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A Beginner’s Guide to Treating Trichotillomania

Clinical Psychologist

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

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. Manysueto’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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Trials are Temporary

A well-cared-for earthly life will grow like a green, healthy field, full of beautiful flowers, ripe for harvest. Yet, this field will wither, storms will destroy crops, and flowers will fall as seasons change. But, God’s Word endures forever.

When we decided to follow Jesus, we made a place for His Word to grow in our hearts. Our flesh will fail, but now with this seed planted in us we will live forever. Trials are temporary, but God’s Word in us—His life in us—is permanent.

Thank you God!!

This is exactly what I needed to hear this morning. It was the message in my morning devotional. I love it when God uses a devotional, scripture, or song to speak to me. I am struggling this week and He has been faithful in reminding me of his promises. He is my rock, my shelter from the storm, my healer, and my redeemed. Because he lives, I also have life. He shows me how to live life to the fullest and have peace despite my circumstances.

The things of the this world will fade away, but my relationship with Him  is everlasting and beyond my full understanding. I am so glad God baffles me. If I had a God who I could understand, He would not be that great of a God. My God is omniscient, omnipotent, omnipresent, and he loves me and you! He wants His children to call on His name and ask for forgiveness so he may dwell in our hearts. All we need to do is ask. It is by faith and not our actions that we are made to new. “He wants us as we are, not how we ought to be.” He will heal our brokenness if we let him and our sins will be washed away. ❤

Drops in the Ocean

By Hawk Nelson

I want you as you are not as you ought to be
Won’t you lay down your guard and come to me
The shame that grips you now is crippling
It breaks my heart to see you suffering
‘Cause I am for you
I’m not against you

If you wanna know how far my love can go
Just how deep
Just how wide
If you wanna see how much you mean to me
Look at my hands
Look at my side
If you could count the times I’d say you are forgiven
It’s more than the drops in the ocean,

Don’t think you need to settle for a substitute
When I’m the only love that changes you
And I am for you
I’m not against you
I am for you
I’m not against you

If you wanna know how far my love can go
Just how deep
Just how wide
If you wanna see how much you mean to me
Look at my hands
Look at my side
If you could count the times I’d say you are forgiven
It’s more than the drops in the ocean

Open your heart it’s time that we start again, oh oh oh
Open your heart it’s time that we start again, oh oh oh

If you wanna know how far my love can go
Just how deep
Just how wide
If you wanna see how much you mean to me
Look at my hands
Look at my side
If you could count the times I’d say you are forgiven
It’s more than the drops in the ocean, ooh ooh
The drops in the ocean, woah
I am for you
I’m not against you
I am for you
I’m not against you

Read more: Hawk Nelson – Drops In The Ocean Lyrics | MetroLyrics

Suffering Produces Perseverance

I do not wish I never had trich or bipolar disorder. Although both come full of pain and suffering, there is another side. Working through my struggles has made me the person I am today. I don’t know if I would have have the same faith, spirit of perseverance, or compassion. I think my best traits have been developed through my pain. God did not cause my suffering, but He will use it for good.

I still hope to be pull free, but I am happy now as I am. My moods are relatively stable, and I have settled on a set of meds that works for me. I still pull, but it does not rule my life. Yes, I do spend a considerable amount of time practicing awareness and coping strategies. However, I do not feel like less of a person because I do this or because I am missing some hair. Everyone has some form of struggle in their life. Learning to use that suffering for good is the key to moving through it and finding a purpose for your pain. I read this devotional earlier today and thought that it lined up so well with the verse that has been on my heart, Romans 5:3-4.

