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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

hands.jpg

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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How Long Does it Take to Break a Habit?

image.jpegYes Trich is more than a ‘bad habit’. However, it is an unwanted behavior that I believe can be unlearned or changed.

My goal is to break this ‘habit’. I have been working at this since beginning this blog 2 years ago. Yes, I tried to stop pulling before that, but my mindset changed. I was willing to do everything I could, including changing my mindset.

Before a bad habit or unwanted behavior can be changed or stopped, I believe you need to change your thinking. Your thinking rules everything you do. This is why cognitive therapy is effective. The fist step of changing your thinking is to accept that you have a real disorder that causes you to pull your hair. It is not a lack of will power or discipline that keeps you in the cycle of hair pulling and self-loathing that often directly follows pulling. Click here for more information about Commitment and Acceptance Therapy.

Once you have changed your thinking, you can focus more on the unwanted behavior (hair pulling or any behavior). Cognitive Behavioral Therapy follows this approach (CBT).

According to The OCD Center of Los Angeles:

“The most effective treatment for Trichotillomania is a combination of various types of Cognitive-Behavioral Therapy (CBT). Perhaps the most important of these is called Habit Reversal Training (HRT). HRT is based on the principle that hair pulling is a conditioned response to specific situations and events, and that the individual with Trichotillomania is frequently unaware of these triggers. HRT challenges Trichotillomania in a two-fold process. First, the individual with Trichotillomania learns how to become more consciously aware of situations and events that trigger hair-pulling episodes. Second, the individual learns to utilize alternative behaviors in response to these situations and events.

Other Cognitive-Behavior Therapy techniques can be used as adjuncts to HRT in the treatment of Trichotillomania. Among these are Stimulus Control techniques and Cognitive Restructuring. Stimulus Control techniques involve utilizing specific physical items as “habit blockers” to restrict the ability to pull hair, while Cognitive Restructuring helps an individual with Trichotillomania learn to think differently in response to the urge to pull their hair.
Skin Picking and Hair Pulling – Reflections

One of the most effective CBT developments for the treatment of Trichotillomania is Mindfulness Based Cognitive Behavioral Therapy. The primary goal of Mindfulness-Based CBT is to learn to non-judgmentally accept uncomfortable psychological experiences. From a mindfulness perspective, much of our psychological distress is the result of trying to control and eliminate the discomfort of unwanted thoughts, feelings, sensations, and urges. In other words, our discomfort is not the problem – our attempt to control and eliminate our discomfort is the problem. For those with Trichotillomania, the ultimate goal of mindfulness is to develop the ability to more willingly experience their uncomfortable thoughts, feelings, sensations, and urges, without pulling their hair. To learn more about Mindfulness Based CBT for the treatment of Trichotillomania, click here.

Here’s how long it takes to break a habit, according to science
*You’re gonna need more than will power.
SIGNE DEAN 24 SEP 2015

From daily tooth-brushing to the 11am coffee, we all have dozens of habits that get us through our daily routine. Some are great – weekly gym visits are often encouraged – others not so much, like smoking a pack a day, or dialling the number of the pizza place way too often. Because we recognise our habits as useful or detrimental behaviours, we often strive to shape them accordingly.

There’s no shortage of apps out there designed to help you form a habit, and many of those are built on the assumption that all you need is 21 days. This number comes from a widely popular 1960 book called Psycho-Cybernetics by Maxwell Maltz, a plastic surgeon who noticed his patients seemed to take about 21 days to get used to their new faces.
However, according to a 2009 study, the time it takes to form a habit really isn’t that clear-cut. Researchers from University College London examined the new habits of 96 people over the space of 12 weeks, and found that the average time it takes for a new habit to stick is actually 66 days; furthermore, individual times varied from 18 to a whopping 254 days.

The take-away message here is that if you want to develop a new behaviour, it will take at least two months, and you shouldn’t despair if three weeks doesn’t do the trick – for most people that’s simply not enough. Stick with it for longer, and you’ll end up with a habit you can keep without thinking.

But what about trying to break an unwanted habit?

It turns out the two – habit forming and breaking – can be quite closely linked. As psychologist Timothy Pychyl explains to Alison Nastasi at Hopes and Fears, they’re two sides of the same coin: “Breaking a habit really means establishing a new habit, a new pre-potent response. The old habit or pattern of responding is still there (a pattern of neuron responses in the brain), but it is less dominant (less potent).”

From daily tooth-brushing to the 11am coffee, we all have dozens of habits that get us through our daily routine. Some are great – weekly gym visits are often encouraged – others not so much, like smoking a pack a day, or dialling the number of the pizza place way too often. Because we recognise our habits as useful or detrimental behaviours, we often strive to shape them accordingly.

There’s no shortage of apps out there designed to help you form a habit, and many of those are built on the assumption that all you need is 21 days. This number comes from a widely popular 1960 book called Psycho-Cybernetics by Maxwell Maltz, a plastic surgeon who noticed his patients seemed to take about 21 days to get used to their new faces.
However, according to a 2009 study, the time it takes to form a habit really isn’t that clear-cut. Researchers from University College London examined the new habits of 96 people over the space of 12 weeks, and found that the average time it takes for a new habit to stick is actually 66 days; furthermore, individual times varied from 18 to a whopping 254 days.

The take-away message here is that if you want to develop a new behaviour, it will take at least two months, and you shouldn’t despair if three weeks doesn’t do the trick – for most people that’s simply not enough. Stick with it for longer, and you’ll end up with a habit you can keep without thinking.

But what about trying to break an unwanted habit?

It turns out the two – habit forming and breaking – can be quite closely linked. As psychologist Timothy Pychyl explains to Alison Nastasi at Hopes and Fears, they’re two sides of the same coin: “Breaking a habit really means establishing a new habit, a new pre-potent response. The old habit or pattern of responding is still there (a pattern of neuron responses in the brain), but it is less dominant (less potent).”

“It’s much easier to start doing something new than to stop doing something habitual without a replacement behaviour,” says neuroscientist Elliot Berkman. “That’s one reason why smoking cessation aids such as nicotine gum or inhalers tend to be more effective than the nicotine patch.”

Experts agree that there’s no typical time frame for breaking a habit, and the right recipe is going to be a mix of personality, motivation, circumstances, and the habit in question. “People who want to kick their habit for reasons that are aligned with their personal values will change their behaviour faster than people who are doing it for external reasons such as pressure from others,” says Berkman.

According to psychology professor Susan Krauss Whitbourne, sometimes a habit can be broken quickly: “In extreme cases, the habit can be broken instantly, such as if you happen to become violently ill when you inhale cigarette smoke or nearly get hit by a bus when texting and walking.” But in most cases it’s going to take longer than that, and you should probably allow for at least two months.

To successfully break a habit, you need to think of your strongest motivation, which will drive you along. Think of a ‘replacement behaviour’ for the habit, but make sure it’s a positive one – replacing smoking with snacking is a common trap, for example. And be patient. The longer you’ve had a habit, the longer it will take to get rid of it.

“Longtime habits are literally entrenched at the neural level, so they are powerful determinants of behavior,” explains Berkman. “The good news is that people are nearly always capable of doing something else when they’re made aware of the habit and are sufficiently motivated to change.”

So stay strong, you can do it.