Treating Trichotillomania

Note: This article is written in honor of the National Trichotillomania Awareness Week. To learn more about Trichotillomania, visit the Trichotillomania Learning Center.

I often tell my colleagues that trichotillomania (hair pulling disorder) represents the wild west of psychological disorders. Unfortunately, it remains one of the least researched and most misunderstood disorders in the DSM. Additionally, there is a lot of pseudoscience, snake oil, and plain old quackery on the internet about the best way to treat it.

In this article, I will highlight what we do know about scientifically supported treatments for trichotillomania. As a disclaimer, this is only an introduction to treating trichotillomania and is not intended to formally train clinicians. Lastly, I will not be reviewing medical treatments for trichotillomania (you can learn more about those here).

Historical Treatments

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Photo by Gregory Parker

The first scientifically based treatment for trichotillomania was Habit Reversal Training (HRT) (Azrin, Nunn, & Frantz, 1980; Duke, Keeley, Geffken, & Storch, 2010). During HRT, individuals become more aware of their hair pulling behavior and practice interrupting the behavior by engaging in incompatible behaviors. For example, people who use their hands to pull from their scalp might practice reaching down towards one’s knees. While HRT has been effective in the treatment of tics and Tourette’s Disorder, it doesn’t work for everyone who has trichotillomania and also has a high rate of relapse. Why? As I described in a previous article, trichotillomania is a very heterogeneous disorder and affects each person differently. A “one size fits all” treatment just won’t work for trichotillomania.

Modern Treatments

Photo by AlicePopkorn

Recently, researchers have developed more comprehensive approaches to treating trichotillomania. Dr. Charles Mansueto pioneered the Comprehensive Behavioral Model (ComB) for trichotillomania (Mansueto, Stemberger, Thomas, & Golomb, 1997). In ComB, clinicians first understand the function of hair pulling. Does it relieve stress? Does it end boredom? Does it reduce anger and frustration? Next, clinicians identify the main types of hair pulling. Some individuals pull for sensory stimulation (trying to find the hair that feels just right), others due to specific thoughts (I have to get rid of all the grey hairs), etc. Lastly, clinicians create treatments that address all aspects of trichotillomania including emotional regulation (learning more adaptive ways of dealing with stress, anger, boredom), physical habits (using HRT and objects to stop motor behavior), and environmental interventions (covering mirrors, getting rid of tweezers).

While research is underway to evaluate Mansueto’s ComB model, other researchers have found support for this approach to treating trichotillomania. In a recent pilot study, Dr. Nancy Keuthen and her colleagues found that Dialectical Behavior Therapy (DBT) was effective at reducing trichotillomania symptoms for at least 3 months (Keuthen et al., 2010). DBT is a form of cognitive behavior therapy that focuses on learning new ways of regulating one’s emotions. Additionally, in a review of all published scientific treatment studies on trichotillomania, Dr. Michael Walther and his colleagues concluded that behavior therapy (HRT), emotional regulation, and acceptance together represent the most promising treatment for trichotillomania (Walther, Ricketts, Conelea, & Woods, 2010). Furthermore, Dr. Martin Franklin and his colleagues have demonstrated that this comprehensive approach to behavior therapy not only works for adults, but it can help children as young as 7 (Franklin, Edson, & Freeman, 2010).

So what does this all mean? To the best of our scientific knowledge, effective trichotillomania treatment includes three things:

  1. An increased awareness of when, where, and why hair pulling occurs.
  2. An effort to control or change hair pulling behavior.
  3. Emotional regulation training to find alternative ways of dealing with negative feelings.

Here’s how I use these scientific findings to treat trichotillomania.

