Eleven-year old Emily Simmons has always been hard on herself.
"I was such a perfectionist at such a young age. I needed everything to be perfect. I have to have everything in the right order. I have to have my grades all A's. I have to have the right friends. I mean, I have to have the perfect clothes," said Emily.
But two years ago, when Emily was just 9, the stress of living this perfect life led to an unexpected result: She started pulling out her hair.
"I remember just fidgeting with my hair, you know? Trying to braid it a little. And then I pulled out a hair," she said.
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What started with a single strand grew into an all-consuming compulsion. Before long, Emily was pulling out more and more of her hair.
"Right before Thanksgiving, I got my first bald spot. It's about the size of a penny ... I remember thinking, 'Oh, gosh. What now?' ... And I remember going to my mom and showing her. And I remember her being a little freaked out. Like, 'Oh, my gosh. What are we gonna do?'" Emily said.
Emily's parents, Michelle and Steven Simmons, were shocked to discover their daughter's hair-pulling compulsion.
"It was devastating. I remember before going into my bathroom and seeing so much hair on the floor that it truly looked like a barbershop," recalled Michelle. "I would sweep it up and then go back in my bathroom an hour later and it would be the exact same way. It was amazing. I never knew that a person could do that."
Emily's hair-pulling would only get worse from there.
"I would pull so much that I made a spot within, like, five minutes, you know? And it'd become really raw. And it would hurt. I remember it would sting, because of all the rawness," she said.
Emily Uses Dad's Pliers to Pull Out Hair
Despite the physical pain caused by the hair-pulling, the practice actually brought Emily pleasure.
"I used to go out in my dad's toolbox. And when I was really, really, really upset, I would get his pliers ... it hurt, but I mean, it was just like -- you know? I was mad ... I was used to doing it. It made me feel good," she explained.
Emily's response is not unique. According to the Trichotillomania Learning Center, there are an estimated 2 million to 10 million Americans with the disorder.
For those suffering with "trich," as it is commonly known, the pulling behavior often -- but not always -- serves as a coping mechanism for anxiety. As unpleasant as it is, the pulling actually brings a sense of relief to the puller.
To prevent their daughter from pulling her hair, Emily's parents took dramatic action: They shaved her head.
"We did a buzz cut. We tried many different styles to cover up the spots that she did have. But it got to the point where it was really hard. And so just decided to shave it," said Michelle.
Emily's hair is slowly growing back in, but the temptation to pull remains.
To fight the pulling, Emily and her parents have sought professional help from psychologist Suzanne Mouton-Odum in Houston, Texas. Mouton-Odum is the author of "Stay Out of My Hair! Parenting Your Child With Trichotillomania," and specializes in cognitive behavioral therapy.
So, why does Emily "feel good" when she pulls her hair out? Not surprisingly, the answer is far from simple.
"It's a little bit different for each person," explained Mouton-Odum. "Some kids may pull because they're overwhelmed. Some pull because they're bored. Sometimes it's a sensory experience, maybe they feel one hair that feels rougher or thicker or bumpier. So it could be many different things that drive it ... that's what makes therapy so interesting, is we have to figure out what those driving forces are."
Hair-Pulling Part of 'Spectrum of Disorders'
Many experts, including Mouton-Odum, believe that hair-pulling is part of a larger "spectrum" of disorders that share the same root as Obsessive Compulsive Disorder: compulsive shopping, pathological gambling, hypochondria, compulsive skin picking and body dysmorphic disorder. Like OCD, trichotillomania is repetitive and seemingly involuntary.
But, she said, there are important differences.
"People with OCD cannot stand their compulsions. They feel compelled to do them, because it relieves anxiety. People with trichotillomania like to pull their hair. It feels good. It's pleasurable," she said.
Mouton-Odum uses cognitive behavioral therapy, a goal-oriented form of psychotherapy that emphasizes the role of thoughts in damaging behavior and emotions, to treat Emily. She has a few other methods to help prevent the hair-pulling and divert the impulse into less destructive behavior.
"We'll use ... hats or gloves, or Band-Aids on the fingers ... things that prevent a person from pulling out their hair," explained Mouton-Odum.
"Another option is to use a substitute behavior, playing with a koosh ball or a toy, or a pipe cleaner, something that can relieve or satisfy a physiological sensation or a sensory need that can help a person to get through that urge," she said.
This combination therapy has helped Emily seize control of her hair-pulling, and channel her perfectionism into winning over the compulsion.
"I've been ready to just kick it. I just want to get in gear and just kick trich's butt," she said. "I just want to get that out of the way and just say I accomplished this. I got through this."