Hair Pulling, Anxiety, and Relaxation Techniques

Dr. Dawn Ferrara
Jul 26th, 2021

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Anxiety is a key component in BFRBs and is sometimes difficult to manage. In a recent TrichStop webinar, Dr. Vladimir Miletic discussed anxiety its biological and psychological underpinnings, and its connection to hair pulling. He also shared a number of relaxation strategies and resources for dealing with anxiety.

So just what is anxiety? Anxiety is an emotion characterized by an unpleasant state of inner turmoil, often accompanied by nervous behavior such as pacing back and forth, somatic complaints, and rumination. What this looks like can vary from person to person. We all experience anxiety, and we all experience it a little differently. The fact is anxiety is not inherently good or bad. It is a part of our biological makeup and serves a purpose. The anxiety response is part of the primitive “fight or flight” survival instincts and originates in the brain.

The Biological Connection

There’s an area of the brain known as the limbic system. Within that system are structures you’ve probably heard of before, the amygdala and the hippocampus. These structures play a central role in anxiety and in the emotional associations we make. When the anxiety response is triggered, the body releases a cascade of neurotransmitters that results in an overly excited brain. You’ve got millions of neurons all trying to talk at once. One of those chemicals, Gaba, is responsible for helping these neurons communicate efficiently. When you don’t have enough Gaba, you can experience anxiety. Another key player in this process is serotonin. You might be most familiar with serotonin and its association with depression. But it also plays a key role in anxiety management which is why certain antidepressants are sometimes used to treat anxiety. From the biological side, it’s all about balance.

One other biological factor that Dr. Miletic mentioned is that of genetics. About 30% of anxiety is thought to possibly be due to genetics. However, that does not mean that things are hopeless. Environment and the choices you make play a crucial role in how anxiety is experienced.

The Psychological Side of Anxiety

As he often does, Dr. Miletic turns to Dr. George Kelly and constructivist theory to examine the psychological dynamics of anxiety. Dr. Kelly viewed emotions as transitional states of being. They provide information about what’s happening. An emotion arises when something is changing or about to change within you. It’s a signal that something is changing. In this respect, emotions aren’t good or bad. They’re just information to use.

Part of what we do as humans are to anticipate what is going to happen. We think about how things might unfold, and what we might say or do.  Anxiety results when we make false anticipations about what’s going to happen. When those anticipations are incorrect, we don’t have good tools for dealing with a situation. And, if we don’t have useful tools, we can’t respond positively. Your brain starts ruminating, searching for something it can use to understand what’s happening. When you’re not quite sure what a situation means, you feel unsafe. And, when you feel unsafe, your body senses danger. We have to use what we have, or we need to build a new structure.

Dr. Miletic draws upon the work of Pema Chodron to illustrate the power in acceptance of our anxiety. Similar to what Kelly describes, when you experience intense emotion such as fear or anxiety, you’re actually moving towards something profound and important. If you’re open to what’s happening, you can learn something about yourself and master a new challenge. Acceptance is a powerful alternative to resistance. As Pema Chodron put it so eloquently:

“We think that the point is to pass the test or overcome the problem, but the truth is that things don't really get solved. They come together and they fall apart. Then they come together again and fall apart again. It's just like that. The healing comes from letting there be room for all of this to happen: room for grief, for relief, for misery, for joy.”

It is important to get to know your own brand of anxiety. What does it feel like? Where do you sense it when is coming on? What are your triggers? Over time, you can learn to connect your anxiety symptoms to your unique triggers. Understanding how your anxiety ebbs and flows can help you to use the strategies most effective for you.

The goals of managing anxiety are to deal with acute anxiety effectively when it occurs and to reduce your reactivity over time. Dr. Miletic offers strategies for both acute anxiety and management of anxiety.

Strategies for Acute Anxiety

Sometimes anxiety comes on quickly and can be quite intense. These strategies can offer relief.

Breathing Exercises – Controlled breathing techniques can be done almost anytime, anywhere, and also aid in grounding. There are several breathing techniques you can try including:

▪ Box Breathing
▪ 3x3
▪ 4-6-8
 ▪ Alternate Nostril Breathing  

Grounding Exercises – Grounding helps to slow the racing thoughts and bring you back to the present moment, shutting off the “what ifs” that can send your anxiety soaring. Grounding techniques include:

▪ doing a body scan
▪ stretching
▪ feet on the ground (noticing the sensation of your feet coming into contact with the ground)
▪ 5-4-3-2-1.  5-4-3-2-1, in particular, can be helpful because it can be done almost anywhere. To do this exercise, look around and identify five things you can see, and breathe. Find four things you can feel and breathe. Identify three things you can hear and breathe. Identify two things you can smell and breathe. Finally, identify one thing you can taste, and breathe. 

For more details about these strategies, check out the video, here.

Reducing Baseline Anxiety and Reactivity

There are also strategies you can learn to use overtime to begin reducing your baseline anxiety. These are not “quick fix” techniques. Rather, they are actions you can use to mindfully work towards less reactivity. You can lower your overall anxiety and increase your sense of calm and control.

Dr. Miletic suggests the following strategies to try:

▪ Progressive Muscle Relaxation
▪ Mindfulness of the Breath (for example, counting your breath)
▪ Body Scans
▪ Visualizations (for example, lake and mountain meditations)
▪ Loving-kindness and self-compassion

While reducing acute anxiety is important, Dr. Miletic emphasizes that the goal is ultimately to transform the way you relate to anxiety and reduce your baseline anxiety. While genetics plays a small part, the rest is up to you. These strategies can help.

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Dr. Dawn Ferrara


With over 25 years of clinical practice, Dawn brings experience, education and a passion for educating others about mental health issues to her writing. She holds a Master’s Degree in Marriage and Family Counseling, a Doctorate in Psychology and is a Board-Certified Telemental Health Provider. Practicing as a Licensed Professional Counselor and Licensed Marriage and Family Therapist, Dawn worked with teens and adults, specializing in anxiety disorders, work-life issues, and family therapy. Living in Hurricane Alley, she also has a special interest and training in disaster and critical incident response. She now writes full-time, exclusively in the mental health area, and provides consulting services for other mental health professionals. When she’s not working, you’ll find her in the gym or walking her Black Lab, Riley.

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