Increasing Awareness

Photo by Wim Mulder

Before creating a treatment plan, I collaborate with my clients to understand the unique patterns of their hair pulling. This usually includes a 1-2 week record of all hair pulling episodes. I ask each client to record the following information after each hair pulling episode:

  • What part of the body was the hair pulled from?
  • Where was the person when they pulled their hair?
  • What time was it when the person pulled their hair?
  • Was an instrument (e.g. tweezers) used to help pull hair?
  • What was the person doing while they pulled their hair?
  • What was the person feeling before, during, and after the hair pulling?
  • What was the person thinking before, during, and after the hair pulling?
  • Was anyone else present during the hair pulling?
  • What did the person do with their hair after they pulled it? (Sidenote: You’ll want to look out for individuals who swallow their hair, this could lead to a potentially lethal condition known as a trichobezoar and will need immediate medical attention).

Changing Hair Pulling Behavior & Emotional Regulation

Photo by Aimee Quiggle

A key component of Dr. Mansueto’s ComB model is the SCAMP Intervention. SCAMP stands for Sensory, Cognitive, Affective, Motor, and Place. Once my client and I have a firm understanding of the hair pulling behavior, I use the SCAMP Intervention to create a customized treatment plan.

Sensory: For individuals who seek sensory activation on their scalp, we might use brushes, combs, pens, massages, or ice to ease sensations. For hands, individuals can get manicures, use lotions, or file their nails. For the face, bath oils, baths, facial scrubs, or a loofah could be used.

Cognitive: Often specific thoughts can lead to hair pulling. Common thoughts include, “My hair has to look perfect”, “I need to get rid of that blemish”, “I’ll just pull a little”, “I’ve already pulled once, so why try holding back?” Here, individuals practice thinking in more realistic way (e.g. “It’s okay to be imperfect”, “The best way to fix it is to let it heal”, and “A slip-up is not a failure, any progress is helpful”).

Affective: When specific emotions lead one to pull their hair, the best way to address this problem is learn more effective ways of regulating your nervous system. To become more relaxed, individuals can use diaphragmatic (belly) breathing, progressive muscle relaxation, practice meditation, listen to white noise, use a heating pad, drink a warm beverage, take a slow relaxing walk, use an eye/face gel mask, or take a long bath. To address intensity and pain, individuals can stick their fingers in frozen ice cream, put their face in a bowl of ice water, suck on a lemon, snap a rubber band on your wrist, take a cold shower, go for a fast run, or chew a large wad of gum. To deal with boredom, individuals can learn about a topic of interest on the internet, write in a journal, draw, play a musical instrument, read a book, paint, take photographs, do a crossword puzzle, and garden.

Motor: In addition to HRT, physical barriers can often help reduce hair pulling. For example, rubber fingers, band-aids, sleep masks, head wraps, glasses, hats, gloves, thumb braces, and tape can all be used to create barriers to hair pulling. Also, changing the condition of your hair and hands can help (e.g. wetting hair, placing Vaseline on your eyelids/brows, wearing false nails, using hand lotion). Objects such as loud bracelets, elbow braces, and perfume can increase awareness of hair pulling. Fiddling toys can sometimes provide alternatives to hair pulling (e.g. koosh balls, silly putty, clay, knitting). For oral rituals, chewing gum, eating sunflower seeds, chewing raw pasta, chewing a toothpick, and eating gummy bears can help.

Place: Comprehensive interventions should also target the environment in which hair pulling takes place. Individuals can try changing light levels, covering mirrors, getting rid of tweezers (or placing them in the freezer), using sticky notes, keeping certain doors open (to decrease privacy), rearranging furniture, and sitting in different positions.

Monitoring Progress and Revising Treatment

As a client and clinician begin treatment, it’s important to keep a daily log of the hair pulling episodes and the attempted interventions. Some interventions will work right away, others will need to be fine tuned, and some will lose their effectiveness over time. The client and clinician must work together, constantly monitoring and reevaluating the treatment until a plan is developed that fits the needs of the client. This process could take weeks or months. Additionally, since trichotillomania changes as we age, treatments that worked at one phase of life may not work in another.

