Exploring the lived experiences of individuals with trichotillomania: a descriptive phenomenological study

Abstract

Background

Trichotillomania (TTM) is a common psychiatric disorder characterized by a recurrent, irresistible urge to pull out one’s hair. This disorder has widespread adverse physical, psychological, social, and emotional effects on the lives of those affected, yet these experiences are under-documented. This study aimed to explore the lived experiences of individuals with TTM in Iran.

Methods

In this phenomenological study, 12 individuals with TTM (with a mean age of 26.1 ± 6.3 and consisting of seven women and five men) were selected using purposive sampling. Data were collected through in-depth semi-structured interviews and analyzed using Colaizzi’s seven-step method. Lincoln and Guba’s (2004) criteria were used to ensure trustworthiness, and data management was performed using MAXQDA 2020 software.

Results

The experiences of individuals with TTM were categorized into six main themes and 23 sub-themes. The main themes included The Compulsion Loop – Trapped in Repetitive Urges, Emotional Struggles, Identity and Socio-Cultural Pressures, The Body as Battlefield – Physical and Psychological Consequences, Journey Towards Recovery and Barriers to the path of recovery.

Conclusion

Individuals with TTM experience intense internal conflict with wide-ranging psychological and social consequences. They are trapped in this destructive behavior due to the immediate gratification derived from hair pulling and tend to conceal the disorder due to social stigma. While some individuals improve through self-regulation and coping strategies such as cognitive behavioral therapy and habit reversal training, others become trapped in a cycle of failure through self-sabotaging defense mechanisms. Increased public awareness, psychosocial support, and the provision of effective therapeutic interventions, such as cognitive behavioral therapy and habit reversal training, are recommended to facilitate the recovery process for these individuals.

Introduction

Trichotillomania (TTM), also known as hair-pulling disorder, is a psychiatric condition characterized by a recurrent and irresistible urge to pull out one’s hair, leading to noticeable hair loss and psychological distress [1]. It is classified within the obsessive-compulsive disorder (OCD) spectrum [2] and is considered one of the body-focused repetitive behaviors (BFRBs), alongside conditions such as skin picking, nail biting, and lip chewing [3].

In Iran’s cultural and social fabric, TTM is often perceived as a stigma and taboo, which leads to concealment and a reluctance to seek professional help among those affected This socio-cultural context not only deepens the psychological burden of the disorder but also influences how individuals interpret, cope with, and respond to their symptoms, factors that are rarely addressed in existing research [4–7].

TTM typically emerges in early adolescence (ages 10–13), although adult-onset cases are also reported [8]. Thomson et al. reported an odds ratio of 2.23 for females when noticeable hair loss was required for defining hair-pulling behaviors, indicating significantly higher prevalence among women in that context. However, no statistically significant female predominance was observed in DSM-defined trichotillomania (OR = 1.29, p = 0.15), suggesting a more balanced gender distribution in clinically [9]. Despite being underdiagnosed and often overlooked, TTM has a significant global prevalence, estimated to range between 0.6% and 3% [8, 10], with a 2024 study in Turkey finding a 2.3% prevalence rate among students [11].

Clinically, TTM involves more than just hair loss. The scalp is the most commonly affected area (72.8%), followed by eyebrows and eyelashes [12]– [13]. Many individuals describe the behavior as soothing or tension-relieving, often engaging in it privately [14]– [15]. Emotional triggers such as anxiety, boredom, and trauma are frequently reported [16]– [17]. The etiology is considered multifactorial, involving both genetic predispositions and environmental influences [18].

TTM frequently co-occurs with other psychiatric disorders [19–21]. Common comorbidities include anxiety disorders, major depressive disorder, substance abuse, eating disorders, post-traumatic stress disorder, personality disorders, and body dysmorphic disorder [22–24]. A 2020 Australian study revealed that TTM often leads to feelings of shame, social isolation, loneliness, and stigma, hindering social participation and interpersonal interactions [25]. This behavior negatively impacts social relationships and occupational and academic performance [26]. A 2021 study indicated that TTM severity correlates with increased psychological distress, reduced functionality, lower self-esteem, and decreased life satisfaction [27]. A 2021 UK study highlighted serious physical complications arising from TTM, in addition to the psychological effects [28]. Approximately 20% of individuals with TTM ingest the pulled hair, a behavior known as trichophagia [1, 29]. A 2023 US study indicated that patients with TTM often struggle with psychological issues such as depression and anxiety disorders [20]. Although various treatment modalities, including cognitive-behavioral therapy and pharmacotherapy, are available, many patients report poor outcomes and avoid seeking help due to shame and stigma [30–32].

While this body of research has substantially contributed to our clinical and epidemiological understanding of TTM, it has primarily taken a quantitative and symptom-focused approach. Much less is known about the lived experiences of individuals with TTM—how they make sense of the disorder, cope with it in everyday life, and relate it to their personal and cultural identities [1, 2, 29, 31, 33]. A small but growing body of qualitative research has begun to explore these subjective dimensions. For example, Rehm et al. (2015) investigated the internal belief systems of individuals with TTM and found that perfectionism and self-criticism were recurring cognitive themes [34]. Roodt et al. (2021) examined why individuals delay or avoid treatment, highlighting the roles of shame, lack of awareness, and perceived ineffectiveness of interventions [28]. In a different vein, Slikboer et al. (2020) emphasized the significance of peer support and social connectedness in the process of recovery [25].

Despite these valuable insights, a systematic review of the literature reveals a lack of in-depth qualitative studies exploring the lived experiences of individuals with TTM within the Iranian sociocultural context. Given the relatively high prevalence of TTM [8] and its significant impact on various aspects of life—including mental health, social functioning, and academic performance [35] there is a growing need for comprehensive research in this area. Understanding patients’ subjective experiences is essential for developing effective and culturally sensitive therapeutic interventions.

TTM is a complex condition, and the meanings individuals ascribe to it are shaped by their sociocultural environment [36]– [37]. A deeper understanding of these lived experiences can enhance our knowledge of the disorder’s psychological dimensions and inform targeted support strategies [28]. In Iran, social stigma and cultural taboos surrounding TTM often lead to secrecy and reluctance to seek professional help [4–7]. Investigating patients’ thoughts, beliefs, and attitudes can offer crucial insights into their cognitive processes and ultimately improve treatment outcomes [34, 38]. Accordingly, this research aimed to explore the lived experiences of individuals with TTM in the Iranian context through a qualitative lens. To guide this inquiry, the study sought to address the following questions:

1. What are the experiences of individuals with TTM?

2. What does having TTM mean to these individuals?

3. How do individuals with TTM perceive their condition?

Materials and methods

Study design

This descriptive phenomenological qualitative study is rooted in the philosophy of Edmund Husserl. Phenomenology is an approach to finding meaning and essence in individual experiences to facilitate understanding [39]. It aims to explore rich and inherently complex phenomena in depth. In this approach, the researcher strives to achieve a deeper understanding of the phenomenon by setting aside preconceptions and prior experiences [40]. This study follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [41].

