Tag Archives: Anxiety


Trichotillomania is a disorder that causes people to pull out the hair from their scalp, eyelashes, eyebrows, pubic area, underarms, beard, chest, legs or other parts of the body resulting in noticeable bald patches.  While for some trichotillomania is mild and can be stopped with extra awareness, for others the urge is strong and makes thinking of anything else almost impossible.  Hair pulling varies greatly in severity, location on the body, and response to treatment. The impulses to pull are so strong.  The body requires a sensation that is satisfied with the hair pulling.

Trichotillomania is a series of complex behaviors, not always easy to understand.  In order to treat trichotillomania, the treatment plan has to meet the complexity of the behavior to meet the complexity of the pulling.  One may wonder, “Why do people have the urge to pull their hair?”  There are several components that contribute to hair pulling including sensory, motor, environment, emotions, and cognitive.

Some people pull their hair because they like the sensation they get from the skin or the scalp.  Some people like the itch or tingle they feel before the pull.   The pull site is not the only sensation individuals feel, as they also have sensations on their fingers.  The physical sensation is not the only sensory fulfillment.  Some individuals enjoy the sound of the snap of their hair the the look of a specific hair that seems out of place from the rest.

Many people find that they pull their hair automatically, without even thinking about it.  These individuals report that their hands have a mind of their own.  Some are aware of the pulling episode, but they can’t seem to stop.  It is very common for people to experience a combination of both awareness and automatic pulling episodes.

For some, there are places or rooms that they are more likely to pull.  For others they will pull anytime, anywhere.  Environments can include rooms in the house, school or workplace, and the car to name a few.  There seems to be something about those environments that trigger the pull.

At one time, people believe that people engaged in hair pulling behavior because they felt anxious.  It is now known that people pull their hair when they feel a variety of emotions, and those emotion.  Some pull when they are bored, depressed, anxious, hungry, frustrated, relaxed, and excited to name a few.  The pull relieves the tension the individual is feeling.

Every day we have a variety of thoughts.  Our thoughts, feelings, and behaviors are all connected.   When pulling, individuals have thoughts before, during, or after an episode.  Hair pulling can lead to frustration, disappointment, humiliation, and shame.  The thoughts related to these feelings play a role in the hair pulling cycle.

Trichotillomania can wax and wane over time.  When working with a trained therapist, individuals with trichotillomania can learn strategies to make it impact their lives less over time.  No two treatment plans are alike for individuals with trichotillomania.  Addressing only one of the components (sensory, motor, environment, emotions, and cognitive) does not help the whole issue.  Individuals need to address the different components simultaneously to meet the complexity of the behavior.

School Refusal

School Refusal may be a child’s response to anxiety over separation from parents, performance anxiety (ie; tests, speeches or presentations), social anxiety, or other situations causing stress at school or at home.

These students show extreme distress about attending school. When your child is refusing to go to school, do not call your child in “sick,” rather let the school know that your child is refusing to attend. When a school is aware that a child is struggling, the school can help intervene and support parents in getting their children to school and support children during their school day.

Some factors that contribute to school refusal or separation anxiety may include the child having difficulty with managing feelings of discomfort, experiencing disappointment, applying conflict resolution skills, and/or communicating needs effectively. When we are anxious or uncomfortable our fight or flight system gets activated by the perception of threat/danger. The perceived fear is greater than the actual threat/danger and everyday occurrences become overwhelming. These behaviors interfere with daily functioning. Maladaptive coping (avoidance) techniques are utilized by the individual, and he/she looks for ways out of the situation, thus he/she does not get to change his/her perception of the situation. Maladaptive coping skills are based on the misappraisal of the threat and the intention is to avoid fear stimulus or the danger it signals. The coping patterns develop as a way to create immediate relief and avoid experience of discomfort. Though these coping patterns provide short term relief, over time the individuals use of avoidance increases, thus making it more difficult for the individual to attend school.

To manage feelings of discomfort, the child should work on distress tolerance. Society has created situations in which every child wins, and with the lack of the “win­lose” in games, kids are not learning to tolerate loss. As a result, children lack crisis survival strategies, have underdeveloped skills to manage feelings such as disappointment, anger, and sadness, and have difficulty applying coping strategies to stressors. When children experience difficulty with emotional regulation, they have difficulty managing emotions, lack self soothing techniques, and have poor impulse control.

Common characteristics or functions of school refusal behavior include: avoidance of negative affect including somatic complaints, depression, and general anxiety; escape from evaluative or social situations including social phobia, OCD, and perfectionism; attention seeking behaviors like separation anxiety or sympathy from family; and a pursuit of tangible reinforcers like video games, internet, and sleep. What might a parent notice with the various functions of school refusal behavior? When a child is avoiding negative affect traits he will exhibit anxiety symptoms, have difficulty advocating for himself, and have an inability to self sooth. Also present are depressive symptoms and low tolerance for managing distress, which commonly presents with a lot of somatic complaints like migraines and stomach aches. If you recognize your child is avoiding negative affect, your response to a child with somatic complaints could be, “Yes, you might be sick, but let’s practice your ways to manage the physical symptoms.” The focus is not on whether or not your child is actually sick, but rather how they can manage those feelings.

When the function of the school refusal is escaping from evaluative or social situations, you will notice your child isolating himself and/or decreasing the number of social activities, as this child will have difficulty managing social situations. Perfectionism and fear of failure occur, and your child will struggle such things as earning a B on a test. In addition, this child will demonstrate absolute or black and white thinking. Furthermore, the child who is escaping evaluative or social situations will perseverate and experience obsessive thoughts.

The child who exhibits attention seeking behavior traits as a function of school refusal is often seeking reassurance from parent(s). Often these children experience separation anxiety. Your role as a parent is not to take on the performance for your child, nor do you need to talk about everything. When you do, then things can get worse for the child. Your response to your child is that they can manage school. The best interventions include structure and routine, clear expectations, altered use of language with the child, and making school attendance not optional. This is a time for purposeful parenting. Purposeful parenting is reactive attachment. We all get emotionally reactive at times, but know that purposeful parenting needs to be the focus. The goal for the child is to be independent, and this is how the parent can help the child be independent and manage. Rather than reassuring your child that everything is going to be ok, it is better to say to your child, “Your day may not be ok, but you can manage it.” The goal is not for your child to be happy, rather to be healthy.

The pursuit of tangible reinforcers is another function of school refusal. Students who exhibit these traits often demonstrate poor sleep patterns; they stay u late and sleep during the day. These individuals have access to privileges without meeting home or schoo expectations. In addition, these students lack motivation to attend school, struggle with limits and resist authority. Furthermore, these individuals possibly abuse substances and or internet/gaming addictions. The parental response is that everything is earned, and everybody in the family has a responsibility. Note, though, that when limits are set, behavior escalates very rapidly because the child may not have had limits or the ability to develop these skills.

Depending on the individual, school refusal may involve significant levels of anxiety and depression that will need to be assessed by a mental health professional who will tailor interventions based on your child’s needs. The goal of therapy is to help the student restructure his thoughts and actions into an adaptive framework to allow for a rapid return to school.