomania, the intrusive thought may focus on how one particular hair feels different in the way it touches the forehead. Further, the intrusive thought in both OCD and impulse control disorders is usually associated with an irresistible behavior the person feels compelled to perform, such as hand-washing in OCD or hair-pulling in trichotillomania. This behavior, whether it involves ten minutes of hand-washing in OCD or pulling out a particular hair that feels different in trichotillomania, is often repetitive, stereotyped, and acted out in rigid patterns.

The First Session

Sebastian entered my office first: a lean forty-something man with deep-set black eyes, wearing a tight-fitting black pinstriped suit, the stripes only a slightly lighter shade of black. A third shade of black, in the form of a partially unbuttoned silk dress shirt, completed the outfit. His glistening, totally bald scalp competed for attention with a shiny silver chain around his neck and heavy rings on his fingers.
Pat followed just behind. As I reflexively do when I am expecting a patient with trichotillomania, I focused on her hair first. My initial impression was that it looked artificially perfect. The immobile, meticulously arranged fringe in front and the impossibly symmetric outward flips on the sides clearly indicated that Pat was wearing a wig. As she shook my hand, I could feel the sweat and tremor in hers.
"I'm glad Sebastian called to make this appointment," she said. "I know it's overdue."
"I'm glad he did, too," I said. "I understand from my brief phone conversation with Sebastian that you have been suffering from trichotillomania for a long time."
"She has," Sebastian interjected. "Where do you want me to start?"
"Maybe we can have Pat start," I suggested.
"He knows me so well," Pat said, "and it's embarrassing for me to talk about this."
"Trichotillomania is probably more common than you think," I said, "and you're in the right place now to do something about it. We can take a break later if this becomes too much for you, but can you tell me how this problem began and how bad it has been lately?"
A long, heavy silence followed, interrupted by Sebastian's muddled outbursts as he tried to control his urge to speak on behalf of his friend. He distracted himself by rotating his rings and moving his swivel chair in semicircles.
"It would be easier for me to just take my wig off," Pat finally said, turning toward Sebastian as if to invite his help. "What you will see is worth a thousand words."
Before I could object to what seemed like an extreme gesture happening too early in our meeting, Sebastian sprang up and positioned himself behind Pat's chair, the speed and energy of the jump causing his chair to complete a full turn on its axis. Then, deftly working his palms underneath Pat's artificial locks, he squeezed both index fingers between scalp and wig, slightly loosening the wig before dramatically and quickly lifting it. Pat closed her eyes, as if she was too ashamed to face me. My eyes, too, briefly closed. I felt like I was somehow violating Pat without meaning to. Before I could establish any rapport with her, before I could offer any meaningful reassurance, an embarrassing problem that she had steadfastly kept from medical professionals for years was now abruptly revealed before the clinical gaze of a complete stranger. Something about the way it had happened felt violent, and for a sad moment, I wished I could roll back the less than five minutes of our meeting and have another chance at my first interview with Pat. But of course there can only be one first interview, and despite my regrets about the course of events, I had to make an assessment of the problem that was now being presented for my evaluation.
The natural light brown hair that Pat's wig had concealed appeared brittle and uneven. It was pulled up and collected in an anemic bun on the vertex of her head. Three one-inch bald spots on the sides were visible through the thin strands that snaked their way back from her forehead. These spots appeared red, indicating inflammation from repetitive damage to the scalp. In part to cover up the bald spots, in part to cover up the redness from inflammation, brown makeup the color of her hair had been applied to the bald areas, complicating the patchwork of color and texture. "See? That is all the hair I have left to work with," Sebastian said, as he regretfully shook his head, sounding unusually subdued and hardly desensitized to the sight. He then released Pat's bun very gently by pulling out the single needle-thin clip holding it, taking the utmost care not to lose one more precious hair in the process. Pat's natural strands fell down, showing a variety of lengths resulting from recurrent bouts of plucking.
"I have these creams I use," Pat said, opening her eyes to locate in her purse two tubes of steroid-based lotion. "My dermatologist prescribed them for me."
"Do they help?" I asked.
"Not really," Sebastian quickly answered. "And neither do all the hypoallergenic products I've prescribed," he added, stressing the "I." "We have a basket in my salon that my helpers jokingly call 'Pat's basket.' It contains a complete line of fragrance-free, dye-free, and paraben-free pomades, shampoos, and conditioners. Very expensive designer products that only our Pat gets to use."
"And what are parabens?" I asked.
"You haven't heard of parabens?" Sebastian retorted, shocked at my ignorance of a seemingly very important toxin. "It's a poison in the estrogen family," he explained. "It's been shown to cause breast cancer. It's usually found in underarm deodorants, but many commercial hair products also have it."
"I'm not familiar with the research on parabens," I said, "but I'm not surprised that all these measures have not helped Pat. They rarely do in trichotillomania, unfortunately."
"So should I stop using these creams, then?" Pat asked, pointing to the tubes in her hands. "I'm not fond of using steroids on my scalp, anyway. I heard they can cause hair loss. Just what I need!"
"Low-strength steroid creams that you apply to the skin should not cause hair loss," I said, trying to reassure her. "Dermatological interventions like these can help with the inflammation and infection that pulling can cause, but they do not deal with the fundamental cause of the problem. They address the consequences of the pulling but not the pulling itself. That is why a psychiatric approach has a much better chance of success."
"'A psychiatric approach?' I don't like the sound of that!" Pat said, looking at Sebastian as though to enlist his sympathy by reminding him of the scars the "psychiatric approach" seemed to have left him with.
"I do," was Sebastian's quick answer, delivered forcefully as he stroked the wig he had placed on his lap. "We've been in denial about this for much too long, Pat."
"How long, Pat?" I asked. "How long have you had this problem?"
Pat paused a bit as though still pondering the benefits of a psychiatric approach, then answered, "I guess it started when I was fourteen or so. Back then, I would just twirl my hair. Innocent enough, right? But then I somehow discovered the joy of pulling, and I haven't been able to stop since."