Study setting and participant selection

This study was conducted between September 2024 and January 2025 in Sanandaj, the capital of Kurdistan Province, Iran. The participants were individuals diagnosed with TTM. Inclusion criteria included a confirmed diagnosis by a psychiatrist, the ability to communicate effectively, and willingness to provide informed consent. Purposeful sampling was employed to ensure maximum variation in gender, education level, age, and disease severity [42], and continued until data saturation was reached [43].

The first author, a female doctoral student in nursing with no involvement in the care or treatment of the patients, collected data. The researcher visited psychiatric clinics and offices, introduced the study, and invited eligible patients to participate. The voluntary nature of participation was emphasized, and interview times and locations were arranged according to participant preferences. Data were collected through semi-structured, in-depth, face-to-face interviews, with many conducted in participants’ homes. This decision was based on the sensitive and often stigmatized nature of trichotillomania and aimed to protect participants’ privacy while fostering a safe and non-judgmental environment. Conducting interviews in familiar home settings helped reduce participants’ anxiety, enhanced their comfort and sense of security, and encouraged more open, in-depth sharing of their lived experiences. This approach also contributed to the richness and credibility of the qualitative data.

Data collection

Data were collected through semi-structured, in-depth, face-to-face interviews, many of which were conducted in the participants’ residences. This decision was based on the sensitive and often stigmatized nature of trichotillomania and aimed to protect participants’ privacy while fostering a safe and non-judgmental environment. Interviews began with open-ended questions such as: “Please describe your experience with TTM,” “What is your understanding of having TTM?” and “What does having TTM mean to you?” Probing questions like “Please explain further,” “Why?” and “How?” were used to elicit detailed and in-depth responses. Field notes were also taken to record non-verbal observations, the interview setting, and the researcher’s initial impressions. Each interview lasted between 40 and 90 min. Twelve interviews were conducted, with data collection continuing until theoretical saturation. Saturation was reached when no new codes or themes emerged from the ninth interview. However, three additional interviews were conducted for confirmation. All interviews were audio-recorded with participant consent using a digital recorder.

Data analysis

Audio recordings were transcribed verbatim immediately after each interview. Qualitative data analysis was performed using Colaizzi’s seven-step method, a suitable approach for interpreting and deriving meaning from data in phenomenological research [44]. First, to fully understand participant statements and immerse in the data, audio files were listened to repeatedly, transcribed verbatim, and the transcripts reviewed multiple times. Subsequently, 532 significant statements related to the meaning of the phenomenon were identified. Meanings and concepts were extracted from these statements, resulting in 342 codes. The researcher reflexively bracketed their preconceptions. After removing duplicates and merging similar codes, 178 primary codes remained. Similar codes were clustered based on shared meanings to form themes. These themes were described in detail, integrated with the research content, and ultimately categorized into 23 sub-themes and six main themes. A comprehensive description of the investigated phenomenon was formulated into a clear and concise statement. Findings were returned to participants for validation and verification [45]. The research team held regular critical meetings throughout the data analysis process to review and analyze the data. MAXQDA 2020 software was used for data management.

Trustworthiness

To ensure the trustworthiness of the data, Lincoln and Guba’s (1994) four criteria were applied [46]. Furthermore, reflexivity [47] and authenticity [48] were emphasized to enhance the credibility of the findings. Prolonged engagement with participants fostered credibility. Peer feedback and member checking were used to validate codes and categories. For confirmability, interview files, transcripts, and the coding process were shared with two faculty members experienced in qualitative research, who confirmed the coding accuracy. Dependability was addressed by meticulously documenting each step of the research process, enabling readers to critically appraise the study. Transferability was assessed by comparing the experiences of three individuals with TTM (not part of the study) to the study participants’ experiences; they confirmed the findings aligned with their perceptions and interpretations. Reflexivity was a guiding principle throughout the research process. Strategies such as maintaining a research journal, conducting group discussions, and consulting with research colleagues were employed to minimize researcher bias. Authenticity was maintained through the use of direct quotations and rich, context-based descriptions. Furthermore, efforts were made to clearly and accurately reflect participant voices in the data analysis and presentation of findings.

Ethical considerations

This study, approved by the Ethics Committee of Kermanshah University of Medical Sciences (ethics code IR.KUMS.REC.1403.461), adhered to ethical guidelines. Before commencing the study, all participants received a thorough explanation of the research objectives and provided written informed consent. Data confidentiality was emphasized, and pseudonyms were used to protect participant identities. Collected data were stored securely on an encrypted server. Participants were free to withdraw from the study at any stage without consequence.

Results

This study involved 12 individuals diagnosed with TTM, with a mean age of 26.08 ± 6.30 years and an average disease duration of 9.3 ± 4.3 years. Most participants were single (n = 8, 66.0%), of moderate socioeconomic status (n = 8, 66.0%), and female (n = 7, 58.0%). Half the participants also held a bachelor’s degree (n = 6, 50.0%).

Regarding physical health, three participants (25%) reported gastrointestinal issues, one (8.3%) had hypothyroidism, and one (8.3%) had cervical disc disease. Notably, all participants (n = 12, 100.0%) reported varying degrees of skin problems, particularly in the hair-pulling areas. In terms of psychiatric comorbidities, one participant (8.3%) was diagnosed with depression, one (8.3%) with obsessive-compulsive disorder (cleaning subtype), one (8.3%) with attention-deficit/hyperactivity disorder (ADHD), and two (16.6%) with an anxiety disorder (Table 1).

Table 1.

Demographic characteristics of participants

Participant Alias	Gender	Age (Years)	Education	Occupation	Marital Status	Monthly Income	Duration of Disorder (Years)	Primary Hair-Pulling Site	Medical comorbidities	Psychiatric comorbidities
1	Female	23	Bachelor’s Degree	Painter	Single	Average	5	Scalp Hair	-	-
2	Female	28	Master’s Degree	Office Employee	Single	Good	15	Scalp Hair, Eyebrows, Eyelashes	-	depression
3	Male	30	Bachelor’s Degree	Office Employee	Married	Average	14	Beard and Mustache	-	-
4	Female	21	Bachelor’s Degree	Student	Single	Average	6	Scalp Hair, Eyebrows, Eyelashes	-	Anxiety disorder
5	Female	35	High School Diploma	Secretary	Single	Poor	11	Scalp Hair	Hypothyroidism	-
6	Female	26	Bachelor’s Degree	Office Employee	Single	Average	10	Scalp Hair	-	-
7	Male	20	High School Diploma	Unemployed	Single	Poor	7	Scalp Hair, Body Hair, Facial Hair (Beard and Mustache)	Digestive problems	-
8	Female	36	Postgraduate Diploma	Homemaker	Married	Average	8	Scalp Hair, Eyebrows	Cervical disc disease and Digestive problems	Contamination OCD
9	Man	24	Bachelor’s Degree	Teacher	Married	Average	9	Scalp Hair	-	-
10	Male	33	Bachelor’s Degree	Freelancer	Married	Good	17	Scalp Hair, Body Hair	Digestive problems	-
11	Male	19	High School Diploma	Student	Single	Average	8	Scalp Hair, Facial Hair (Beard and Mustache)	-	Attention deficit hyperactivity disorder
12	Female	18	High School Diploma	Apprentice	Single	Average	2	Scalp Hair	-	Anxiety disorder
Mean ± SD§		26.1 ± 6.3					9.3 ± 4.3

The qualitative analysis of the interview data yielded six overarching themes and 23 sub-themes. The main themes comprised: The Compulsion Loop – Trapped in Repetitive Urges, Emotional Struggles, Identity and Socio-Cultural Pressures, The Body as Battlefield – Physical and Psychological Consequences, Journey Toward Recovery, and Barriers to the path of recovery (Table 2).

