I lived a placid childhood in an interior suburb of Houston, in a green neighborhood with an annual decorate-your-bicycle parade on the 4th of July. The summers were sweltering hot and spent outside, in backyards, dodging wasps and playing beneath the rain of sprinklers, or inside, drying off in refrigerated air, complaining of boredom. It was a small, talkative world within a large, indifferent city, and along the way I began to pull out my hair.
As I write this, I have two bald spots on the back of my head, just behind my ears. These, my hot spots, have grown and shrunk over the years according to the severity of my pulling. At the moment they are more like streaks; imagine a quarter squashed on a train track and that’s about the size of each. Neither is entirely bald, just sparse with intrepid strands in various stages of wispy or stubbly regrowth. No matter how hard I pull, my hair always comes back fighting.
I began, I think, by pulling out a chunk of my eyelashes. I felt a young panic over the exposure, and so I resolved to stick to my head, where my secret could be kept. More than two decades later, I’ve kept that resolution. In middle school, in a brief but intense pulling spell, I attacked the crown of my head. It wasn’t until I’d pulled a perfect circle around my cowlick that I realized I couldn’t hide the damage. I wore a side part, which helped, and wrapped my hair up into a bun, which helped more, but people noticed, and asked me why. I dreaded this question, as the only sufficient answer was a lie.
Feigning perplexity, as if I’d had nothing to with it, I’d reply, I don’t know, it’s just always been like that! This remains my reply to the only people who ever see, hairstylists. Only recently have I gone to the same stylist twice, because he took my explanation blithely and hasn’t mentioned it since. But I seldom get my hair cut. The moment the stylist clips up half my wet hair is equivalent to the nightmare of being naked in public, only real.
I suspect that people repeatedly accept my implausible answer because they know the real one is unpleasant: I pull out my hair because I have an impulse control disorder called Trichotillomania, or “Trich,” the impulsive desire to pull out one’s own hair. Pluck is a more apt term than pull, however, because this is not careless work. The very tips of my forefingers are calloused from feeling out “bad” hairs, wiry strands with just the right kinky texture. If I pluck these well, without breaking the hair and wasting a good “bad” hair, I’m rewarded with the touchstone of a good pluck, the bulb, the wet sock from which the hair grows, that I drag against my fingertips and occasionally bite. I experience a momentary, but delicious satisfaction, and then I unfetter the hair. Wherever I go, I leave behind hair like a trail of crumbs.
This is no answer for polite conversation. Secret bodily pleasures are often assumed perverse. Even if to diffuse the shame you confess, people raise an eyebrow; they’d rather not know about your eccentric, self-gratifying habits. Such habits suggest anxieties deeper and weirder than the thing itself. To a skinny third-grade girl standing alone before her white wicker vanity mirror, angling a pink compact to see the underside of her scalp, and discovering there a kind of diseased lawn, patches of long dirty blond hair growing alongside islands of barren, tender skin, the message is omniscient and clear: Something is wrong with you.
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The French dermatologist François Henri Hallopeau coined the term "Trichotillomania" in 1889, from the Greek, “Tricho” (hair) and “tillien” (to pull). It wasn’t until 1980 that Trich appeared in the third diagnostic and statistical manual of mental disorders. The near century-long darkness between its identification and its official recognition speaks to the secrecy surrounding hair pulling. Given what we now know, that it’s rarer to pull hair in the extreme than it is to pull hair at all, and that between 2 and 5 percent of the general public does this, one can imagine how many thousands (millions?) of people — women in particular — hid bald spots beneath hats and wigs and handkerchiefs, pulling in silent isolation, and relegated, if only in their minds, to the province of freaks of nature.