"The joy of pulling?" I repeated after her, intrigued by her choice of words.
"Yes, pulling, for me, actually feels good," Pat answered. "It calms my nerves."
"She's even used the word orgasmic once—jokingly, of course—to describe the sensation," Sebastian ventured, lowering his voice and looking away from his friend as he pronounced "orgasmic."
"Sebastian!" Pat yelled, reprimanding him for crossing a boundary she clearly did not want crossed.
"Sorry, sweetheart," Sebastian said, sounding genuinely apologetic as he reached over to squeeze Pat's hand. "We have to be completely honest with the doctor if he is to help us."
"It's an anxiety-relieving behavior, Pat," I explained, "so it doesn't surprise me that you experience it as pleasurable—most people with trichotillomania do. That is one reason trichotillomania can sometimes be challenging to treat. I will be asking you to stop a behavior that, at some level, you find soothing." Then, after a brief pause, I added, "But saying you find the behavior soothing is simplistic, of course. Even though the behavior itself feels good, you obviously don't like the consequences, and you don't like the fact that you have the disease. You wouldn't be here if you did."
"I can absolutely, unequivocally, and without reservations, tell you that I hate the fact that I have bald spots!" echoed Pat, nodding in agreement as she squeezed Sebastian's hand more tightly.

The Pleasures and Perils of Pulling

The largest study to look at characteristics of people with trichotillomania shows an average age of thirteen for the start of hair pulling. Most people with trichotillomania find special qualities in the hairs they pull, preferring coarse, curly, or thick hairs, or hairs that they feel touch their skin in an uncomfortable way. Further, most can identify high-risk situations that are more likely to trigger pulling, such as driving, talking on the phone, reading in bed, or watching television. Finally, the severity of the behavior often correlates with the person's overall level of stress.
Although many people with trichotillomania pull hair from their scalps, pulling also commonly targets the eyebrows and eyelashes, as well as facial and pubic hair. In fact, the natural tendency for the disorder is to migrate over time, so that a person who started pulling hair from one site may, for reasons that are unclear but do not include running out of hair in the first site, switch to pulling from another location.
The resulting bald spots cause great embarrassment and guilt for the victim, who will often go to great lengths to hide them. Commonly used cover-up strategies include creative hair styling, wigs, excessive makeup, hats, bandanas, and false eyelashes and eyebrows. The disfigurement can lead to avoidance of social situations, dating, sexual relationships, activities like swimming and other sports, and even exposure to windy places.

Despite the Threat of Surgery

For our second appointment, Pat arrived alone, wearing the same wig she wore to our first meeting but with a brace around her neck.

"What happened to your neck?" I asked.

"It's acting up again," she said. "My right arm is so numb and tingly I can't get anything done. It happens every so often, usually when my pulling is out of control."

"What's the association between pulling your hair and numbness and tingling in your arm?" I inquired.