Table 2.

Themes and sub-themes of the experiences of people with trichotillomania

Themes	sub-themes
The Compulsion Loop – Trapped in Repetitive Urges	Cycle of Self-Injury
	Unconscious Compulsive Cycle
	Captivity in Pleasure
Emotional Struggles	Struggle Between Restoration and Destruction
	Paradox of Pain and Pleasure
	Destructive Perfectionism
	Symbolic Expression and Inner Protest
Identity and Socio-Cultural Pressures	Gender Identity Crisis
	Social Stigma and Discrimination
	Deprivation of Life Opportunities
	Hiding Behind Masks
The Body as Battlefield – Physical and Psychological Consequences	Physical Deterioration
	Immersion in Isolation
	Psychological distress
Journey Toward Recovery	Making Peace with Oneself
	Self-Regulation and Behavioral Reconditioning
	Social and Interpersonal Support Networks
	Recognizing the Depth of the Disorder
Barriers to the path of recovery	Self-Destructive Defenses
	Avoidance of Acceptance and Treatment
	Denial and Neglect of the Disorder
	Entrapment in a Cycle of Failure and Helplessness
	Stressful Experiences and Life Pressures

The compulsion Loop – Trapped in repetitive urges

Participants described the dynamics of a compulsion-reinforcement cycle, characterized by being trapped in repetitive urges to pull hair. This behavior was reported as a form of self-destructive compulsion with profound impacts on daily life. Many participants viewed the urge as a restrictive force that hindered their personal goals, frequently referring to the immediate gratification and emotional relief it provided. However, reliance on this temporary relief paradoxically trapped individuals in a repetitive loop, where momentary comfort reinforced the compulsion and intensified feelings of entrapment and helplessness in resisting the urge.

Cycle of Self-Injury

Several participants revealed being trapped in a self-perpetuating cycle of self-harm. This cycle often began with feelings of inadequacy, failure, and self-blame, which fostered a belief that they deserved pain and suffering. They engaged in hair-pulling to cope with these negative emotions, which provided temporary relief.

“I don’t feel good about myself. I feel weak and powerless and believe I deserve punishment for this weakness. The pain I feel from pulling my hair gives me a fleeting sense of relief, as if I’m accepting my inability to control situations or succeed. But at least I’m punished for it.” (Participant 1).

“I fight with myself and have destroyed my facial beauty and hair with my own hands. I feel deeply ashamed and disgusted with myself.” (Participant 6).

Captivity in pleasure

Participants reported being unable to stop pulling their hair due to the sensations of pleasure, relaxation, increased focus, and reduced tension that the act provides. This dependency has kept them bound to a harmful yet gratifying habit.

“I feel like an addict who enjoys the drug but can’t break free. I pull my hair because of the pleasure and relaxation it gives me.” (Participant 10).

“If I don’t pull my hair, I can’t focus or study properly. That’s why I keep doing it—I want to get into a good university this year.” (Participant 12).

“I pull my hair, tear it into tiny pieces, and even swallow it. I don’t know why, but it gives me a lot of satisfaction. I do it unconsciously most of the time, but I enjoy it.” (Participant 5).

Unconscious compulsive cycle

Participants described an intense, automatic inner drive to pull their hair. They experienced it as a deeply rooted and irresistible internal compulsion that unconsciously overtook them, severely impairing their voluntary control over the behavior. They felt as though they were trapped in a repetitive internal cycle that occurred without conscious intent and stripped them of agency. Many emphasized that stress and anxiety intensified this compulsion and triggered the hair-pulling episodes.

“At first, I thought this issue was temporary and that I could easily control it. But I never imagined how difficult it would be to stop. It seems so simple—you just don’t pull your hair—resisting this internal urge that operates on an unconscious level, and remains imperceptible and incomprehensible to others, presents a formidable challenge. It’s like telling an addict not to use drugs or a person struggling with obesity not to eat.” (Participant 4).

“The thought of pulling my hair consumes me. I feel like I must pull, or something bad will happen. I might resist for an hour or two, but then I get so anxious and restless that I give in and think, ‘Forget it, who cares?’ Afterward, I realize I’ve been pulling my hair for about 15–20 minutes—it’s as if it happened unconsciously, without me even being fully aware.” (Participant 9).

“It’s like being stuck in quicksand. No matter how much I try, I can’t get out. I want to stop this behavior, but it feels like a stronger force inside me is pulling me toward it. This strange urge to pull my hair is driving me insane.” (Participant 3).

While most participants described a strong and unconscious compulsion to pull, the perceived degree of control varied. A few described moments of partial awareness or active attempts to resist, which were often overridden by escalating emotional tension. These subtle differences underscore the complexity of the condition and reflect individual variations in how the compulsion is experienced, managed, and internalized.

Emotional struggles

The findings of this study revealed that participants faced profound emotional struggles, particularly involving the experience of conflicting feelings. They simultaneously reported a paradoxical combination of pain and pleasure associated with the act of hair pulling. Additionally, participants expressed concurrent urges both to destroy and to repair their hair, which entrapped them in a cycle of hair pulling and further damage, driven by a perfectionistic desire for “flawless” hair. Some participants also described hair pulling behavior as a symbolic expression of their internal emotional conflicts and inner protest.

Struggle between restoration and destruction

Many participants found themselves trapped in a distressing contradiction. After pulling their hair, they felt deep regret and tried to repair the damage using treatments such as sprays, supplements, or oils. However, these efforts often proved futile as the repetitive nature of hair-pulling negated any progress. This cyclical behavior reflected a persistent conflict between their desires for destruction and restoration.

“I buy strengthening sprays, expensive shampoos, supplements, oils, and hair serums. Every morning, I care for my hair to make up for the damage, but what’s the point? I take care of it in the morning, and by night, I’ve undone everything.” (Participant 2).

Paradox of pain and pleasure

Participants often spoke of experiencing complex and contradictory emotions. While hair-pulling brought temporary feelings of pleasure, relief, and calm, it was followed by guilt, distress, and deep regret due to the harm caused.

“When I pull my hair, it feels good and brings me calm, but then I feel guilty and very regretful.” (Participant 12).

“At the moment, I don’t think about how harmful it is; I just enjoy pulling and it helps me focus. But when I see the pile of pulled hair, I regret it so much.” (Participant 10).

“Hair-pulling gives me a sense of calm and control, but afterward, I feel even more anxious and upset about what I’ve done.” (Participant 6).

Destructive perfectionism

Some participants engaged in hair-pulling to achieve symmetry, order, or eliminate perceived imperfections. However, they reported that such attempts often led to greater harm without achieving the desired outcomes.

“I feel like my eyebrow is uneven compared to the other one. I start pulling to make them symmetrical, but the more I pull, the worse it gets. Before I know it, half my eyebrow is gone.” (Participant 8).

