Trichotillomania Relapse: When the Pulling Comes Back

If you’ve started pulling your hair again after a good stretch, you might feel like you’re back at square one. You’re not. A trichotillomania relapse is one of the most common parts of recovery, and it happens to many people who did everything right.

This guide is for adults whose pulling has come back, whether after a few weeks or many years. It explains the difference between a lapse and a relapse, why pulling returns, and a simple plan for what to do next.

Is it normal for trichotillomania to come back?

Yes. Relapse is common in trichotillomania, and it’s a normal part of the condition rather than a sign that you’ve failed. Cleveland Clinic, a large US hospital, says many people have spells of improvement followed by relapse, and calls this normal.

Trich tends to run in waves. You might have months or years of little or no pulling, then a flare-up during exams, a breakup, a new job, pregnancy or grief. Our complete guide to trichotillomania describes this up-and-down pattern.

Treatment research shows the same thing. Habit Reversal Training (HRT) is the approach with the most research behind it. It teaches you to notice when you’re about to pull and to do something else with your hands instead. You can read how it works in our guide to Habit Reversal Training.

HRT helps many people a lot in the short term, but the gains often fade. In a Dutch study of 28 adults who had six sessions of behaviour therapy, the benefit two years later was about 70% smaller than just after treatment. Across earlier studies, between half and two-thirds of people who responded well had slipped back by the last check.

Those numbers aren’t a reason to lose hope. They show that trich usually needs ongoing care, a bit like asthma or migraine, rather than a single course of treatment. Newer approaches that add skills for handling urges and feelings may hold up better. In a 2024 trial of 85 adults, pulling didn’t get worse in the six months after therapy ended.

What’s the difference between a lapse and a relapse?

A lapse is a slip: one evening of pulling, or a single hair after weeks pull-free. A relapse is a slide back into your old pattern, pulling regularly over weeks or months. A lapse doesn’t have to become a relapse.

These terms come from relapse prevention, an approach developed by the psychologist Alan Marlatt and colleagues to help people keep up changes to habits like drinking and smoking. Trich researchers have borrowed ideas from it, because hair pulling shares some features with those habits, including strong urges and a feeling of reward.

One idea from this research matters most. After a slip, many people think, “I’ve blown it. I have no willpower. I’ll never stop.” Marlatt called this reaction the abstinence violation effect. In research on drinking, people who blamed a lapse on a fixed personal failing were more likely to give up and relapse fully. People who saw it as one tricky situation they hadn’t yet learned to handle were more likely to learn from it and carry on.

With trich, the thought often sounds like “I’ve already pulled, so the day is ruined.” Shame and self-criticism are strong triggers for more pulling, so the moment after a slip is the moment to be kind to yourself.

Why did I start pulling again?

Pulling usually comes back because something changed, not because you did something wrong. Common reasons include:

• Stress or big life changes. Exams, a new job, a move, a loss, illness or a new baby can all bring pulling back. In the Dutch study, people with more low mood before treatment tended to do less well two years later.
• Boredom and tiredness. Long quiet evenings, screens and poor sleep make automatic pulling (pulling without noticing) easier to slip into.
• Letting your tools go. When pulling stops, it’s natural to stop tracking, put the fidget away and take off the plasters. The urges can outlast the routines that were keeping them in check.
• Regrowth. Short, stubbly new hairs often feel “wrong” in exactly the way that sets off pulling.
• A new place or routine. A new desk, bedroom or commute doesn’t have your barriers built in yet.

Practice seems to matter too. In a 2025 study of 35 adults having therapy that combined HRT with acceptance and commitment therapy (ACT, which teaches you to make room for urges without acting on them), those who did more of their between-session practice had less pulling six months after therapy ended.

What do I do next?

Treat the slip as information, restart a few tools you know work, and get support if it keeps going. Here’s a reset plan:

1. Stop and put the hair down. Catching it after one hair or one minute is a win.
2. Be kind to yourself first. Try saying, “This is a slip, not a restart. I still have my skills.”
3. Work out what happened. Where were you, what were you doing, how did you feel, and what was different this week?
4. Track for a week. Note each pull or near miss. This shows you where to aim your effort.
5. Bring back two or three tools that worked before. That might be a barrier, like plasters on your fingertips or a soft hat; a fidget kept where you pull; or your competing response, such as pressing your palms onto your thighs for about a minute when an urge hits.
6. Ride out urges. Urge surfing means watching an urge rise, peak and fade like a wave, without acting on it. It was first described as part of Marlatt’s relapse prevention model.
7. Tell someone you trust, if it helps. Ask them to support you, not to watch you.