"Well, there's this area at the upper left side of the back of my neck, right about here, that I enjoy pulling from for some reason," Pat explained, slipping her right index finger under the brace to demonstrate the location and grimacing with pain as she did. "The problem is that this part of my neck is not easy to reach with my right hand, which is the hand I use for pulling. Well, imagine spending two to three hours a day, your right arm wrapped behind your neck, and your neck bent forward, as you focus on finding more hairs to pull. Now imagine doing this for years... Talk about repetitive motion injury! I have a bulging disc in my spine as a result, and it's causing pain to radiate down my right arm. The brace is to immobilize my neck so I can avoid surgery."

"And does the brace help with the pain?" I asked.

"Yes, it does, as long as I wear it," Pat answered.

"Does it help in other ways, too?" I asked. "Does it reduce pulling as well by preventing access to your favorite pulling spot?"

"Well, yes," Pat answered, "but that's one reason I take it off when I should be wearing it. When the urge to pull is too strong to ignore, I simply take the brace off."

"Despite the pain?" I asked.

"Despite the pain."

"Despite the threat of neck surgery?"

"Despite the threat of neck surgery. Isn't that crazy?"

Dating Stress

"Tell me, Pat," I said at our next meeting, "these urges to pull that you describe: what makes them better, and what make them worse?"

"Well, they certainly get worse around stress," Pat replied, "especially dating stress. I'm an attractive—except for my hair—and successful mortgage broker, forty-two, still single, and with no prospects for intimacy as long as I have this problem. The thought of finding myself in an intimate situation that might expose my problem is enough to send me into a panicked frenzy."

"So the bald spots prevent you from dating because they're too embarrassing, and when you do find the courage to date, the stress around that leads you to pull even more," I recapped.

"Exactly," Pat concurred. "It's a vicious circle, and I'm caught in the center of it! I haven't gone out on more than two dates with the same guy for a very long time. The likelihood of some form of intimacy taking place on the third date if things go well is too scary to contemplate...What if he crosses the four-foot normal social distance and gets into my personal space? What if he approaches me in bright light for a kiss and spots the thick brown foundation covering parts of my scalp? What if he runs his fingers through my hair? What if? What if? What if?"

"That is really tragic, Pat," I said. "The idea that even with men you do like, you have to resist seeing them a third time and feel forced to end things prematurely..."

"Absolutely," Pat said. "I always sabotage things to turn the guy off and avoid seeing him again. Like this last guy Sebastian introduced me to, who turned out exactly as Sebastian had described: a handsome, gentle, successful Realtor—a nice Jewish boy, really. And did I say handsome? Well, it came up on our second date that his sister had OCD and, as kids, she would spend three hours in the shower every day while he waited patiently for his turn, and as a result, he now won't allow any of his clients to buy a house with less than two bathrooms...Well, instead of empathizing with his childhood experience or using it as an invitation to open up about my own personal struggles with rituals, I went on to make fun of his sister's OCD in the most insensitive way imaginable! And I wouldn't shut up! Imagine, half-bald me making fun of his poor sister's showering rituals! Talk about the pot calling the kettle black! Well, needless to say, the third date didn't happen.. . And when Sebastian started asking what went wrong, the best I could come up with was, 'Well why don't you date him if he's so perfect?' I don't have to tell you that I haven't forgiven myself for this fiasco yet..."

"So you were intentionally pretending to be a mean person to turn off a guy you really liked so he would not want to ask you out on a third date," I summarized.

Pat nodded, her eyes welling up. This painful real-life example of the consequences of her illness brought Pat's tragedy home to me. Her tears drew me in. More than at any point in my meetings with her, I was able to get past wig and brace to appreciate the real hurt that lay much deeper than the outside manifestations of her illness, disturbing as those were.

I struggled to show Pat I was caring without losing control over my own reservoir of feelings. My theory has always been that you have to project resilience and empathy, almost simultaneously. Any "breakdown" on my part could be interpreted by Pat as a sign of weakness or inexperience and might lead her to doubt that I possessed the emotional backbone and resolve needed to address her problem.

On the other hand, by closely identifying with Pat and openly and transparently sharing my feelings with her, perhaps to the point of tearing up in her presence, I might be- come more "human" in her eyes, thus enhancing our doctor-patient bond. But is this not what Sebastian and other people close to her attempted to do, without lasting success, and are patients not looking for something different from their doctors? And what about my own mental health? Should I not be protective of that, too? Is there not a limit to how much I can identify with patients' problems before I, too, succumb to depression, negatively affecting my own life and severely impairing my ability to help others? Should I not be more like an oncologist, a cancer specialist who empathically delivers bad news all day but who does not bring these tragedies home and is able to sleep peacefully at night?