Even today, in the current DSM, Trich is listed alongside impulse control disorders that land people in jail: kleptomania, pyromania and pathological gambling. But the similarity between these conditions and Trich is only the mind’s furtive hunt for short-term reward. Trichotillomania is more often categorized, by those who study it, as a body-focused repetitive behavior, or BFRB, a more accurate description given the centrality of grooming to the behavior. All of us, to some extent, practice repetitive grooming habits in nail biting, eyebrow plucking, pimple popping, scab picking. The same holds for any species with covering; primates pull their own fur, and groom one another for mites, dogs and cats lick their fur bald, birds pluck their own feathers. Trichotillomania is a harmless, primal behavior gone awry.
Over the years the hair in my pulling sites has grown coarse from so much pulling, which only makes me want to pull it out more. I’m careful, though. I never pull more than what would prevent me from wearing my hair up, or too much in places immediately noticeable, as I did in middle school, tempting as that spot remains to this day. I’ve marveled at how Trich has stayed with me, often as the measure of my experience: during good times, I’ve come within a breath of having no bald spots, but that’s exactly when I give myself permission to pull again. During times of stress, the hot spots expand, my awareness of the pulling increases. I’ve learned that I trust a man, that we love each other, when I feel comfortable showing him my scalp. I’ve learned I can normalize Trich for myself if I laugh about it.
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Last year, in San Francisco, I attended the Trichotillomania Learning Center’s annual weekend-long conference on hair-pulling and skin-picking disorders. The Trichotillomania Learning Center is the only official resource on Trich, and the muscle behind much of the research into our current understanding. Its founder, Christina Pearson, is the beating heart. One cannot write about Trich without mentioning Pearson, a woman with a full head of undulant fair hair, who gives the sort of rare hugs that make you miss your mom, and for whom Trich is not a devastation. She beat it after pulling for 25 years, despite feeling “fractured at the core of [her] being” for much of that time. When she opened the center in 1991, she didn’t hang up a sign because visitors wouldn’t walk through the door for fear of being seen.
The first question people asked at the conference was are you a picker or a puller? — in low tones, or with casual pep, as if inquiring as to whether you prefer cats or dogs — and it felt both empowering and mortifying to proclaim it: I’m a puller. A man replied to me outright, “I’m a groin puller. The head just doesn’t do it for me.” I nodded, and remarked how fortunate he was, as a man, to have facial hair that he could pluck and shave at will. Why pull from your groin when you have all those nerve-sensitive whiskers on your chin? A lash puller expressed her amazement that I could ever pull from my head. Assembled as we were under the banner of Trich, we did not necessarily understand one another’s pulling preferences.
Out of 488 attendees, most of us were pullers of some kind — scalp, brow, lash, or mix and match — and women, wearing bandannas or scarves, or baring patchy scalps, drawn-on brows, or like myself, betraying no signs. Pre-pubescent girls in baseball caps clutched their mothers’ hands. Teenagers stood in circles twirling the ends of their low ponytails. Pearson was there, and accompanying her was an almost ethereal quality of what healing might mean: that you’ll be like her, radiating faith, assurance, self-love. At the meet and greet, we seemed like fallen birds, gathered to nurse our damage. But the thing is, we’re just a bunch of people who happen to pull out our hair. That we were gathered at all, believing ourselves “fractured,” is essential to understanding the mystery of Trichotillomania.
I use the word "mystery" because it’s hard to write about Trich in absolute terms. It is a condition singular to the individual puller. Some people pull with focus, before mirrors, planning their sessions ahead of time and collecting their hairs as treasures to examine later. Often these were the individuals at the conference without eyebrows or lashes. Others, like myself, are habitual pullers. We pull automatically, while reading or driving, seeking tactile reward in the bad hair and the juicy bulb.
But every puller has his or her own specific ritual. Some people are both focused and habitual pullers. Why people are one or the other, or both, is an open question. Neurological and biological studies into Trich are very much in their infancy. What is known is that Trich can be hereditary, and that women outnumber men 4-to-1 as sufferers, but research has yet to solidify an explanation. It may be that we are genetically more disposed to develop Trich. Recent studies have pointed to male and female hormones at the onset of puberty. What is also known is that women are more likely to network around Trich, which suggests they’re more likely to actually suffer from it. Culturally, baldness is undesirable in both men and women, but a bald man is not regarded as anything more than a bald man. For women, what Trich implies is deeper, more consequential. When I “suffer” from Trich, it’s not while I’m pulling my hair (that I enjoy), it’s when I think about what it means that I do.