“I want my hair to be flawless, free from split ends, frizz, or tangles. So, I pull out damaged or frizzy strands, but this only creates more split ends. Even though I know this, I still do it.” (Participant 6).

Symbolic expression and inner protest

For some participants, hair-pulling served as a symbolic way to express their feelings, assert their identity, or protest against unfavorable life conditions. They often viewed it as a coping mechanism and a tool for expressing discontent and resistance.

“My parents never paid attention to what I wanted, and I could never express my objections because they would immediately argue with me or punish me. When I started pulling my hair, they finally realized what they had done to me and were forced to listen to me.” (Participant 7).

“For me, pulling my hair initially became a way to express the pain I experienced in my married life, something I couldn’t talk about. I had no other way to show my suffering but to hurt myself. Pulling my hair gave me a sense of ownership over my body and my hair, at least.” (Participant 5).

Identity and socio-cultural pressures

This theme explores the intricate interplay between individual identity and the cultural, gender, and social expectations that have profoundly influenced participants’ lived experiences. Participants described how these external pressures not only shaped their self-perception but also dictated their social presence and interactions. They further elaborated on the social and cultural pressures exerted upon them.

Gender identity crisis

Hair plays a crucial role in gender identity. In Kurdish culture, a thick mustache symbolizes masculinity and power in men, while long hair is a hallmark of beauty in women. Hair loss on the scalp, eyebrows, or eyelashes damages women’s sense of femininity, while facial hair loss diminishes men’s sense of masculinity and self-image.

“My sparse mustache makes me look like someone with less masculinity. In our tribe, a thick mustache is highly valued as a sign of masculinity and strength. Because of my condition, I have to shave my mustache and beard regularly, which makes me feel like I’ve lost an essential part of my male identity.” (Participant 3).

“It’s true that appearance doesn’t define a person’s identity, but hair is part of a woman’s essence, and I’ve lost that for years. Now, I feel like I can never be a complete woman.” (Participant 2).

“In the past, they used to say a woman’s beauty lies in her hair, and now I have none. For this reason, I believe I can never be considered beautiful.” (Participant 1).

Social stigma and discrimination

Many participants reported experiencing stigmatization and inappropriate labeling. They described being ostracized and subjected to verbal and physical abuse by others.

“My ex-husband called me crazy, announcing it to the whole family. He’d say, ‘This woman is crazy; she pulls out her hair.’” (Participant 5).

“I started pulling my hair after giving birth, and my in-laws tormented me. They said I was insane and told my husband to divorce me, claiming I wasn’t fit to care for my baby and might pull out its hair too.” (Participant 8).

“My friends spread rumors that I had cancer because I didn’t have lashes or eyebrows.” (Participant 11).

Deprivation of life opportunities

Many participants identified TTM as a significant barrier to achieving their professional, social, and emotional goals. They explicitly stated that this disorder has deprived them of a wide range of life opportunities, significantly impacting their quality of life.

“I met a man who was a good person; he genuinely met all my criteria. But I didn’t have the confidence to accept his proposal because I felt that if he found out about my condition, he would leave me, and I would lose my dignity. After all, what kind of man would want a wife with bald patches and wounds on her head?” (Participant 6).

“I got accepted into a top university, but I couldn’t control myself in the dormitory, and the other students made fun of me. So, I had to transfer back to my hometown and study at a less prestigious university because I couldn’t stay in the dormitory.” (Participant 4).

Hiding behind masks

Many participants attempted to conceal their disorder through strategies such as makeup, wigs, hair extensions, false eyelashes, or tattoos. Some women used religious veiling as a means to hide symptoms, leveraging cultural norms to mask their condition.

“I tattooed my eyebrows in a way that looks like natural shading so no one can tell I have this disorder.” (Participant 8).

“I always wear a scarf, even at family gatherings, and tell everyone it’s my belief. But really, it’s my shield. I only pull hair from the back of my head, so no one notices.” (Participant 2).

“I spend a lot of time on makeup to cover the flaws I’ve caused. I use heavy makeup to distract attention from my lashes and eyebrows. Whenever I go out, I wear false eyelashes and fill in the gaps in my eyebrows with a pencil.” (Participant 4).

The body as Battlefield – Physical and psychological consequences

The body functions as a multifaceted battlefield, representing not merely a habit or superficial behavior, but a profound and exhausting internal struggle for individuals with this disorder. With extensive repercussions at physical, psychological, and emotional levels, the disorder compels patients to endure a continuous experience of conflict and turmoil involving their body, mind, and self. In this internal battleground, the body becomes the site of damage inflicted by the behavior, while the individual’s psyche suffers under overwhelming pressures. Negative emotions, diminished sense of self-worth, and deteriorating relationships with oneself and others gradually erode the person’s overall well-being.

Physical deterioration

Participants reported a wide range of physical complications, leaving them feeling physically broken. These included weakened hair follicles, hair loss, baldness, scalp wounds, eyelid inflammation, neck and shoulder muscle pain, teeth grinding, and fingertip injuries.

“These days, I can’t pull my hair as often as I used to. Constantly bending my head and pulling my hair has caused neck disc issues. Now, every time I try to do it, I feel severe pain in my neck and shoulders. It’s as if my body is telling me to stop.” (Participant 8).

“Hair-pulling hasn’t just made me bald and unattractive—it’s ruined my teeth. Strands of hair that got stuck between my teeth caused excessive grinding, and now my teeth are sensitive and damaged.” (Participant 4).

“My scalp is covered with wounds and bald patches. My hair roots have become so weak that even light combing or washing causes large clumps of hair to fall out.” (Participant 12).

“I’ve pulled out my mustache and beard so much that bald patches and scars have formed on my face. The old scars are visible because I keep repeating this behavior, giving my skin no time to heal—it just gets worse over time.” (Participant 3).

Immersion in isolation

Participants expressed a strong preference for social withdrawal. Rather than participating in social activities, they opted for solitude to shield themselves from judgment and criticism.

“I don’t like attending celebrations because I’m ashamed of my short, boyish hair while other women have long, beautiful hair. Seeing them makes me feel envious and embarrassed.” (Participant 6).

“I hate parties and never go because I just sit in a corner like an old woman. I’m too ashamed to show myself, thinking everyone will notice my problem and call me crazy.” (Participant 12).

“I prefer being alone. I hate when people ask why my hair looks like this or try to recommend hair-strengthening products.” (Participant 2).

“I love solitude because it gives me peace. I don’t have to worry about anyone noticing my problem or explaining the bald patches on my head.” (Participant 1).

“I feel lonely even though I live in a crowded house. No one understands me—they constantly judge and blame me for my behavior. That makes me feel deeply alone.” (Participant 11).

Psychological distress

The findings indicate that participants in this study experienced profound and multifaceted psychological distress resulting from hair-pulling behavior. This condition is accompanied not only by persistent negative emotions such as pervasive anxiety, overwhelming worries, and deep sadness but also by intense negative self-perceptions. As a consequence of these distressing experiences, patients frequently reported feelings of isolation and a sense of being different from others, with an internal void and loss profoundly impacting their psychological core. This heavy emotional burden creates a fertile ground for the emergence and persistence of depressive states and significant mood decline, with these feelings recurrently dominating their daily experiences.