My internal debate was interrupted when Pat's growing discomfort with the subject of dating and this sad memory started manifesting itself in pulling urges that she seemed close to acting on right there in my office. I could see her reach under her brace with her right hand to that favorite spot in the left upper back part of her neck. I shook my head in an effort to dissuade her from pulling, a gesture I hoped she would interpret as "Don't do it." I wanted her, instead, to process with me the negative emotions our conversation was bringing up and to discuss other ways to dissipate them.

But before I could say anything, I heard Pat's voice come out, almost pleading.

"Please...just one more," she whispered. Then, withdrawing her hand from underneath the cumbersome brace, Pat reached for a much more conveniently located hair sticking out from the side of her wig. With a deliberate, firm motion, as she held the wig in place with her other hand, Pat pulled one more hair—from her wig. I may be imaging this, but I think I saw Pat's tense facial features immediately relax.


No agreement exists among mental health professionals on the treatment of trichotillomania. In the absence of large clinical studies to provide clear guidelines, treatment usually starts by focusing on what has been called habit reversal. This strategy borrows from cognitive behavioral therapy and includes increasing awareness of the pulling behavior, enhancing motivation to reduce pulling, using a competing response to substitute for pulling, using relaxation techniques to decrease the urge to pull, and changing the internal monologue that justifies pulling.

It is very common for people with trichotillomania to comment that, by the time they "catch" themselves pulling, it is too late and too much damage has already occurred. Increasing self-awareness aims to bring pulling into consciousness. I usually start by identifying with my patient the situations that are likely to trigger pulling. For example, after tracking my patient Laurie's trichotillomania problem over two weeks using a daily pulling log that I asked her to keep, it became apparent that Laurie's worst pulling occurred while driving. With this information, I could tailor an intervention that targeted this high-risk situation. I asked Laurie to keep a pair of gloves in her car to wear whenever she drove. This seemed to reduce her pulling by taking the tactile pleasure out of it.

Competing responses are more socially acceptable, harmless behaviors the person can substitute for pulling. These are usually objects that provide some tactile stimulation, such as a stress ball the person can squeeze when feeling an urge to pull, a rubber band to pull on, or a makeup brush to stroke.

Motivation enhancement helps people with trichotillomania understand and remember why they want to stop pulling. With the therapist's help, the patient develops a list of reasons for stopping. For Laurie, the list initially included feeling more comfortable in social situations, feeling like she did not have to explain herself to anyone, setting a good example for her children, and finding healthier ways to release anxiety. Laurie posted the list on her bathroom mirror to serve as a daily reminder. I kept a copy, too, updating it as needed based on Laurie's progress in therapy.

Changing the internal monologue involves confronting assumptions about pulling that provide justification for continuing the behavior. For example, instead of "I've done so much damage, what difference does it make if I pull one more hair?" the patient is taught to shift her thinking to "Hair pulling is like self-mutilation, and I deserve better than this." Instead of "I'll only pull one hair and stop," the puller is taught to say, "I've never been able to stop at one hair, so I'm not going to test myself."

As with OCD, anxiety can trigger trichotillomania. Relaxation training can diffuse stress, thereby reducing pulling. Helpful self-relaxation techniques include deep, rhythmic breathing, visualization of a pleasant, soothing scene, and progressive muscle relaxation where the person is taught to tighten and then relax each muscle group in sequence from the toes to the scalp. Patients practice these tools in the therapy session and then apply what they've learned in the outside world to reduce pulling when they feel anxious.

Research studies on medications for treating trichotillomania are limited but do suggest that the SSRIs and clomipramine—all serotonin-based drugs well established for OCD—can be helpful. However, for most people, medications should be combined with therapy, as this is likely to give better results than medications alone.

"Treating trichotillomania can be long and difficult," I warned Pat, "but trichotillomania is treatable, and you shouldn't let the effort and time it might take us to control the symptoms discourage you."

"I've never been in treatment before," Pat said, "and I'm as motivated as I can be to get better."

"You told me you were most likely to pull while sitting at your computer at work," I said. "Here, I want you to take this stress ball. Keep it on your desk at all times and try clenching it in your fist when you feel the urge to pull."

