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Posted by on Apr 19, 2014 in Mental Health, Psychology, Science, Teaching | 6 comments

Evidence-Based Treatments for Trichotillomania

This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course during Spring 2014. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders, with one of those focusing on evidence-based treatments for those disorders and the other focused on a particular myth or misunderstanding about mental illness.

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Evidence-Based Treatments for Trichotillomania by Kelly Jent

I want to tell you a short story.  It takes place in 5th grade.  It was an ordinary day, and I was up in my room waiting for my grandparents to get to my house for dinner.  As a 5th grader, I hadn’t given too much thought about wearing makeup, shaping my eyebrows… all those  “normal” girl things.  However, this afternoon I was sitting in front of my mirror and began plucking my eyebrows.  And kept plucking them.  Until they were all gone.  And yes, by all gone, I mean completely pulled everything out.  What!  Who does that?  I immediately grabbed a big floppy hat to try to cover the bare spots above my eyes, and went downstairs because my grandparents had arrived.  After dinner, my dad approached me and asked what happened.  I shrugged and said I didn’t know why I did it; I was just plucking them and went too far I guess.  He told me to be careful because the same sort of thing happened to him when he was a child.  He even gave what I had done a name: Trichotillomania.  He explained that this ran in his side of the family and said that it was a disorder that caused you to pull your hair out. Um, okay, dad. Sure.

Fast forward to today.  I have been dealing with trichotillomania consecutively for nine years.  After dealing with a short episode of it from 5th-6th grade, the symptoms disappeared until my freshman year of high school.  Trichotillomania (trich or TTM), also known as “hair pulling disorder”, is classified as an OCD related disorder in the DSM-5.  Trichotillomania involves the recurrent pulling of one’s hair.  This can include any areas of the body; however, the three most common sites are the scalp, eyelashes, and eyebrows.  Trich varies in severity across the population who suffers from it.  By having this disorder manifest itself outwardly, it is associated with anxiety and shame, and the desire and need to appear “normal”.  This struggle for normality comes in the form of wigs, makeup, fake eyelashes, extensions, headbands, hats… anything to attempt to cover the damage.

Why would someone want to pull their own hair out, you may ask?  To be honest, I’ve been asking myself that for the past nine years.  The exact biological cause of trichotillomania is unknown; however, the disorder is widely accepted as having a strong genetic influence, and when mixed with the right environmental factors, it is more likely to present itself.  It is considered a self-soothing or coping mechanism for anxiety or stress.  However, get ready for a curve ball; it can occur in times of relaxation as well as in stressful or anxiety provoking circumstances.  Oh good, thanks, that really narrows it down.  So how do you treat something if you aren’t sure of the underlying cause, how it started to begin with, and symptoms that occur under the influence of many different factors?  Medications as well as behavioral techniques have been used to attempt to treat trichotillomania.  There is currently no treatment that is effective for every patient because the disorder varies so much from person to person.  With no direct biological cause, medical treatment options are limited, and, rather, a form of cognitive-behavioral therapy called habit reversal training is the most effective, supported, and accepted treatment of trich today.

Cognitive behavioral therapies (CBT) focus on determining the relationship between thoughts, feelings, and behaviors.  By changing someone’s thought patterns that are associated with certain behaviors and by practicing new behaviors and thoughts in the same familiar situations or while experiencing the same emotions, we essentially train our brain to respond in a new way to the original stimulus.  Due to the frequent repetition, the act of pulling one’s hair out can eventually become automatic.  There may not be any feelings that are urging you to pull; rather it is more of a habit – an automatic go-to in certain situations.  The automatic aspect also occurs in individuals who may not even realize that they are pulling.  This treatment approach relies on the ability of the person to learn how to recognize the environment where they pull, and change their habitual behaviors as well as the thoughts and feelings behind it.

Habit reversal training (HRT) typically consists of two main phases: awareness training, and competing response training.  The first phase of HRT increases the consciousness of the behavior by challenges the patient to become actively aware of when they are pulling.  This phase incorporates self-monitoring techniques such as observing when you tend to pull, where you are, your emotional state, which hand and fingers you use, etc.  A detailed record is kept of the hair pulling episodes including cues that triggered it.  These cues may be internal (anxiety, boredom, visual or tactile sensations, or thoughts associated with hair) or external (tools such as a mirror or tweezers, and certain environments free of people: bedroom, bathroom).  By pinpointing and becoming aware of the warning signs, it allows the patient to combat the creeping urge to pull with a competing response.  This is phase two of HRT: competing response training.