“This disorder has robbed me of joy and pleasure in life and has immersed me in a constant feeling of depression and distress. Moreover, the persistent perception of defect and inadequacy compared to other girls intensifies my discomfort and significantly undermines my self-confidence.” (Participant 1).

Hair-pulling severely undermined participants’ self-confidence and self-esteem, leaving them feeling powerless to control their behavior.

“I feel like, as a man, I can’t even control my actions, and this creates an overwhelming sense of humiliation. Whenever I look in the mirror and see my thin, sparse mustache, I feel weak and defeated.” (Participant 3).

“I am a failure who will never succeed because I can’t even stop myself from pulling out my hair—a seemingly simple task.” (Participant 11).

Many participants expressed profound regret and sorrow for their self-harming behavior. They missed their former selves and the healthier lifestyles they led before developing TTM. Persistent guilt and longing for the past were recurring themes.

“I miss myself—the girl who was once known for her long, beautiful hair. I wish I could go to the mountains, let down my hair, and feel the wind pass through it. But now my scalp is full of bald patches, and when the wind touches it, it feels like an open wound with salt being rubbed in.” (Participant 1).

Journey toward recovery

Some participants adopted an active approach toward accepting their condition and working toward recovery. Through self-regulation, effective strategies, strengthening support networks, and engaging with healthcare systems, they managed their behavior and moved closer to overcoming the condition.

Making peace with oneself

Many individuals with TTM sought to improve their quality of life by adopting a more accepting attitude toward their disorder and themselves. By fostering self-compassion and self-acceptance, they worked to cultivate a more positive outlook on their experiences.

“When I accepted that I was sick and needed to seek treatment, everything changed. As long as I denied the illness, I couldn’t recover. But once I accepted my condition and began to understand myself better, I started to love myself again. Instead of blaming myself, I now understand and accept my situation more.” (Participant 2).

“One of my main concerns is reaching the end of this inner struggle and empowering myself to quit this behavior. I would say that making peace with my hair and accepting it as a part of who I am is one of my most important goals in this journey.” )Participant 6(.

Self-Regulation and behavioral reconditioning

Some participants reported employing effective strategies such as behavioral substitution, attention diversion, relaxation techniques, visual stimuli, setting realistic goals, and enhancing personal motivation to manage hair-pulling behavior and improve self-regulation.

“Whenever I feel the urge to pull my hair, I try to distract myself by squeezing a soft ball instead.” (Participant 9).

“I’ve drawn a cross on my hand to remind myself not to pull my hair every time I look at it. I’ve also put motivational stickers around the house and set a childhood picture of myself with long hair as my phone wallpaper to motivate me to continue my treatment.” (Participant 8).

“I’ve identified situations where I feel a strong urge to pull my hair and try to avoid them.” (Participant 1).

“Each time I successfully resist the urge, I give myself points, and when I fail, I subtract points. This system has helped me feel more in control and stay motivated.” (Participant 6).

Social and interpersonal support networks

Many participants emphasized the critical role of extensive social and familial support in effectively managing TTM. They highlighted comprehensive support from loved ones as essential for recovery and progress.

“Both my family and I need counseling because one reason for my hair-pulling is the stress caused by their improper behavior. If they treat me better, I’ll have more control over myself.” (Participant 11).

“My mother played a big role in my recovery. Instead of blaming me, she would sweep my room daily to avoid seeing the hair I had pulled out. She always encouraged me and bought me wigs so I could feel more comfortable in public.” (Participant 2).

Effective treatment systems

Participants underscored the pivotal role of efficient healthcare systems, including anonymous appointment scheduling, appropriate insurance coverage, effective doctor-patient communication, and maintaining the confidentiality of medical records, in facilitating their recovery journey.

“Counseling sessions are long and expensive, and I can’t afford them. I believe insurance should cover these costs, or the government should provide free counseling sessions for those facing financial difficulties.” (Participant 10).

“Having a good and trustworthy psychiatrist is crucial during treatment. Trichotillomania is stigmatized, and you can’t even talk about it with those closest to you.” (Participant 9).

“I attended several sessions with a psychotherapist, who helped me significantly. Together, we identified the thoughts and situations that triggered my hair-pulling and developed strategies to control my behavior effectively.” (Participant 2).

Recognizing the depth of the disorder

Many participants reported a strong motivation to quit hair-pulling after realizing the severe consequences and complications of TTM. Fear of worsening symptoms and deeper entrenchment in the disorder prompted them to seek effective treatment.

“Initially, I didn’t think much of it. I thought it was no big deal, and my hair would grow back. But when I realized I had permanently lost some hair, I was terrified. That’s when I understood this disorder was more serious than I thought and that I needed treatment.” (Participant 11).

“I eat the hair I pull out. Once, I saw on TV that a woman had a massive hairball in her stomach and almost died. Since that day, I’ve been scared and now eat my hair much less than before.” (Participant 5).

Barriers to the path of recovery

A significant portion of participants, despite living with TTM, refrained from acknowledging its pathological nature. As a result, they were reluctant to seek specialized treatment. Complex life circumstances and psychological pressures further exacerbated their challenges, leading them to feel overpowered in their internal struggle and trapped in a vicious cycle of failure and helplessness.

Self-Destructive defenses

Some participants resorted to destructive approaches, such as completely shaving their heads, permanently removing facial hair, or replacing hair-pulling from the scalp with pulling other body hair.

“One day, I decided to solve the problem for good. I thought, ‘If I have no hair, there won’t be a problem.’ So, I shaved my head completely. Unfortunately, I started pulling my eyebrows after that.” (Participant 4).

“Instead of pulling the hair on my mustache and beard, I now pull the hair on my arms more often.” (Participant 10).

“I even visited a faith healer to pray for me and help me quit this habit.” (Participant 5).

Avoidance of acceptance and treatment

Many participants avoided seeking mental health support and pursuing psychological or pharmacological treatments due to fears of social stigma or concerns about medication side effects. Misconceptions about psychiatric care and treatment led to the denial of the need for professional help and the perpetuation of their destructive behavior.

“The medications made me lethargic and sleepy, and I couldn’t keep up with my responsibilities, so I stopped taking them.” (Participant 11).

“I’m not crazy to go to a psychiatrist and take medication!” (Participant 7).

“In my opinion, hair-pulling isn’t a big enough issue to see a psychiatrist. I’m not insane to need one.” (Participant 3).

“I don’t believe in psychiatrists. I’ve never seen them solve any problems. They just prescribe medication and make people drowsy. My brother had depression, and his condition worsened. That’s why I refuse to visit a psychiatrist.” (Participant 10).

Denial and neglect of the disorder

Some participants completely denied the existence of the disorder or refused to acknowledge it as a serious issue. They often dismissed hair-pulling as a trivial habit or a natural response to specific circumstances and avoided seeking specialized treatment.

“I don’t care that I’ve lost my hair. I tattooed the bald spots, and they look pretty stylish! Hair isn’t that important; it’ll grow back.” (Participant 7).

“I don’t think there’s anything to hide because it doesn’t matter. Let everyone know that I pull my hair. It’s just a simple habit, and it’s nobody’s business.” (Participant 10).