I handed Pat a squeeze ball that a drug company rep had given me. I believe he meant it for my personal use—a way for me to handle stress on the job, so I would subliminally associate the relief I got from squeezing the ball with the product he was marketing. It had Paxil emblazoned all over it in phosphorescent blue. The bright colors caught Pat's eye, and she seemed momentarily amused. She gave the Paxil ball a good squeeze and seemed to approve of its consistency. "I feel better already," she joked. Shortly after that, though, her amused look morphed into circumspection. "But the problem is, most of the time I'm not even conscious of pulling," she worried. "How can I reach for my squeeze ball if I'm not aware that I'm pulling in the first place?"

"Excellent point," I replied. "That is why there is a parallel component to this therapy to make you conscious of the behavior itself. It involves having you collect the hairs you pull every day and put them in individual envelopes with the date and number of hairs written on the outside of each envelope. You then bring the sealed envelopes with you to our weekly meetings, and we use them as an objective way to track your progress." Hearing this, Pat's circumspection changed into utter disbelief. And not without some irritation. "Did I hear that right?" she protested, sounding both incredulous and annoyed. "You're asking me to bring a week's worth of hair stuffed in envelopes to your office every week? Is this a joke? Did I forget to mention that sometimes I lick the hairs I pull? Do you still want me to collect them? I'm sorry, but this is a bit on the disgusting side, and I find it hard to believe that people actually do it! I'm afraid your treatment, Doctor, is too embarrassing for this patient."

"I agree that there is an embarrassing aspect to this, Pat," I said. "But some people do it—and with good results, I might add. One way to look at this is to say that we would be using the embarrassment factor to our therapeutic advantage, almost as a motivator. Here's how it works: the fact that you are saving and counting the hairs will make you more aware of the behavior, and the embarrassment of having to produce these hairs in my office every week will discourage you from pulling."

"I still can't believe this," Pat continued, already sounding a bit more resigned and a bit more accepting of the unconventional treatment recommendation. "Can't I just take a pill? Paxil, for instance? I already have their ball! It really would be a lot cleaner..."

"It would, for sure," I agreed. "But in my experience, behavioral therapy is at least as likely to help with trichotillomania as medications are. Plus, it is free of side effects!"

"Unless you consider embarrassment a side effect, that is," Pat quipped.

"I consider embarrassment in this case to be part of the intervention's mechanism of action." I said. "I look forward to seeing you in a week. Just make sure you seal those envelopes!"


One week later, I was interrupted by a page from Dawn my assistant in the middle of a noon talk I was giving to students. I called her right back.

"Pat, our trichotillomania patient, just stopped by," Dawn said. "She says she's sick with a cold—although she sounded perfectly fine to me! Anyway, she said she needed to rest and wouldn't be able to make it for her weekly appointment today. She did drop off some paperwork for you to review, though. She said it was important that I get it to your desk soon."

"Do you know what it's about?" I asked.

"I haven't a clue," Dawn answered, "but it looks very official. Seven nicely sealed envelopes, all dated and numbered, although the numbers don't seem to follow any sequence. Insurance company correspondence would be my best guess."

"I think I know what this is about," I said, feeling a bit guilty at having Dawn unknowingly handle a patient's hair—especially hair that might have been licked! At the same time, I really did not want to go into a detailed explanation of what Pat and I were up to. This was a hairy Pandora's box best left closed for now. "Just save the mail in her chart until her next visit," I said.

"I can sort through them now if you want," Dawn replied. "Her insurance probably just wants more documentation before they'll authorize more visits. You know how I can sweet-talk insurance companies into almost anything..."

"I know your clout with insurance companies, Dawn," I said, "but no, really, this should wait until Pat's next appointment...Have you had your lunch break yet?"


A week after depositing her first batch of seven envelopes with Dawn, Pat arrived with Sebastian for another appointment. While Pat looked a bit brighter that day, Sebastian seemed preoccupied and less at ease than I remembered from our first meeting.

"The neon writing has rubbed off on my hands," Pat announced at the outset of the session. "I think I need a new squeeze ball!"

"That's a good sign!" I replied. "It means you've been taking full advantage of it. You've been doing the hair-collecting part of the treatment, too; I got your envelopes last week."

"And I have another week's worth for you here," Sebastian added, opening his black leather messenger bag to produce a stack of seven sealed envelopes. He looked numb and somehow mechanical as he handed over the envelopes, with none of the drama I had come to expect from him. Pat looked away. "It was either me coming with Pat today to hand-deliver these to you or Pat mailing them to your office," Sebastian added. "She has a very difficult time bringing the envelopes in, although she is religious about collecting the hairs!"