A competing response is designed to make it hard or impossible for the individual to pull.  This could be an action such as making a tight fist and putting their hands in their lap, sitting on their hands, etc.  This action is to be repeated each time the individual is faced with an urge to pull, or in situations where pulling typically occurs.

Incorporating a few other CBT techniques in with HRT to create a comprehensive behavioral model allows the heterogeneity of this disorder to be attended to.   This method, using HRT as the central component, allows for the individual idiosyncrasies in each case to be accounted for and assures that the patient be treated accordingly.  By considering thoughts, actions, environmental factors, and emotions, the therapist is provided with the information necessary to help cognitively change the patients’ attitude about pulling and provide suggestions for ways to combat the urges.  A nice overview of this model can be found here.

Finally, medicine has been used in the treatment of trich but overall is not as supported as the behavioral techniques.  Results are generally mixed, and no medication has been shown to be clearly effective.  While certain medications may temporarily help some people, if behavioral therapies are not incorporated into treatment, the symptoms will usually return once the patient stops taking the medicine.  Clomipramine, a tricyclic antidepressant, has been used and there was some success in treatment in the first study done with it.  SSRI’s such as Prozac, Paxil, and Zoloft have also been considered for treatment, but results are typically mixed.

In my personal experience, I have never stuck with anything long enough to figure out what works for me – but that’s a whole different story.  However, I can say, and I think that I can speak for many others with trich, that through this journey the ability to trust friends and family with this “secret” plays a crucial role not only for accountability purposes, but for unconditional encouragement and support.

  • An Ardent Skeptic

    I read this post and the links provided for treatment of this disorder last night because, when I was a child, I knew someone who had this disorder. She pulled out her eyelashes, and her eyelids were always red and swollen, with a crust of yellowish flakes. Thinking back on her now, these may have been indicators of infection. Then, as I was trying to fall asleep, I thought about the other health risks which might be associated with this disorder like the possibility of hairballs from digesting hair. I have now checked for this possibility and find that hairballs can be a serious issue for those who ingest the hair they pull. Those of us who don’t suffer from these types of disorders rarely consider all the difficulties that sufferers can experience. The girl I knew was laughed at for pulling her hair out. Being the little worrier that I was, I never laughed at her because I thought her red, swollen, crusted eyelids looked as though she might be suffering some pain.

    I was also curious if needlework was sometimes recommended as a way of keeping hands busy, and I see that it is. For those who enjoy the sensory stimuli of hair pulling, taking up tatting might be a good choice. No. 70 tatting cotton is quite thin and rather hairlike, and tatting is one of the few types of needlework which requires significant handling of the fiber used to engage in the craft. The cotton is manipulated by both hands to make lace. It’s also a very portable craft, as it only requires a tatting shuttle and the tatting cotton, so it’s an activity which can be engaged in anywhere. (BTW, needlework is a unisex endeavor despite the general notion that it’s women who do it. One of the world’s best knitters is a man. And many men engage in needlework activities, particularly after they have retired.)

    • http://www.caleblack.com/ Caleb W. Lack

      Infection was a very common side-effect of repeated pulling in the past (less common now due to higher amounts of hygiene). The shame and stigma from the pulling is often at least as problematic for people with TTM as the pulling itself.

      Needlework is something that I sometimes recommend, if the person is open to it, for when they are doing things like watching TV or a movie or prior to falling asleep in bed, as these are prime pulling times for many folks. My fingers are much too clumsy for it, myself, though!

      • An Ardent Skeptic

        If you recommend needlework, then tatting might be a good choice. It’s rather like playing Cat’s Cradle with a lot of pulling of the tatting cotton involved to make full and half hitches and close the loops.

        • http://www.caleblack.com/ Caleb W. Lack

          One of the first clients I ever had in graduate school was a tatter. I had never heard of it prior to that, but am now QUITE familiar with it :)

  • Adam Braly

    Kelly Jent! I don’t imagine that I will ever fully understand how excruciatingly stressful this act of self-disclosure has been for you. I am honored that you have chosen to share this with a few of us individually and I envy the degree of bravery you have demonstrated in composing a blog post for the world to see. You inspire courage that resonates deeply within, and for that I thank you. You are beautiful throughout and I will speak for us all when I say – you’re fucking awesome.

    • http://www.caleblack.com/ Caleb W. Lack

      Amen, brother. This was one of the bravest things a person with TTM could do, and she’s done it in style.

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