Your Pain Often Reveals God’s Purpose for You

BY RICK WARREN — NOVEMBER 25, 2014

Your pain often reveals God’s purpose for you. God never wastes a hurt! If you’ve gone through a hurt, he wants you to help other people going through that same hurt. He wants you to share it. God can use the problems in your life to give you a ministry to others. In fact, the very thing you’re most ashamed of in your life and resent the most could become your greatest ministry in helping other people.
Who can better help somebody going through a bankruptcy than somebody who went through a bankruptcy? Who can better help somebody struggling with an addiction than somebody who’s struggled with an addiction? Who can better help parents of a special needs child than parents who raised a special needs child? Who can better help somebody who’s lost a child than somebody who lost a child?
The very thing you hate the most in your life is what God wants to use for good in your life.
The Bible says in 2 Corinthians 1, verses 4 and 6, “God comforts us in all our troubles so that we can comfort others. When we are weighed down with troubles, it is for your comfort and salvation! For when we ourselves are comforted, we will certainly comfort you. Then you can patiently endure the same things” (NLT).
This is called redemptive suffering. Redemptive suffering is when you go through a problem or a pain for the benefit of others.
This is what Jesus did. When Jesus died on the cross, he didn’t deserve to die. He went through that pain for your benefit so that you can be saved and go to Heaven.
There are many different causes for the problems, pains, and suffering in your life. Sometimes the stuff that happens you bring on yourself. When you make stupid decisions, then it causes pain in your life. If you go out and overspend and buy things you can’t afford and presume on the future, and then you go deeply in debt and lose your house, you can’t say, “God, why did you let me lose my house?” You can’t blame God for your bad choices.
But in some of your problems, you’re innocent. You’ve been hurt by the pain, stupidity, and sins of other people. And some of the pain in your life is for redemptive suffering. God often allows us to go through a problem so that we can then help others.

Peace

Reflections on Skin Picking and Hair Pulling - OCD Center of Los Angeles

Reflections on
Skin Picking and Hair Pulling

__________________________

Peace is not something you wish for; it’s something you make, something you do, something you are.

~ Robert Fulghum

__________________________

Peace

It’s quite natural to crave a feeling of peace. This is true whether you are experiencing a significant mental health issue, coping with a personal crisis such as a divorce or the death of loved one, or just trying to effectively manage the vicissitudes of every day life.

If you suffer with Skin Picking Disorder or Trichotillomania, peace is likely something you have been “wishing” for throughout your struggle. Of course, it would be wonderful if a feeling of peace would descend upon us just by wishing for it. But in reality, peace requires action. If you are committed to finding peace, you must wholeheartedly agree to do the work involved in attaining it.

In many ways, peace is a function of conscious acceptance in that it requires us to choose to accept reality as it is, rather than as we would like it to be. Of course, this may not be easy – sometimes the urge to pick or pull may be so powerful that it feels almost impossible to peacefully accept. Some with Skin Picking Disorder or Trichotillomania describe their urges as being like a loud sound that simply can’t be ignored – as if someone has turned the volume of the urge up so high that it is the only thing they can pay attention to.

In order to move through and past this extremely distracting urge, the first thing you must do is to fully accept its existence. If you spend your time attempting to control or avoid your picking and pulling urges, all you are doing is spending time engaging with something you cannot control.

Once you have accepted the presence of your loud and annoying urges to pick or pull, you can choose to engage in other activities. When you do this, you will notice the volume of your urges decreases because they are no longer front and center. They will still be there, but they will not be all-consuming. By choosing the action of doing something other than engaging with the urge, you take an enormous step forward in your recovery.

Choosing to act differently in response to your urges may at first feel quite difficult. But keep in mind that peace is not just wishing or hoping – peace is “something you do”. It is something that requires repeated practice. And with effort and commitment, it eventually becomes “something you are”.

__________________________

1) In what ways are you accepting, or not accepting, of your unwanted urges to pick or pull?

2) What actions might you take to further develop a peaceful, accepting relationship with your urges?

3) What are some activities that you find peaceful, and how can you implement them in your daily life?

__________________________

Weekly Tip: This week, try to be mindful of your thoughts, feelings, and actions at those times when you are able to accept and move through an urge without giving in to it. Notice if there is a sense of peace after you accept an urge rather than trying to control it. Practice this approach in order to develop a consistent, new pattern of responding to your urges with acceptance, action…and peace.

__________________________

For a free subscription to “Reflections”, please click here.

The OCD Center of Los Angeles is a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of OCD, Skin Picking Disorder, Trichotillomania, and related conditions. We offer the following services:

  • Individual Therapy
  • Low-Fee Group Therapy
  • Online Therapy
  • Phone Therapy
  • Home Visits
  • Intensive Outpatient Program
We treat adults, adolescents, and children, and offer services six days a week, including evenings and Saturdays. For more information, please contact one of our client coordinators at (310) 824-5200 (ext. 4), or click here to email us.
__________________________

OCD Center of Los Angeles
http://ocdla.com

(310) 824-5200

Written by
Kelley Franke, MA
and Tom Corboy, MFT

© 2016 OCD Center of Los Angeles

We will never share, rent or sell your personal information to third parties.

