The Pull to Pull: What Is Trichotillomania?

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For years, Cheryn Salazar never went anywhere without her makeup. Even in labor, she waddled over to the mirror to make sure her eyebrows were still drawn on. "It was like, ‘Don’t dab my brow, it might take my makeup off,’" she told Racked.

Salazar has trichotillomania, or "trich," which means she compulsively pulls out her hairs one at a time. The disorder is a cousin of nail biting and skin picking, and was added to the psychiatric bible, the DSM, in 1987.

Salazar has lived with this disorder for more than 40 years; now 55, she started pulling at 12. Decades of pulling have damaged her eyelashes and eyebrows, so they don’t grow back anymore.

"It was difficult, years and years living a life trying to hide that I didn’t have any eyelashes," she told Racked. "I felt very crippled and broken, I was hiding all the time."

Decades of working on herself, as well as relationships with a supportive husband and other women with trich, have helped her come into the light about her disorder. She even occasionally goes outside without her makeup on.

But knowing how much self-confidence good makeup can bestow led her to start two companies, The Wig Emporium and Cheryn International, dedicated to selling natural-looking beauty products for people dealing with medical hair loss — especially from trich.

The companies do steady business, mostly through word of mouth and people Googling for solutions to the disorder. Salazar provides dedicated customer service, including consultations with struggling parents and tutorials on eyelash and eyebrow application to teenage girls. Salazar and her husband sell about $280,000 worth of products a year, of which she estimates a third are sold to people with trich.

"It restores normalcy. A lot of times you can’t tell, with the wonderful sophistication of wigs out there," Salazar told Racked. "There’s nothing wrong with wanting to look your best."

One of the Wig Emporium’s loyal customers is Kim Sabedra, a registered nurse in California. She started pulling when she was seven or eight years old; though she hasn’t pulled in years, the hair on the front of her head can’t grow back anymore.

"It made me extremely self-conscious, and not do normal kid stuff like swimming and sports that would show the bald spots," Sabedra told Racked. "[Wearing a wig] gives me such a self-confidence boost, because I got such a cute one. People are always saying, ‘Where do you get your hair cut?’"

Christopher Flessner, the director of the Pediatric Anxiety Research Clinic at Kent State University, mostly sees kids, so his patients generally haven’t had a lifetime to develop an identity around trich — and around how other people respond to hair pullers. But the reactions of others (or their perceived reactions) shape how everyone with trich moves around in the world, even kids.

"It’s pretty common for kids and adults with trichotillomania to miss out on every day stuff that many people might take for granted," Flessner told Racked. "They don’t go on roller coasters or swimming, or do things that involve interacting with people in windy weather or where their hair might get wet."

And according to Flessner, body image issues and trich often go hand-in-hand, especially in the middle school and high school girls who are most often affected by trich. It’s a relatively under-studied condition, but estimates range from 2.5 million to 15 million Americans living with trich. It usually develops in childhood and adolescence, seems to be most prevalent in women, and can be short-lived or last a lifetime.

That’s why Salazar thinks it’s so important that natural-looking replacements be available for all the people dealing with trich. She often does consultations with clients, to discuss the best products and how to apply them — as well as to offer moral support to people who are struggling

"I know what their pain is, and I know what their experience is in school. I know if one person rejects you, the pain of that, and the fear of not ever meeting someone who will love you," Salazar said.

Judith Rapoport, now chief of child psychiatry of the National Institute of Mental Health, was one of the first to write about trich, in her ground-breaking 1989 book on obsessive-compulsive disorder, The Boy Who Couldn’t Stop Washing. She told Racked that she once did an informal survey of wig shops and came away believing that as many as a third of wigs in the U.S. are sold to hair-pullers.

"Talking to these women, all so amazingly alike, gave me the eerie sense that a primitive behavior pattern has come loose," Rapoport wrote of trichotillomaniacs who came to her OCD clinic in The Boy Who Couldn’t Stop Washing. "An innate, atavistic urge to groom, to preen that can’t be suppressed."

Everyone who spoke to Racked about spending time with other people with trich mentioned a feeling of comfort in their similarities. The Trichotillomania Learning Center, which Salazar was a founding member of, is often credited with driving a rise in public awareness of the condition. The Center (now known as the TLC Foundation for BFRBs) hosts conferences and retreats for hair pullers, usually with a pool for people with trich to swim in without shame.

"I see girls at conferences now and they’re so strong and proud. It shows people that we are normal and we can live normal lives," Sabedra told Racked. She met Salazar at a conference five years ago, which is how she first started buying wigs from The Wig Emporium.

Salazar feels the same way about the conferences. "Being around people who have this, you think, oh, I’m normal… There’s usually always a pool, and people are taking their wigs off and swimming and laughing, it’s just a life-changer."