Entrapment in a cycle of failure and helplessness

Many participants described being trapped in a repetitive and destructive cycle of attempting to quit hair-pulling behavior, only to relapse repeatedly. These individuals expressed feelings of despair and helplessness due to their repeated failures. Some even accepted hair-pulling as an inseparable part of their identity, ceasing efforts to seek treatment.

“Every time, I promise myself it will be the last time I pull my hair, but I end up doing it again. There have been times when I managed to quit for a while, but the slightest stress or pressure triggers me to start pulling again.” (Participant 1).

“I feel like I can never stop pulling my hair because every time I try, I fail. It feels like hair-pulling has become an inseparable part of who I am.” (Participant 9).

“I feel trapped by this disorder and unable to escape it. I’ve tried several times to stop, but I always fail, and it feels like all my efforts are in vain. It’s like a monster in my mind that awakens easily. Stress, anxiety, and life’s challenges always seem to wake it up.” (Participant 6).

Stressful experiences and life pressures

Participants in this study identified stressful events, such as marital issues, workplace pressures, family crises, the loss of loved ones, and psychological trauma, as primary triggers for the onset and exacerbation of TTM. The high-stress conditions in their lives contributed to the persistence of hair-pulling behavior.

“My ex-partner used to compliment my beautiful, silky hair and would always stroke it. After losing that relationship, I was emotionally devastated and began hating my hair. Seeing my hair reminded me of the days I spent with my ex, which made me anxious. That’s when I started pulling my hair.” (Participant 4).

“I started pulling my hair when my parents separated and left me with my grandmother. When they noticed I was pulling my hair, they were initially concerned and took me back with them. But eventually, they stopped paying attention.” (Participant 7).

“I was very attached to my father. When he passed away, I was deeply traumatized, and that’s when I started pulling my hair. Every time something bad happens, this behavior intensifies.” (Participant 3).

Discussion

The findings of this study, which provided an in-depth exploration of the lived experiences of individuals with TTM, reveal the complex and multifaceted nature of this challenge. Our results demonstrate how TTM profoundly affects the daily lives of individuals, generating a cycle of compulsion, deep internal conflicts, and extensive emotional struggles as reflected in participants’ narratives. The efforts to conceal the disorder, coupled with sociocultural pressures, cast a shadow over the personal and social identities of these individuals, exacerbating their distress. Moreover, their bodies become battlegrounds for these psychological conflicts, resulting in significant physical and psychological consequences. Despite these challenges, within this struggle lies a journey toward recovery—an effort toward self-acceptance and improving quality of life. However, the path to recovery is not always straightforward, as numerous obstacles impede liberation from the disorder, causing some participants to ultimately surrender to this persistent battle.

The lived experience of individuals with TTM is often marked by profound The Compulsion Loop – Trapped in Repetitive Urges, manifesting through Cycle of Self-Injury, Unconscious Compulsive Cycle, and Captivity in Pleasure. Many participants described feeling trapped in a vicious cycle, attempting to soothe psychological pain through physical harm. Some even internalized this suffering, perceiving it as a deserved punishment and a form of self-penance. Previous research supports this interpretation, identifying TTM as a self-injurious behavior with compulsive and repetitive features, often linked to a heightened risk of other self-harming behaviors [49, 50]. This creates a self-perpetuating cycle where negative cognitions and harmful behaviors mutually reinforce one another [34, 51]. Consistent with this, Demirci et al. (2022) found that heightened anxiety and a range of maladaptive cognitive patterns—such as punitive thoughts, excessive responsibility, perfectionism, distorted body image, and perceived lack of control—were significantly associated with worsening TTM symptoms and other self-injurious behaviors [52]. To break this destructive cycle and improve quality of life, it is essential to promote self-focused skills such as self-awareness, cognitive restructuring, and the development of a more positive self-image. Strengthening one’s inner connection allows individuals with TTM to recognize maladaptive behavioral patterns and gradually replace them with healthier, more adaptive responses.

In contrast to the cycle of self-harm and negative emotions, many participants reported pulling their hair to achieve a sense of calm and relief from stress and internal tension. The associated feelings of pleasure and tranquility serve to reinforce this destructive behavior. Previous studies have found that individuals often engage in hair-pulling to alleviate anger, anxiety, and other negative emotions [13, 53]. Individuals with TTM often do not experience significant pain from hair pulling [49]. Hair pulling can temporarily relieve undesirable emotions, functioning as a form of emotional regulation [54]. The intense and impulsive urge to pull hair often arises in response to overwhelming tension, and subsequently, individuals experience a reduction in tension after performing the act. A 2019 study from North Africa study similarly indicated that patients use hair pulling as a means of emotional regulation [55]. Additionally, a 2021 study in Turkey found that while some patients are unaware of their hair-pulling behavior, others, despite being aware, demonstrate an inability to stop the behavior in response to anxiety or negative situations [56].

This study found that individuals with TTM are driven by an internal compulsion to pull their hair—an urge that is often overwhelming and difficult to resist. Previous research supports the habitual and quasi-addictive nature of this behavior, emphasizing the persistent internal tension and irresistible pull that sustain it over time [57, 58].

A 2021 study from Turkey further clarified this phenomenon by identifying two distinct patterns: while some individuals are unaware of their hair-pulling episodes, others, despite being fully conscious of their behavior, are unable to stop in response to anxiety or distressing emotions [56]. Recent research has emphasized the role of impulsivity in TTM, showing that hair-pulling often occurs as an impulsive response to internal tension or emotional dysregulation, rather than as a deliberate act. The behavior is typically followed by a temporary sense of relief or reduction in internal tension [59].

Given the central role of negative emotions, such as stress, anxiety, and anger, in maintaining this behavior, teaching effective emotional regulation and coping strategies becomes essential in therapeutic interventions. By developing healthier ways to manage emotional distress, individuals with TTM can begin to disengage from this maladaptive cycle and gradually replace hair-pulling with more adaptive behavioral responses.

The findings of the present study reveal deep emotional conflicts in the lived experiences of individuals with TTM. These conflicts manifest in the form of contrasting emotions—such as the tension between reconstruction and destruction, the paradox of pain and pleasure, and the burden of destructive perfectionism. In particular, this study highlighted the complex interplay between pleasure and suffering, noting that many participants were caught in a persistent paradox: while hair-pulling provided temporary relief and a deceptive sense of pleasure, it was quickly followed by intense feelings of guilt, regret, and anxiety. Previous qualitative studies have also emphasized this paradox of pleasure and remorse [13, 34]. However, these nuanced emotional dynamics are often underrepresented in quantitative research, which tends to focus on symptom severity, frequency, and comorbidities rather than the subjective experience of internal conflict. This study further builds on prior work by revealing how some participants, in an effort to cope with guilt and restore a sense of control, engaged in excessive and costly haircare routines. This behavior reflects a compensatory strategy aimed at reducing self-blame and emotional distress. These findings provide critical context for interpreting quantitative data on TTM-related distress and functioning, suggesting that emotional and behavioral responses may be more complex than previously assumed. Thus, the qualitative insights presented here help bridge gaps in the literature by offering a richer understanding of the emotional and cognitive struggles underlying TTM—insights that may inform more effective, individualized interventions.