Measure progress by fewer hairs pulled and more pull-free hours, not an unbroken streak. A streak resets to zero with a single slip, and that feeds the “I’ve ruined it” thought.

Our guide on how to stop pulling your hair goes through each of these tools in detail.

How can I stop it happening again?

You can’t rule out every flare-up, but a written plan can make them shorter and less frightening. Relapse prevention teaches you to spot your risky situations ahead of time and to have a plan ready for a slip, like an emergency kit you hope never to need.

Your plan could include:

• Your risky situations: the places, moods and times of year that set you off, taken from your tracking. Plan extra support before known busy or stressful stretches.
• Your early warning signs: searching through your hair more, checking the mirror, or quietly dropping your routines.
• Your go-to tools: the barriers, swaps and skills that work best for you, kept where you tend to pull.
• Your slip steps: what you’ll do in the first hour after a lapse (the reset plan above).
• Your support: who you’ll tell, and when you’ll contact a practitioner.

Two studies found that people who had stopped pulling completely by the end of therapy were more likely to keep their gains. So it can help to keep using your tools for a while after pulling stops, rather than dropping them straight away. Cutting down is still real progress, and it counts.

Look after your life as well as your hands. Relapse prevention puts weight on balancing the things you have to do with things you enjoy, because long stretches of stress with little relief make urges harder to resist.

When should I get help?

Get support if a slip has turned into weeks of regular pulling, if it’s causing you distress, or if the tools that worked before aren’t working this time. You don’t need to wait until it’s “bad enough”.

If you had therapy before, you can ask for a few top-up sessions, sometimes called booster sessions, to refresh your plan. If you’ve never had therapy, a relapse can be a good time to start. Our guide to trichotillomania treatment explains each option and the evidence behind it.

Many doctors and therapists have never worked with someone who pulls. Everyone in our directory has told us they understand trichotillomania and already help people who pull, in person or online. You can search the directory for someone who understands hair pulling. Our guide to finding someone who understands trich explains what to ask on a first call.

If you’re a parent whose child has started pulling again, our guide to parenting through a relapse is written for you.

If you’re feeling very low or hopeless, please talk to someone today.

In an emergency, call 112 or 999 or go to your nearest emergency department.

• Samaritans — 116 123 (www.samaritans.org/samaritans-ireland)
• Pieta — 1800 247 247 (text HELP to 51444) (www.pieta.ie)
• Text About It — text HELLO to 50808

Questions people ask

Sources

1. Keijsers, G.P.J., van Minnen, A., Hoogduin, C.A.L., Klaassen, B.N.W., Hendriks, M.J. & Tanis-Jacobs, J. (2006). Behavioural treatment of trichotillomania: Two-year follow-up results. Behaviour Research and Therapy, 44(3), 359–370.
2. Falkenstein, M.J., Rogers, K., Malloy, E.J. & Haaga, D.A.F. (2014). Predictors of relapse following treatment of trichotillomania. Journal of Obsessive-Compulsive and Related Disorders, 3(4), 345–353.
3. Barber, K.E., Woods, D.W., Ely, L.J., Saunders, S.M., Compton, S.N., Neal-Barnett, A., Franklin, M.E., Capriotti, M.R., Conelea, C.A. & Twohig, M.P. (2024). Long-term follow-up of acceptance-enhanced behavior therapy for trichotillomania. Psychiatry Research, 333, 115767.
4. Barber, K.E., Woods, D.W., Twohig, M.P., Saunders, S.M., Compton, S.N. & Franklin, M.E. (2025). Examining the role of homework compliance in acceptance-enhanced behavior therapy for trichotillomania. Behavior Therapy, 56(4), 823–837.
5. Larimer, M.E., Palmer, R.S. & Marlatt, G.A. (1999). Relapse prevention: An overview of Marlatt’s cognitive-behavioral model. Alcohol Research & Health, 23(2), 151–160.
6. Cleveland Clinic (2026). Trichotillomania (hair pulling disorder).