Trich is now considered a separate disorder from OCD, under the umbrella of body-focused repetitive disorders, which include skin picking, hair pulling, and extreme nail-biting. While some medications, including antidepressants, are helpful for some people with trich, for many people the best treatment is cognitive behavioral therapy to replace hair pulling with other behaviors, like playing with fidget toys.

Though several advocacy groups and support networks now exist to help people trying to get a handle on their condition, Salazar didn’t meet another person with trich until she was 30. She met a friend of a friend, Christina Pearson, who lived two doors down, and together they compared the naked spots they spent so much time hiding.

"It’s like meeting your long lost twin," she told Racked. "It was wonderful to be able to cry and have someone understand."

The two started a support group, and Pearson went on to found the Trichotillomania Learning Center. It was after the second annual Center retreat that Salazar decided to develop natural-looking eyelashes for people without them.

"It occurred to me there were no natural looking eyelashes for people that don’t have eyelashes," she told Racked. "And then the doors opened up."

The wig business started a few years later, all of it growing slowly at first. Salazar was busy raising four kids, two of whom themselves have trich. One of her daughters started pulling out her eyelashes at five years old; the other started with her teddy bear’s hair before moving on to her eyelashes.

"We know, just like alcoholics, the predisposition is there," she told Racked. "Believe me, when I didn’t know and hadn’t worked on my own recovery, she starts to pull and I’m thinking — did I cause it?"

Mackensie Freeman, a 17-year-old junior in high school and an active member of the Trichotillomania Learning Center, is a very public face of trich; she’s been interviewed by BuzzFeed, HelloGiggles, and MTV. She’s also been wearing eyebrow makeup everyday since ninth grade.

"It’s something I have to do every day — I can go downstairs and eat breakfast with my family without it, but even if I’m going to the pool, I can’t go out without makeup," she told Racked.

Since hair pulling is a medical condition, baldness from trich is considered medical hair loss. That means places like the National Health Service in the UK subsidize wigs for poor people with trich. And the charity Hair Club for Kids provides wigs for people under 18 with the condition, including Freeman. But it wasn’t a perfect solution.

When the custom wig was ready, her mother wouldn’t even let her pick the wig up. "I think she thought I was too young, or it wouldn’t solve the problem," Freeman told Racked. "But once she saw how much better I felt, she got fully on board."

Salazar says that kind of reaction from moms is pretty common. "I’ve had people go, ‘I don’t want to give it to my child like it’s a crutch,’" she told Racked. "The moms are trying to help, they’re frantic."

Once her mom agreed to let her get it, Freeman wore the wig through sixth and seventh grade, and at first it seemed like a miracle.

"It was amazing, it just made me so much more self-confident. For two weeks, I didn’t pull. But then I started pulling from the wig," Freeman told Racked. She stopped wearing the wig after her hair grew out enough to put it in a bun. She’s experimented with a hairpiece, too, but generally now she just draws on eyebrows and styles her hair to cover the bald spots.

Freeman feels very lucky, because she hasn’t dealt with much bullying. She goes to a small private school, and in sixth grade her guidance counselor explained to everyone in her class what trich was.

But many people with trich do get bullied — sometimes viciously.

"I wouldn’t relive high school for a million dollars," Sabedra told Racked. She wishes she’d had access to wigs in high school, to help protect her from the judgment of other adolescent girls. "I think it would have helped me cover up and feel more confident… When women don’t have hair, that’s a very self conscious thing. It can make you feel like less of a woman."

All of that time spent on maintaining a look can be exhausting.

"In some of the adults I’ve worked with, it feels like a lot of their time is spent managing their appearance so other people don’t know about it," Flessner of Kent State University said. "It’s really unfortunate, because that’s a lot of time spent dealing with something that’s beyond their control."

For people who are ready to give up hair pulling, Flessner often works with them to develop awareness of their habits, since a lot of the time people with trich pull automatically, without realizing it. And when they have the desire to intentionally pull, he gives them skills to redirect the urges.

"Helping with the trichotillomania can help with a lot of other areas, like body image," Flessner, who has studied trich for 15 years, told Racked. Organizations like the TLC Foundation for BFRBs are important, he said, not just because they connect patients, but because they bring clinicians and researchers together to collaborate and share information.

"Until 20 years ago, when the TLC came around, no one really knew what trich was or how to help it," he said.

Kim Sabedra can’t say she’ll never pull again. But she says she stopped because she was ready, and because of all the skills she learned at conferences and from others with the disorder.

"I always have urges, but I don’t pull," she told Racked. Her one wish is that her hair would grow back, since she hasn’t pulled any out in years. But her wigs, which are so good even hair stylists have asked where she gets it cut, are a saving grace.

"Thank God I have wigs," Sabedra told Racked. "If I didn’t have that I’d probably start pulling again."