Advice for Treatment Seekers and Treatment Providers

As you can tell, treating trichotillomania is a complex and long process. It takes a lot of time, courage, and motivation on the part of the individual and a lot of training and experience on the part of the clinician. If you are someone who is suffering from trichotillomania, make sure that your clinician is using scientifically supported treatments. Ask them about the type of treatment they are using. If you don’t hear anything about increasing awareness, changing behaviors, or emotional regulation, their treatment may not be based on science. If they start using personal testimonials and wild theories to backup their treatment, or say their treatment cannot be evaluated by science, run away – they’re probably selling you snake oil.

I recommend using the Trichotillomania Learning Center’s list of health care providers to find individuals trained in scientifically supported treatments. If you are a health care provider wanting to learn more about these treatments, I highly recommend attending a Trichotillomania Learning Center Professional Training Institute and browsing through their clinical resources.

References:

Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hair-pulling (trichotillomania): A comparative study of habit reversal and negative practice training. Journal of Behavior Therapy and Experimental Psychiatry, 11, 13-20.

Duke, D., Keeley, M., Geffken, G., & Storch, E. (2010). Trichotillomania: a current review. Clinical Psychology Review, 30, 181-193.

Franklin, M. E., Edson, A. L., & Freeman, J. B. (2010). Behavior therapy for pediatric trichotillomania: Exploring the effects of age on treatment outcome. Child and Adolescent Psychiatry and Mental Health, 4, 18.

Keuthen, N. J., Rothbaum, B. O., Welch, S. S., Taylor, C., Falkenstein, M., Heekin, M., Jordan, C. A., et al. (2010). Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania. Depression and Anxiety, 27(10), 953-959.

Mansueto, C. S., Townsley-Stemberger, R. M., McCombs-Thomas, A., & Goldfinger-Golomb, R. (1997). Trichotillomania: A comprehensive behavioral model. Clinical Psychology Review, 17, 567-577.

Walther, M. R., Ricketts, E. J., Conelea, C. A., & Woods, D. W. (2010). Recent Advances in the Understanding and Treatment of Trichotillomania. Journal of Cognitive Psychotherapy, 24(1), 46-64.

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I’ve been pulling my eyelashes and eyebrows out since I was about 9 and I’m 32 now. It affects me everyday of my life. I wear false eyelashes and draw on eyebrows everyday to try to cover up my habit…however, my hands still find a way to pull, often times leading me to accidentally pull off my false eyelash or make a gap in my drawn in eyebrow. I can’t get my face wet in front of people in fear they will see me without my makeup…so I never swim or leave a bathroom after a shower without putting on my makeup. I have a boyfriend now that moved in with me and I don’t even take off my eye makeup to sleep, which causes irritation and makes me even more aware of my eyelashes so I pull more.

I recently started to see a psychiatrist to try meds to help me. I am on 200 mg of Luvox and take klonopin 3 times a day. At first it was working and my pulling calmed down. But after two months I pulled everything out and feel even more of an urge. I am constantly tired and just want this to stop.

I am going to try CBT in April along with th meds. This article and the support helps let me know I am not alone. It feels like such an uphill battle so definitely need the support that it can be done and this isn’t hopeless. Good luck and vibes to all that share this journey.

I have battled this since I was about 13 years old and a few times I was able to over come the disorder an my hair actually grew back to the point I cold wear it down. I live with the shame every day… its so bad that I think people think im ugly cuz I always have to wear my hair up or wear a hat. People have never asked me why I never wear my hair down or even questions why I always wear hats, they just chop it up to that’s my style. Ive talk to friends about it and unless you live with this disorder then you will never fully understand that its not just as easy as just stopping. When I have a bad night of hair pulling I always feel this horrible sinking feeling and a wave of shame just consumes me. I have talked to my family doctor and they keep sending me to therapy and physiologists who mostly pump me fully of drugs that make matters worse. I have met one person in my life that had the same disorder and it was almost a relief finding someone else going threw the same issues I go threw on a daily basis. for a long time I thought there was something wrong with me and I was all alone. I wish there was support groups set up for people like us ..I feel like if we had an open form or group to talk about our experiences about this disorder it would help a lot cuz I know as a adult u kinda just try to deal with it but as a child growing up with the problem you feel absolutely isolated from the world so more awareness I think would help people and children realize they are not alonezbthstths 5 months ago