Hair pulling is only Trichotillomania when it impairs the individual who pulls, and men have lower, if not fewer, hurdles to jump in living peacefully as Trichsters. Not only in their physical advantages for controlling it, but in our cultural dictates for beauty, which send women mixed messages regarding body hair. Our hair is our sexual currency. We are to rip our labia bare, wax our legs and armpits smooth, tweeze our brows just so, and over our breasts should tumble the locks of Rapunzel. In 2006, sales of women’s depilatory products in the United States totaled $86.9 million (men’s were just $8.6 million), yet we value the hair on our heads as if it determines our worth. A mother in a panel for parents called “Stay Out of My Hair: Parenting Your Child with Trichotillomania,” admitted, in tears, that her greatest fear was that Trich would prevent her daughter from marrying, that she would spend her life alone. Her confession was met with sympathetic feminine sighs.
How one “gets” Trich is anticlimactic considering the potential breadth of the effects. At the conference people described plucking a hair by chance, and finding it pleasurable. Others were shown by someone else who already pulled. Most of the people I spoke to at the conference had no idea why they began. It’s common for kids to begin pulling after getting lice at school.
In my case, my dad asked me to help him groom the hairs in his ears that he couldn’t reach, and I liked the job. There is no necessary causal connection between trauma or abuse and Trichotillomania. So while the genesis is often innocuous, as the results of Trich become visible, hair pulling actually becomes a symptom of its own physical consequences, a form of emotional regulation in response to the stress of having bald spots. The nervous system expresses distress over the knowledge of (and supposed defectiveness of) repetitive pulling, deepens the pattern, and the pattern becomes a need, satisfied only by pulling. Anxiety over pulling exacerbates pulling. Conversely, a puller may have no conscious awareness of stress, especially a habitual puller with no visible baldness, or no bald spots at all. But all pullers, no matter the extent to which they pull, tend to agree on the fact that they get something from Trich — relief, pleasure, comfort. It is both friend and foe.
In a workshop on “energy psychology,” the counselor leading the group asked us to conjure the sensation of plucking out the thickest, best “bad” hair we could imagine, and then to resist the urge to pull. She lowered the blinds and switched off the lights. We closed our eyes. Almost immediately, my attention zeroed in to the left side of my head behind my ear. The spot felt hot, not quiet throbbing, but alive, and desperate to be touched. My thoughts tried to wander, but the hunger to pull leashed them back (in describing this now, the sensation rises, begins to distract).
She then led us through a series of hand and breathing exercises — tapping the temples, crossing the elbows and braiding the fingers, I don’t recall them all —- intended to redirect our focus. The hands play a role here because they are the instrument of the pattern, their motion the means. As we finished the exercise, a young woman began to sob. Soon she was bowled over, clutching her head. The impulse to pull was too intense to bear. I knew, as I’m sure the others did, that plucking a hair at that moment wouldn’t quell what must have felt like a fire in her mind. Plucking every last hair on her head wouldn’t have quelled it either. Why she experienced this attempt at resistance to an extreme, while the rest of us just seemed edgy and frustrated, is specific to her psychology. Part of understanding Trich is recognizing that we have such a limited understanding of it. It is an individual within each individual’s mind. We told her to breath deeply and rub her hands together. She told us she hated herself.
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In my ultimate Trich fantasy, a thick hair grows from deep inside of my ear. I pull on it, and discover it’s rooted in my brain. I grip it, pull it harder, and pluck my brain right out of my ear. In other words, I pluck Trich right out of my brain — the ultimate bulb — right from the source. It’s a form of imaginative self-treatment, and it helps me to think about Trich without actually pulling.