A quick glance at the numbers written on the envelopes revealed a slow decrease in the hairs pulled, from around 150 some two weeks earlier to about 100 now.

"It looks like you are doing a better job controlling your pulling," I commented.

"I'm more conscious of it," Pat explained, "and that translates into better self-control. Plus, I really don't want to have to bring them here, so when I pull now, it's when the urge is impossible to resist and the squeeze ball fails to make it go away."

"May I interject something here?" Sebastian broke in, looking more animated. "I mean, that is all fine and dandy, but it seems to me like we're missing the point. We're not addressing the root of the problem, if you will excuse the pun. I mean, what is causing this? Why is she pulling in the first place? Why does someone as normal as Pat self-mutilate like this? I can't see how squeezing a ball or collecting saliva-soaked hair can be a long-term solution...A band-aid maybe, but as long as the deeper issues troubling her are not addressed, it seems to me that the problem is likely to come back again."

"Well, what do you think, Pat?" I asked.

"I'm torn," Pat answered. "Part of me says, 'Whatever works, I'll take it,' but another part craves some kind of explanation, some kind of answer."

"I can understand your frustration, Pat," I said, "but—as is the case with so many conditions in psychiatry, and in medicine in general—we are far better at fixing the problem than at telling you exactly why you were the unlucky person who got it. Take diabetes, for example—"

"But this is not diabetes!" Sebastian interrupted, becoming louder and more irritated. "Can't you see? Deep inside, Pat-the-patient hates Pat-the-person, and this is her way of punishing herself. We need your expertise in reversing this, so she can start believing she deserves better. Unless she starts liking herself again, she will never stop this self-mutilation nonsense...When I brought Pat in here, I was hoping you would help us get there. I suppose I could have had her work in my salon, sweeping hairs off the floor and stuffing them in envelopes all day long. I guess that would have fixed the problem, too, but I chose to bring her here instead, hoping for more than that!"

"I could not agree with you more that Pat deserves better than to have to deal with this problem," I said, trying hard to hide my irritation at Sebastian's interference in the treatment Pat and I had agreed on, and which already seemed to be bearing fruit. I felt that a change in treatment approach could sabotage Pat's recovery, now in progress. I also wondered about the role his own history of unsatisfying psychiatric treatment might be playing. "I just do not believe that spending hours in expensive therapy to try to come up with a story that may or may not be true about why Pat pulls her hair will ensure that the behavior goes away," I added.

"And I can't see how stuffing hair in envelopes guarantees anything either," Sebastian snapped back.

Feeling that continued confrontation was unlikely to lead anywhere and hoping to talk with Pat alone at the next visit, I suggested we postpone any decisions regarding the future course of therapy until our next meeting, when we would have more data on Pat's progress. Then, clearly addressing Pat, I said, "My recommendation is for you to continue with the hair-collecting and squeeze-ball tools until I see you back in my office in one week." I then discreetly slipped a brand new phosphorescent stress ball into her bag.

The Absent Patient

There was no sign one week later, however, of Pat-the-patient or Pat-the-person. Not the following week, either—not for two long months after our fateful meeting. Her envelopes, though, kept arriving reliably in the mail; I could count on finding one in my inbox every day, neatly addressed to "Dr. A.," with a stamp from a flower series in the upper right corner and a discreetly written number in the upper left one, where her name and address would have been. Dawn, increasingly pregnant and by now, I'm sure of it, quite aware of the envelopes' content, kept filing them in Pat's ever-expanding chart. "This is one bursting-at-the-seams ex-patient chart that I dare not send to medical records," she sarcastically told me over lunch one day, winking. "It might get us in trouble..."

"Pat is not exactly an ex-patient, Dawn," I corrected. "Not with a piece of mail arriving from her every day...In a strange and unique way, Pat remains a very active patient."

"In a very strange and unique way," Dawn quipped. Then, after a brief pause, she added, "I just can't understand why she hasn't responded to our calls. It's been almost two months already. Maybe I should stop by Sebastian's salon and check on her. I'm thinking of getting a perm before the baby comes anyway."

"Absolutely not, Dawn!" I interrupted. "Perm or not, you are not to have a conversation with Sebastian about our patient. That would be a breach of confidentiality, and I cannot allow it."

"My, my, are we short and testy!" Dawn exclaimed. "Who's the pregnant one here, Dr. A.?"