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Conflict in Relationships

img_5156Any type of stress, anxiety, anger, or conflict makes my pulling worse. It is a self-soothing behavior that helps me calm down and often dissociate from my feelings. Over the past few years, I have been working to use helpful strategies that help me relax without pulling my hair (which only leaves me feeling worse in the end).
As a high stress person, I have suffered with anxiety for most of my life. It still plagues me at times, but I have learned strategies to calm my mind and body. Taking a quick break from the situation, praying, practicing deep breathing, and trying to find a more positive outlook are some simple tools that have helped me.

If I catch myself being negative or getting stressed out, I try to take a step back and look at the situation objectively. In the past, I would catastrophize my situation. Now, I can identify those feelings and look for the truth.

  • Are my concerns based on truth?
  • Can I do anything about this?
  • Is there a more positive outlook I can strive for?
  •  If the worst case senario does play out, is it really that bad?

Beyond my stress and anxiety is anger that can cause relationship problems. The following article presents 3 ways to create conflict (and therein, 3 ways to avoid it). I know I am guilty of these and am making it a priority to avoid them. Reducing conflicts in our relationships, greatly increases our overall well-being.

when-you-say-something-really-unkind-when-you-do-something-in-retallation-your-anger-increases-anger-quote

Three Sure Ways to Create Conflict

By Rick Warren

“Any fool can start arguments; the honorable thing is to stay out of them” (Proverbs 20:3 TEV).

Wise people are peacemakers, not troublemakers. Wise people don’t carry a chip on their shoulder. They’re not always looking for a fight, and they don’t intentionally antagonize other people.

The fact is, if you’re around anybody for any length of time, you’ll figure out what that person does that irritates you, and you file that information in the back of your mind as a tool to use when you get in an argument. It becomes a personal “weapon of mass destruction”! When you get in an argument, and that person says something that hurts, offends, or slights you in any way, then you pull out the big gun. You push the hot button. And it works every time!

You know what the Bible calls that? Foolishness! You’re not getting any closer to the resolution. You’re not helping the relationship. In fact, you’re hurting it. It is not wise.

Proverbs 20:3 says, “Any fool can start arguments; the honorable thing is to stay out of them” (TEV).


We all use tools, tricks of the trade, and skills in relationships that are actually counter productive. They’re hurtful, they’re harmful, and they don’t get you what you want out of relationships. In fact, they get you the exact opposite behavior. But when we lack wisdom, we use them anyway.

There are many of these tools, but here are just a few:

1. Comparing. Never compare your wife, your husband, your kids, your boss, or anybody else, because everybody’s unique. Comparing antagonizes anger.

2. Condemning. When you start laying on the guilt in a relationship, all you’re going to do is get the exact opposite of what you expect. It doesn’t work. It’s foolish.

3. Contradicting. William James, the famous psychologist said, “Wisdom is the art of knowing what to overlook.” There’s some stuff you just need to overlook.


The Bible says in Proverbs 14:29, “A wise man controls his temper. He knows that anger causes mistakes” (TLB). Have you ever said or done anything stupid out of anger? Yes? Because when you get angry, your intelligence goes out the window. When you get angry, you say and do foolish things that are actually self-defeating.

Did you ever think about the fact that there is only one letter difference between “anger” and “danger”? When you get angry, you are in dangerous territory. You are about to hurt others — and yourself — with your own anger.

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BFRB Awareness Week

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The TLC Foundation for BFRBs

Share this Video

We can all relate to the universal feelings of isolation, sadness, and anxiety. But when BFRBs contribute to these feelings, they can become difficult to manage, and have a significant impact on our well-being. Share the video online – everywhere you can – using the hashtags #notalone and #BFRBweek.

“Much of the suffering experienced by those of us with a BFRB is caused by shame we feel about the disorder, and that is curable now,” says Jennifer Raikes, Executive Director of The TLC Foundation for BFRBs. “By raising awareness about BFRBs, we can end the isolation, and much of the suffering, so prevalent with these disorders.”

 

http://www.bfrb.org/volunteer-get-involved/raise-awareness/bfrb-awareness-week