I have pulled for over 50 years. I thought it started when I was about 12 or 13. But my mother talked about a teddy bear I used to have where I pulled the hair out of and ate the hair. So I must have been a toddler when it began. My younger also sister began pulling at about the same age I did, but managed to stop it. She is, however, an obsessive nail biter to this day. She even used to bite her toenails when there were no nails left on her fingers. I noticed my mother had dermotillomania (sp?). She had picked at the skin on the back of her thighs ever since I can remember. None of us ever had any issue with addiction of any kind…unless this disorder could classify as such…no drugs, alcohol, no obesity, no sex addicts, no gambling….nothing of the sort. I’m almost 60 and still trying to stop. I know I’ve stopped for a year or two at a time, definitely for months at a time, but I have no idea how or why. The stopping was not a conscious effort. It just happened on its own. I would love to know what the difference was at those times in my lifeikki 8 months ago

Thank you for writing this. I have been through the disorder since I was a teenager. I thought I had been “cured” many times, but somehow it keeps creeping back into my life. I’m recently engaged and planning a wedding. I don’t think I realize the stress I am under at work and the stress from creating a whole new life, with the love of my life. I find myself pulling at work when I’m alone. It helps me cope with stressful situations, but I know in reality, it is just making matters worse. It is helpful to know that I am not alone in my struggle. I again thank you for sharing this post and brining awareness to this disorder.

I have faith that God will give me health everyday I pray this goes away I don’t have it as bad as I did a year ago but I have left myself bald you can’t lose faith in yourself keep trying to control it I Jesus name amen

abby 10 months ago

I feel you:( I have the same disorder, I even broke my engagement because of it. I can’t live my life as I want to:(

 Cathy Scott 2 years ago

http://www.gofundme.com/twingirlshair
Please help fund these twin girls ( the above website link) medical bills for hair pulling.

this disorder is absolutely humiliating and soul-crushing.

for some reason many providers simply look upon it as “just a bad habit” or phase like nail-biting, or if newer to the issue, are fixated/fascinated/repulsed and cannot get past their own intellectual interest in the specifics of pulling. WE ARE SUFFERING AND NEED COMPASSION!!!

…and the isolation and shame is far worse than the vanity considerations.

it seems there are many and varied reasons as to why and how pullers pull, as well as solutions, but for the lifelong and SEVERE level puller, like myself, answers or in-depth treatment isn’t coming fast enough or available widely enough. i also suspect skin-picking and hair-pulling are even more prevalent than is stated at this time.

the fact is, for me, if hair/skin were a drug, I would have OD’d many, many years ago.

every aspect of life has been limited and diminished by this addiction. and it is so difficult to find a support community, like NA/AA, or a therapist familiar enough with this matter. why is their no resident facility for someone like me?

my point here isn’t to grind on about my (self-imposed) pain, but to bring up hard questions where i feel there is an open and caring ear. thank you Dr. Mattu for this comprehensive post, and i hope these questions from a puller provoke thought and action by other professionals.

EVERY therapist should be comfortable or aware of these concepts, just as Cutting & Anorexia Nervosa & Bulimia are no longer exotic conditions. please, researchers and practitioners, take into account just how severe

 itsTrichy 7 years ago

This is a great overview. I am a firm believer in ComB and SCAMP, as I’ve seen how awareness of the sensory component can be crucial in treating the disorder. Even if you hit all the other ones, but don’t pay attention to the sensory aspects, I don’t think treatment will be as effective.

Yet, our more overwhelming problem in all of this is finding GOOD therapists who are TRAINED. There aren’t enough. In my area, there’s one therapist who is TLC recommended, but with whom I don’t mesh well. Therefore, I can try treatment without a good client/therapist relationship (which seems doomed to fail), or I can go to a therapist whom I work well with but is under trained. This happens all over the place, especially if you don’t live in or near a big city. We need to EDUCATE the professionals & get them on board!!