Besides the obvious ethical concerns around patient privacy issues, one explanation for my irritability with Dawn was my defensiveness around the mention of Sebastian, who, in a sense, had been right to confront me, although he could have done it more tactfully and without the I-could-have-told-her-to-do-that-myself attitude. Like him, doctors—and perhaps especially psychiatrists— want to understand the why behind the symptom and feel some insecurity admitting their ignorance. After all, as doctors, we are not only called upon to fix a problem; we have to try to explain it, too. Only after a satisfactory explanation can patients avoid the triggers that brought on the symptom in the first place and thus feel confident in their recovery and the permanence of the fix.

This powerful drive to explain mental illness has given rise over the years to some fabulously simplistic and often ultimately wrong hypotheses for mental disorders.

This powerful drive to explain mental illness has given rise over the years to some fabulously simplistic and often ultimately wrong hypotheses for mental disorders—from the "schizophrenogenic mom" whose aloof and diffident nature somehow led her child to start hearing voices as a young adult to, more recently, the conceptualization of major depression as simply a disease of "too little serotonin" that is easily treated with medications that raise the levels of this neurotransmitter in the brain. Doctors should feel less threatened answering "I don't know" to questions that push the boundaries of medical knowledge, and patients should not necessarily interpret this "I don't know" to mean "I can't help you."

But even in the midst of my defensiveness around my inability to produce a satisfying cause-and-effect story to explain Pat's pulling, I could not help but notice that the discreetly written numbers in the upper left corner of Pat's daily envelope continued their steady decrease, from around 150 on the envelope at the bottom of the pile to less than 15 as the two-month anniversary of our last meeting approached.

Then, at exactly two months after our last encounter, Dawn paged me with her phone number followed by 9-1-1. I called her right back. "What's the emergency, Dawn?" I asked.

"Dr. A.! Pat is here!" she answered, out of breath. "She wanted to personally drop off an envelope with me, but I told her I wasn't comfortable playing the intermediary for her anymore, and she would have to give it to you in person this time. Should I schedule an appointment for her, or...

"I suppose I can squeeze her in right now," I interrupted, trying to downplay my excitement at seeing Pat again. "Have her come up," I said. "No! Dawn, wait! Is she alone?"

"Yes, she is. Don't worry!" Dawn reassured me. "I'll send her right up."

Barely two minutes later, Pat and I were sitting face-to-face in my office. She exuded an air of both refined elegance and serious business in her white pantsuit with oversized lapel, decorated with a large sunburst brooch whose shiny silver surface echoed the large metal hoop handles of her white leather purse.

It was a mark of undeniable progress that I was struck by other aspects of Pat's appearance before focusing on her hair. Pat was no longer presenting herself as someone who, because of deformity or extreme self-consciousness, was working hard to go unnoticed. That afternoon in my office, Pat had a physical presence, and a self-assured, attractive one at that! As to her hair, it was not lifeless or perfectly symmetric (as in fake), not overly luscious or flowing (as in exaggerated hair product advertisements), and not uneven, brittle, or combed-over (as in "trich hair"). It was pulled back in a neat-looking bun on the vertex of her head, with no random hairs sticking out from the bun or the sides, and no evidence of redness, bald spots, or makeup on the scalp underneath.

"You look very good, Pat!" I exclaimed. "But where have you been?!"

"I have something to give you," she said, avoiding my query into her extended absence.

"OK, but you did not answer my question," I insisted. "It's been two months!"

Before I could press her further, Pat slowly separated the large silver hoops of her bag, then quickly snapped it open to reveal a familiar-looking envelope.

"Please open it," she requested, handing me the envelope. "I'll explain—or try to explain—afterward."

My hesitation and confusion must have been visible as I assessed the envelope, which carried neither the customary flower series stamp nor the number of hairs on it. Just "Dr. A." in large script.

My hesitation and confusion must have been visible as I assessed the envelope, which carried neither the customary flower series stamp nor the number of hairs on it.
"Just open it," Pat insisted. "That's the last thing I will ask you to do for me."

So I did. I opened the white envelope labeled "Dr. A." and found it completely empty inside.

"I'm down to zero!" Pat said, flashing a big smile.

"That's great news, Pat!" I said, my surprise visible. "I'm proud of you."

"I do feel like I owe you an explanation, though," she said. "After our last meeting, I felt like..."

"You don't really owe me an explanation, Pat," I interrupted. "Feel free to explain yourself if you want, but you don't 'owe me an explanation.' I was just worried about you, and I'm thrilled to see that you are doing so much better now."

