How to Stop Pulling Hair: A Habit Reversal Plan for Trichotillomania

About this tool

How to stop pulling hair is one of the most searched questions about a behavior almost nobody discusses out loud. Repeated pulling that leads to hair loss, that has survived repeated attempts to stop, and that causes distress or interferes with daily life is called trichotillomania, or hair pulling disorder, in the American Psychiatric Association's DSM-5-TR. Grant and Chamberlain's 2016 review in the American Journal of Psychiatry puts community point prevalence at 0.5 to 2.0 percent and notes a large female preponderance in adults, around four to one. Scalp, eyebrows, eyelashes, beard and body hair are all common sites.

Pulling runs in two modes, and the plan differs for each. Focused pulling is deliberate: you go to the mirror or sit down in a particular chair, and there is usually a search involved, for a coarse, wiry or uneven hair that feels wrong between the fingers. Automatic pulling happens while you read, drive, work or watch something, and the first sign of it is often the hair in your lap. Many people do both, in different rooms and at different times, which is why the worksheet below starts with times and places rather than with reasons.

A good deal of what keeps pulling going sits in the ritual around it rather than the pull itself. Rolling the hair between the fingers, inspecting the root, running it across the lips, and in some cases biting or swallowing it are all common, and the relief that follows is part of why the behavior persists. One point here is medical rather than psychological: swallowing hair can, rarely, form a mass in the stomach, which needs a doctor rather than a worksheet. If you swallow hair, say so at your next appointment even if nothing hurts.

Mansueto and colleagues described a comprehensive behavioral model for pulling in 1999, usually shortened to ComB, and it is a useful map. It sorts what maintains the behavior into domains: sensory, meaning the textures your fingers hunt for and the feeling in the scalp; cognitive, the permissions and rules such as just the gray ones or evening it out; affective, the tension, boredom or relief wrapped around an episode; motor, the postures and movements involved; and place, the rooms, chairs, mirrors, lighting and hours where pulling actually happens. Plans that address two or three domains tend to hold better than plans that address willpower.

The behavioral core is habit reversal, introduced by Azrin and Nunn in 1973, and the best controlled evidence for pulling in adults comes from Woods, Wetterneck and Flessner in 2006. Twenty-five adults with trichotillomania completed a trial comparing acceptance and commitment therapy combined with habit reversal against a waiting list. The treated group showed reductions in pulling severity, in impairment and in the number of hairs pulled, along with lower experiential avoidance, anxiety and depressive symptoms, and the gains generally held at a three-month follow-up. With twenty-five completers, that is a pilot-scale controlled test rather than a definitive one.

The honest version of the evidence is that the best supported approach rests on small studies. Lee, Mpavaenda and Fineberg reviewed randomized trials of habit reversal across the obsessive-compulsive related disorders in 2019, found eight in trichotillomania, judged their methods questionable against standard reporting criteria, and concluded that a gap remains in the literature. Relapse after an initial gain is also common and well recognized. On the drug side, no medication has regulatory approval for hair pulling and the trial findings are mixed, which makes it a conversation for a prescriber rather than a self-help decision.

Barriers are the half of the plan that works while your attention is elsewhere. Make the route from hand to hair harder in your worst setting first: a hat, a bandana or a tied-back style during your highest-risk hour, a plaster or tape on the first two fingertips, nails filed short and smooth, thin gloves on the sofa in the evening. Put tweezers away. Control the mirror and the light the same way, since magnification and bright overhead light turn a scalp or a brow into a list of jobs. Give the hands a textured object so the search has somewhere else to go.

The competing response is what fills the moment instead. When you catch a hand moving upward, hold a position that cannot coexist with pulling for about a minute: loose fists resting on your thighs, palms pressed flat together, both hands gripping the arms of the chair, or hands worked slowly through hand cream. The minute is the point. Urges rise, peak and fall rather than climbing forever, and holding still through the peak is how you learn that firsthand instead of taking it on trust. Rehearse the position when no urge is present, so it is available when one is.

Working with urges rather than against them is the part most people have never been taught. An urge is information, not an instruction, and it passes whether or not you act on it; the Urge Surfing Worksheet walks through noticing where it sits, rating it, and watching it drop. Two practical notes. First, expect urges to spike at predictable times, usually alone, tired, in the evening, in front of a mirror. Second, expect them to return after a good week. A plan built on never feeling the urge again fails at the first bad evening.

Regrowth deserves a straight answer. Most hair regrows when pulling stops, and many people see change within weeks to a few months. Long-standing pulling in the same area can damage follicles and leave thinning that does not fully recover, which a dermatologist can assess, and the same appointment can rule out other causes of patchy hair loss worth excluding. Lashes and brows often regrow more slowly than scalp hair and the wait is genuinely frustrating. Judge progress by counted episodes rather than by what the mirror shows, because the mirror lags behind the behavior by weeks.

Two more things are worth knowing. The TLC Foundation for Body-Focused Repetitive Behaviors maintains therapist listings and peer resources for pulling, picking and biting, and naming the behavior to a clinician who knows these terms shortens the search considerably. Ask specifically for habit reversal, the ComB approach, or acceptance and commitment therapy. If pulling, picking and biting all appear, screen for the set rather than one behavior: the BFRB Test (Hair Pulling, Skin Picking, Nail Biting) test covers all three, and the Trichotillomania Test (Hair Pulling) test is the pulling-specific one.

The worksheet below is our own design, informed by the habit reversal, ComB and acceptance-based literature cited here rather than copied from any published or copyrighted instrument, and it is educational rather than treatment. Keep the review concrete: count episodes and, if you can bear it, hairs for one day before you start and one day two weeks later, and note which single barrier interrupted a real episode. Keep that one. A two-item plan that stays in place beats a ten-item plan abandoned after a difficult week.

Reviewed by Michael Callans, MSW
Checked the focused and automatic distinction, the ComB domains and the habit reversal steps against the cited sources, confirmed the trial sizes and prevalence figures are stated as published, and made sure swallowed hair and unexplained hair loss are sent to a clinician.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text revision. American Psychiatric Association Publishing; 2022.
2. Grant JE, Chamberlain SR. Trichotillomania. American Journal of Psychiatry. 2016;173(9):868-874. https://doi.org/10.1176/appi.ajp.2016.15111432
3. Woods DW, Wetterneck CT, Flessner CA. A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behav Res Ther. 2006;44(5):639-656. https://doi.org/10.1016/j.brat.2005.05.006
4. Mansueto CS, Golomb RG, Thomas AM, Stemberger RMT. A comprehensive model for behavioral treatment of trichotillomania. Cognitive and Behavioral Practice. 1999;6(1):23-43.
5. Azrin NH, Nunn RG. Habit-reversal: a method of eliminating nervous habits and tics. Behav Res Ther. 1973;11(4):619-628. https://doi.org/10.1016/0005-7967(73)90119-8
6. Lee MT, Mpavaenda DN, Fineberg NA. Habit reversal therapy in obsessive compulsive related disorders: a systematic review of the evidence and CONSORT evaluation of randomized controlled trials. Frontiers in Behavioral Neuroscience. 2019;13:79. https://doi.org/10.3389/fnbeh.2019.00079

How to Stop Pulling Hair FAQ