A 2019 North African study indicated that individuals with TTM utilize hair pulling as a coping mechanism to alleviate stress and anxiety. However, observing the consequences of this behavior, such as hair loss and skin problems, exacerbates their stress and distress [55]. While prior quantitative studies have documented behavioral patterns and emotional consequences of hair pulling, the current qualitative findings offer more nuanced insights into the cognitive and motivational processes behind these actions. For instance, this study found that some individuals pull damaged, knotted, or split ends, seeking flawless hair; they aim to eliminate imperfections and achieve symmetry and perfect beauty. However, this behavior only intensifies the imperfections and asymmetry. Previous studies have also shown that many individuals pull coarse, split, white, or thin hairs [24, 34]. A deeper exploration of participants’ experiences in our study revealed two underlying motivations for this behavior: (1) a strong desire for perfection and uniformity in hair appearance, and (2) a greater sense of pleasure and reduced guilt when removing hairs perceived as “damaged.” These findings expand upon existing literature by highlighting the role of subjective interpretation and moral reasoning in hair-pulling behavior. Given the central role of obsessive thoughts in TTM, our results suggest that cognitive restructuring and thought-management strategies may be especially beneficial therapeutic targets. These insights bridge the gap between surface-level behavioral data and deeper emotional and cognitive experiences, thus enriching current understandings of TTM.

One emerging and significant finding of the present study, which has been less emphasized in previous research, is the role of hair-pulling as a symbolic expression of inner protest in the lived experience of individuals with TTM. These findings suggest that this inner protest gradually becomes institutionalized into a compulsive and seemingly unavoidable cycle, transforming into a behavior that is difficult to cease. This experience may have roots in the historical and cultural context of hair plucking among Iranian women as an expression of protest and mourning. Accordingly, hair-pulling behavior can function as an ironic metaphor for expressing dissent, whereby the individual unconsciously utilizes this symbolic interpretation as a mechanism to justify the behavior and resist breaking out of the cycle. This qualitative insight adds new dimensions to the phenomenological understanding of TTM and may challenge or expand existing theories on self-injury, as it addresses a deeper semantic aspect of the behavior that quantitative studies cannot capture.

One notable finding of the present study is the central role of identity and socio-cultural pressures in the experiences of individuals with TTM. This finding demonstrates how cultural values, aspects of personal and sexual identity, as well as social judgments and discrimination, can meaningfully influence the lived experience of this disorder. In some cases, these factors lead to social deprivation and isolation for individuals with TTM, further exacerbating their challenges. One potential explanation for the present findings may lie in the cultural significance of facial hair for men and long hair for women within Kurdish communities. In this cultural context, long hair is commonly perceived as a symbol of delicacy and femininity for women, while facial hair is regarded as a marker of authority and masculinity for men. Thus, involuntary hair loss—especially when visible—can evoke feelings of shame and threaten individuals’ perceived alignment with their gender roles. This is particularly relevant for men who pull facial hair, where such actions may undermine social perceptions of masculinity and strength. Similarly, for women, damage to long hair may be experienced as a loss of traditional feminine identity. Accordingly, any involuntary alteration or loss of hair may be perceived as a threat to one’s gender identity within these societies. This cultural perspective on hair likely has roots in Iran’s historical traditions. In the 19th century, shaving women’s heads or removing men’s facial hair was employed as a form of humiliating punishment for behaviors deemed deviant from social norms. This historical association between hair, shame, and discipline may have contributed to the formation of deeply entrenched cultural attitudes toward the symbolic importance of hair in Iranian society, including Kurdish regions [60]. Over time, such views have become institutionalized and are now embedded as integral components of the cultural fabric of these communities. Furthermore, in premodern Iranian traditions, a man’s beard was considered a symbol of honesty and integrity, to the extent that it was sometimes pledged as collateral for debts and obligations. Additionally, Islamic teachings, which exert a strong influence in Iran, emphasize the desirability of maintaining facial hair as a sign of male piety [61]. Therefore, the findings of the present study may help explain why facial hair-pulling among men with trichotillomania could be perceived as a threat to culturally embedded concepts of honesty, masculinity, and religious virtue. This qualitative analysis deepens our understanding of the cultural and psychological burden of hair loss beyond mere physical symptoms and extends quantitative findings on the influence of socio-cultural factors by providing historical and semantic context.

In addition to the profound cultural influences on identity formation and its connection to hair, participants in this study reported experiencing various sociocultural and identity-related pressures, including concealment, social stigma, discrimination, and deprivation of life opportunities. To hide their condition, participants employed strategies such as wearing head coverings, wigs, heavy makeup, or even tattoos. A 2024 study conducted in Romania highlighted the considerable amount of time individuals with TTM dedicate to concealing their perceived defect in an effort to appear as ordinary members of society [13]. Similarly, previous research indicates that fear of judgment and social rejection often drives individuals with TTM to hide their condition [62]. Findings from this study revealed that participants experienced stigmatization and labeling from their families, peers, and the broader community. This is supported by a 2016 U.S. study, which found that individuals with TTM are frequently perceived as psychologically unstable or lacking emotional resilience [63]. As a result, social withdrawal, isolation, and feelings of shame are common social consequences associated with TTM [64]. Moreover, TTM often leads to the loss of significant life opportunities, including those related to marriage, employment, and education. Previous studies have shown that hair pulling can limit individuals’ access to certain occupational, social, and academic roles [64, 65]. These findings underscore the need to increase public awareness about TTM, enabling affected individuals to seek professional help without fear of judgment and to resume a more fulfilling and normalized life.

One of the prominent findings of the present study is the conceptualization of the body as a battleground in the experience of individuals with TTM. This study’s findings highlight the physical dimensions of TTM. Participants reported many physical consequences, including alopecia (hair loss), weakened hair follicles, skin lesions and inflammation, and musculoskeletal problems. A 2021 UK study, aligning with these findings, comprehensively examined the physical effects of TTM, noting skin infections, bleeding, inflammation, carpal tunnel syndrome, and dental and gastrointestinal issues resulting from hair ingestion, in addition to the aforementioned effects [28]. Raising awareness about the physical risks of hair pulling is essential, as this awareness can serve as a powerful motivator for behavior change. This approach can help individuals gain a deeper understanding of the long-term consequences of the disorder and find the motivation to modify their behavior. This study revealed that.

In addition to the extensive physical manifestations, individuals with TTM experience a significant burden of psychological distress. TTM is more than a mere habit; it reflects complex psychological mechanisms [51]. Our findings corroborate this, showing that individuals with TTM frequently endure feelings of worthlessness, low self-esteem, and profound self-deprecation. The compulsive act of hair pulling both arises from and exacerbates these negative emotional states, functioning as a maladaptive coping strategy. A 2015 study from Australia similarly reported that individuals with TTM often harbor persistent negative self-beliefs and experience intrusive thoughts and ruminations centered on feelings of emptiness and inadequacy [34]. Moreover, Grant et al. (2023) highlighted that feelings of hopelessness, low mood, depression, and suicidal ideation are prevalent among patients with TTM [66]. These findings underscore the necessity of designing comprehensive and integrated interventions that address both the physical and psychological dimensions of TTM. Effective approaches may include a combination of cognitive-behavioral therapies, body-based stress management techniques, psychoeducation, motivational enhancement, relaxation training, relapse prevention, and self-acceptance-based interventions. Given the central role of the body in the experience of TTM, training in body awareness to facilitate early detection of urges and promote adaptive response substitution, along with Acceptance and Commitment Therapy (ACT), is particularly important for reducing psychological distress and improving quality of life [33].