"I'm doing better for sure," Pat said. "In fact, I can't stay too long! I'm meeting my date in a half-hour."

"You're starting to date again! That's as good a sign as any that things have drastically improved. Is it the same nice Jewish boy you liked so much, by any chance?" I asked, excited that a promising, prematurely aborted relationship might get another chance. "He seemed to really like you, too, as I recall, but you sabotaged the whole thing out of embarrassment that he might find out."

"Who? God, no!" Pat said, letting out a loud laugh. "Didn't you hear? Well, there's no reason why you should have heard..."

"Didn't I hear what, Pat?" I asked, intrigued.

"Well, it turns out he was...Well, he and Sebastian are, umm, together..." Pat said hesitantly. "As like, dating each other," she added. "In fact, Sebastian perceived you as wanting me to pursue my relationship with Neil—that's the guy's name—which I think made him a little jealous. In retrospect, that explains some of his outright hostility toward you last time we all met. I'm very sorry about that, by the way. You didn't deserve it at all!"

"That's OK," I said. "H2O under the bridge, as Sebastian would say. But I must tell you I'm very confused now. Wasn't Sebastian the one who introduced you to Neil in the first place?"

"He did, he did," Pat conceded, "but I'm now convinced that he was using me to test some hypothesis he had about the guy all along. Frankly, I'm confused, too. I could sense Neil was interested in me, but I also know he's seeing Sebastian now. Maybe he's bisexual or something... Anyway, it doesn't take a psychiatrist to guess that I'm a little mad at Sebastian right now. But it's nothing that he and I won't get over in time."

"Well, this is all very fascinating but also very sad, Pat," I said, wanting to give her an opportunity to process her feelings around what had happened. "I know how close you and Sebastian were, and I hope you can salvage your friendship."

But the non-doctor part of me was also simply curious, in a way that was perhaps inappropriate—more gossipy than clinically relevant to my patient. "Tell me more!" I said. "Do you think the two of them are a good match?"

Fortunately, however, Pat would not indulge me. "Well, I could go on and on analyzing this," she said, "but what purpose would it serve besides prolonging the same pointless drama? The fact is, I've moved on, and it's all H2O under the bridge at this point... Plus, you don't want me to be late for my date, now, do you? Thanks for everything, Dr. A. Really, thank you."

With that, Pat stood up, gave me a hug, and disappeared into the labyrinthine hallway of our clinic, sounding a lot more confident in her step and a lot less anxious.

The Psychiatrist's Lot

Yet my happiness at seeing Pat do so much better was somewhat spoiled by the sad suspicion that I would probably never see her again. I would never get the follow-up I was craving about all the new exciting possibilities in her life. I was also left with some cliff-hangers that I would never resolve to my satisfaction. But such is the lot of psychiatrists! Almost necessarily, we lose our patients right at the point when their lives are fullest and most interesting, right when we might want to be more, not less, involved. In wanting to watch our patients successfully navigate life, part of us—our ego—undoubtedly feels some pride for having helped them get there. Happily, however, Pat's problem was fixed, at least for now. Her life had taken off, and my role was officially over. I had to accept the fact that I would never see her again unless we were to meet at some awkward social function or she were to visit me in a disturbing Felliniesque dream.

But what to do with two months of hairy correspondence? Except for the final empty envelope, which I held tightly in my hands and then pinned to the wall in my office, I pushed the rest of the stack toward the edge of my desk, letting it drop off into the trash can. The thud of the falling pile as it hit the bottom caused a feeling in me that, however tinged by a sense of loss and separation, I can still best describe as satisfaction.

Excerpted (with permission) from Compulsive Acts: A Psychiatrist's Tales of Ritual and Obsession by Elias Aboujaoude, MD. Now available in paperback and on sale. For more information and to order, please visit the publisher's website, UC Press, or read reviews and purchase at Amazon.com

Copyright © 2008 University of California Press, Berkeley, CA. Reprinted with permission, November, 2009.
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Elias Aboujaoude Dr. Elias Aboujaoude is a psychiatrist at Stanford University School of Medicine, where he is Director of the Impulse Control Disorders Clinic. His work has been featured in The New York Times, The Wall Street Journal, The Los Angeles Times, on NBC, and elsewhere. His most recent book is Virtually You: The Dangerous Powers of the e-Personality.

CE credits: 2

Learning Objectives:

  • Describe the application of cognitive-behavioral techniques to trichotillomania.
  • Describe some common patient presentations of trichotillomania

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here