I’ve worn shower caps while reading, kept rubbing stones in my pockets to busy my fingers. Women at the conference confessed to binding their own wrists with tape. If I’m stuck in a pulling cycle, I take a shower to “reset” the sensations on my scalp. Every puller has a personal strategy, but strategies need to be accompanied by therapy for pulling to stop. Therapies taught at the conferences ranged from self-hypnosis to finger crafts. Cognitive behavioral therapy is the established treatment because it helps pullers identify their triggers. These can be thoughts or feelings, internal narratives, habits or activities, or environmental factors. A mirror can be a trigger, or a change in temperature, or tiredness. I told Christina Pearson that during busy, happy times, I forget all about pulling my hair, and she replied that when she’s busy and happy, she’s more attuned to Trich than ever. She never forgets, and because of this, she doesn’t pull.
A 2009 study out of the University of Minnesota found promising results with the over-the-counter supplement N-acetylcysteine (NAC), an amino acid that moderates glutamate, a chemical associated with excitement. This is a shift from prescription drugs targeting serotonin. When I approached my parents about my pulling in high school — I was feeling lethargic and uninspired, and I blamed Trich — they sent me to a psychiatrist, who immediately put me on Prozac. I continued pulling, and after the adolescent novelty of possessing a medical justification for my ennui wore off, I quit the Prozac. The NAC results are encouraging, because they suggest patients may not require strong prescription drugs in order to stop pulling, and that the impulsive need to pull may be related to a nutritional deficiency. However, it’s likely that pills or supplements will still be used in tandem with CBT, not only to identify triggers, but to target the deeper dimensions that so often accompany, and feed, Trich: the unremitting negative self-critique, the shortage of self-worth.
On the last night of the conference, I went down to the hotel jacuzzi to relax. After two days of workshops I was gorged on information, and there was an overall group sense of communion I wasn’t jibing with. Instead of bonding with others over the experience of Trich, my sense of marginalization felt placated by the group ethic. I wanted Trich to return to being a quirk, and go about my familiar, manageable pulling. Which suggested to me two opposing things: that I had come a long way already in accepting myself as a person who plucks her hair, and that I was still buying into the idea that hair pulling is a repellent behavior. In wondering if I was a double misfit for not fitting in with my own cluster of supposed misfits, I was admitting my reluctance to be associated with Trich — the very problem the conference aims to dispel. This is not to say the conference failed, but to indicate how ingrained these ideas are even among adult pullers who intellectually recognize their unfoundedness.
The jacuzzi was already full of noisy teenage girls when I arrived. In my attempt to close my eyes and tune them out, I didn’t notice at first that they all had bald spots, big bald spots, or scattered thin patches, worse than I’ve ever had. (Swimming pools are a shared avoidance among women with severe Trich as wet hair reveals baldness). One girl in a bikini had a significant patch of re-growth at her hairline, six or so inches shorter than the rest of her hair.
I watched them for a while. They talked the way teenage girls do, with upturned lilts. They huddled in a self-aware circle. They giggled. They splashed. They were carefree and happy, conscious of onlookers, but unconcerned with their curiosity. They seemed to wear their exceptional scalps with pride.
Later that night, as I was thinking about their confidence, admiring it, I caught my hand trying to pull. I started recalling high school — if only I’d been that self-assured — caught my hand again. I began to worry about the fact that I was pulling — caught my hand. What’s wrong with you, stop it — up went the hand. I told myself to resist, but my hand resisted more; forcing it down was like tugging on the arm of a stubborn child. In writing this now, I just paused to remember how I felt that night, and what I did to get out of the cycle — suddenly my left arm is off the keyboard and I’m pulling. Why can’t you remember exactly how you felt or what you did? — and I’m trying to pull again.
The need feels like an itch, but an old, familiar one. If I had a nickel for every hair I’ve pulled since the conference, I would take those bright teenage girls to lunch, so they might teach me what they know.