The journey towards recovery, a central finding, involved themes of making peace with oneself, self-regulation and behavioral retraining, social and interpersonal support networks, effective treatment systems, and recognizing the depth of the disorder. Some participants utilized self-regulation, behavioral retraining, and adaptive strategies such as behavior substitution, realistic goal setting, avoidance of triggering situations, thought diversion, and relaxation techniques to manage their behavior and facilitate recovery. Previous research has shown that some individuals employ diverse strategies, including stress management techniques, replacing hair pulling with a non-destructive behavior, identifying triggers, and enhancing self-control skills [13, 25].

Self-acceptance emerged as another practical approach. Participants emphasized the importance of self-compassion, self-empathy, and cultivating positive self-regard. In an Australian study, Slikboer et al. (2020) highlighted the significant role of self-compassion and fostering a positive attitude towards hair in controlling hair-pulling behavior [25]. Training in self-awareness skills, meditation and yoga practice, and acceptance and commitment therapy is crucial. These practices foster self-acceptance, reduce self-judgment, and promote positive self-perception, thereby mitigating self-harming behaviors like hair-pulling.

One of the most significant findings of this study, based on both its high frequency across participants and the intensity of emotional distress it elicited, was the overarching theme of “Barriers to the Path of Recovery.” This central theme encompasses several key sub-themes that hinder individuals from overcoming their condition, including denial and neglect of the disorder, the pervasive impact of stressful experiences and life pressures, entrapment in a cycle of failure and helplessness, the utilization of self-destructive defense mechanisms, and avoidance of acceptance and treatment.

This study revealed that stressful experiences and life pressures, such as marital and familial conflicts, as well as personal and social challenges, were significant factors preventing individuals with TTM from ceasing hair-pulling behavior. These pressures primarily act as exacerbating agents, often turning individuals’ efforts to overcome trichotillomania into failures. Supporting these results, previous studies have shown that traumatic and stressful experiences, combined with difficulties in emotional regulation, can significantly intensify hair-pulling behavior [67, 68].

Our findings also revealed that a major barrier to successful recovery in individuals with TTM is not the ineffectiveness of treatment per se, but the initial rejection of treatment and disbelief in therapeutic methods. In line with this, a study conducted in the United Kingdom (2021) reported that many patients refrain from seeking professional help, believing that healthcare providers lack adequate understanding of the disorder and cannot effectively assist them [28]. This indicates that one of the core challenges lies in the underutilization of available treatments due to skepticism or mistrust, rather than issues encountered during the treatment process itself. Therefore, addressing this preliminary challenge requires targeted strategies to actively engage individuals with TTM before they seek care, including responding to their concerns and misconceptions about treatment, and working to enhance their trust in the effectiveness of available interventions. Creating a safe and supportive environment—both within and beyond clinical settings—based on accurate information and the provision of high-quality services through treatment centers and publicly accessible resources, appears essential. Moreover, initiatives such as early outreach, peer education, and community-based interventions may help reduce hesitation in treatment-seeking behavior. Additionally, the role of primary care professionals in the early identification and timely referral of individuals suspected of having TTM is significant. Finally, raising public awareness about the nature of TTM, informing individuals about effective treatments, and addressing the social stigma not only associated with the disorder but also with help-seeking behavior, can significantly facilitate earlier and more consistent treatment acceptance among affected individuals.

This study also found that individuals with TTM often become trapped in repeated cycles of relapse and recovery. These recurring failures lead to the development of beliefs in their inability to recover and the invincibility of the disorder, and a feeling of being trapped in the trap of this disease. Prior research has also emphasized the high prevalence of relapse in TTM, indicating that maintaining abstinence is particularly challenging for this population [69, 70]. Therefore, providing ongoing support during periods of recovery and addressing patients’ dysfunctional beliefs—such as all-or-nothing thinking—is crucial. It is important to educate these individuals that a single lapse does not signify total failure, and they should be encouraged to persevere.

Limitations

Although cultural stigma surrounding TTM was discussed earlier, it is important to emphasize that its status as a social taboo in Iranian society had a direct impact on both participant recruitment and data richness. Feelings of shame and fear of judgment led to hesitancy in participation and, in some cases, surface-level responses during interviews, possibly limiting the depth of insights gained. To mitigate these challenges, we implemented strict confidentiality protocols and created a safe, empathetic, and nonjudgmental setting to foster trust and encourage openness. However, these efforts could not fully eliminate the impact of social stigma, and some participants may still have withheld deeply personal or culturally sensitive experiences.

In addition, this study employed a qualitative phenomenological design with a relatively small, purposive sample drawn from a single cultural context (Iran). These methodological choices were appropriate for capturing in-depth, subjective experiences, but they inherently limit the generalizability of the findings. The insights presented here are context-specific and cannot be assumed to represent the broader population of individuals with TTM, either within Iran or globally. Therefore, readers are encouraged to interpret the results as exploratory and situated rather than universally representative.

Moreover, although this study focused on the subjective meanings and lived experiences of individuals with TTM rather than quantitative characteristics, it is worth noting that many participants had been living with the disorder for an extended period—often beginning in early adolescence and persisting into adulthood. This chronicity did not merely reflect the passage of time but profoundly shaped their psychological landscape. The prolonged struggle appeared to deepen feelings of helplessness and reinforce maladaptive coping patterns. For some, this led to emotional numbness or disengagement from treatment; for others, it contributed to a hard-earned sense of acceptance or self-regulation. These findings suggest that chronicity is an integral component of the lived experience of TTM and merits further qualitative exploration.

Conclusion

This study highlighted the internal struggles of individuals with TTM, revealing a cycle of self-harm intensified by stigma, concealment, and psychological distress. While some participants found paths to recovery through self-awareness, support, and treatment, others remained trapped by resistance and external pressures. These insights emphasize the importance of public education and integrated treatment approaches. Future research should assess the effectiveness of targeted therapeutic interventions in culturally diverse contexts.

Author contributions

ZB and AK jointly contributed to the study design. ZB conducted the data collection. ZB and AK performed the data analysis. The initial draft of the manuscript was prepared by ZB and AK. Both authors critically reviewed and approved the final version of the manuscript for submission.

Funding

This study received funding from the Kermanshah University of Medical Sciences (Grant number 50005007), and the allocated budget was utilized to conduct the study.

Data availability

The data used in this study are not publicly available due to licensing restrictions. However, interested parties may contact Alireza Khatony for further information regarding data availability.

Declarations

Ethics approval and consent to participate

This study with code IR.KUMS.REC.1403.461 was approved by the Ethics Committee of Kermanshah University of Medical Sciences. Participants were informed that their participation in the study was voluntary. The study objectives were explained to all participants emphasizing the confidentiality of personal information and participant data. Written informed consent was obtained from all participants. The study procedures were conducted in accordance with relevant guidelines and regulations and were approved by the Ethics Committee of Kermanshah University of Medical Sciences.

Consent to publish

Not applicable.

Competing interests

The authors declare no competing interests.