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Cognitive-Behavioral Treatment of Trichotillomania
Friday, 15 April 2011 16:09


By Fred Penzel, Ph.D.

Of all the disorders belonging to the OCD family, trichotillomania is probably one of the least understood by both sufferers and practitioners alike. It has also been, for many years, among the most frustrating and difficult to treat for all parties concerned.

The name trichotillomania (TTM) coined in 1889 by Francois Henri Hallopeau, is in itself an unfortunate and misleading one. It seems to pigeonhole the disorder with other unrelated problems such as kleptomania, pyromania, etc. In addition, it seems to imply an enjoyment and attraction on the part of sufferers to pursue their hair pulling activities. Those who have the disorder understand that this obviously is not true. The term 'mania' itself seems to suggest a serious mental illness.

Given what we now understand about TTM, it appears to be a disorder that has both biological and behavioral components. The fact that antidepressant medications such as Celexa, Prozac, Paxil, Luvox, and Zoloft can, in many cases, relieve much of the urge to pull, is strong evidence of an underlying neurochemical basis. To those who would go the route of medications alone, I would say that while medications can be helpful in treating TTM, I have rarely seen them eliminate 100% of the problem. I strongly believe in combining behavioral treatment with drug therapy. As in other obsessive-compulsive disorders, both appear to work better than either one alone. Medications may also be imperfect for some in terms of the side effects they produce. Sometimes these side effects prevent individuals from taking effectively high enough doses to lower their symptoms substantially. One other situation where medications cannot help is in the case of women who wish to become pregnant and need to be drug-free.

The gap between what the drugs can and cannot do can be bridged by behavioral therapy. Over the years, many assorted techniques for treating TTM have been tried, with little or no success. These would include psychoanalysis, biofeedback, relaxation training, aversion therapy, etc. I have heard a few isolated reports of the successful use of hypnosis, but only a few small studies are available on its effectiveness. Although more formal scientific studies of the use of behavioral therapy for TTM remain to be done, it appears that it is the most effective treatment that we possess.

TTM is an extremely complex disorder with many potential inputs. It is my own hypothesis, and that of others, that TTM is the result of a dysfunction of a mechanism that regulates levels of stimulation within the central nervous system. People seem to pull when they are either overstimulated (stressed, anxious, or excited) or when understimulated (bored or inactive). Obviously, there are many things that can influence a person's stimulation levels. This is why there does not appear to be one single technique, approach, or device that can relieve the problem. TTM appears to respond best to an approach made of a number of different components.

There are two main components at the heart of behavioral therapy for TTM, and these are Habit Reversal Training (HRT) and Stimulus Control (SC). I like to refer to this package as HRT Plus. HRT was pioneered in 1973 by Dr. Nathan Azrin in 1973 for the treatment of tics and nervous habits. Unfortunately, as TTM was not known to be widespread at the time (we now believe that there are possibly several million sufferers in the U.S. alone - one estimate claims eight million) and because there were practically no practitioners involved in its treatment, this technique remained relatively unknown

- except to a handful of specialists around the country. This obscurity is confirmed by a quick scan of the literature, which revealed that since 1973 it has been mentioned in only about eight studies involving the treatment of around 44 individuals with TTM. Studies of this technique show good results, though. One study, done in 1980 by Azrin, Nunn and Frantz showed decreases in hair pulling of over 90%.

Generally speaking, there are four steps to HRT. Each step is practiced separately and then all four are finally integrated into a unified program. The first step involves the development of an awareness of the habit itself. While many with TTM feel an urge or a tension prior to pulling, many also pull hair at times when their attention is focused on some other activity, such as watching TV, talking on the phone, reading, driving the car, etc... They seem to go into what can best be described as something like a trance. They do not realize what they have been doing until the bout of hair pulling has stopped. Those who do notice it, tend to quickly forget recent incidents as they are unpleasant to think about or remember. Getting those with TTM to pay attention to hair pulling is not always easy for this last reason. In any case, it is easier to control a habit when you are aware of the circumstances surrounding it.

We accomplish our first step by giving patients special self-monitoring sheets to fill out in between weekly sessions. They are instructed to keep track of when hair pulling episodes occur, how long they last, how many hairs were pulled, how strong the urge was, where the episode occurred, what they were doing at the time, and what their emotional state was. Interestingly enough, even those with TTM who seem to be aware of the circumstances surrounding their pulling, are often surprised at what they discover about their own patterns. This recording continues throughout the full treatment period. In addition, patients are also instructed in how to graph the number of pulling episodes they have had on a daily basis. This makes progress very visible, and also enables us to spot daily or weekly patterns that occur in the person's pulling.

Generally, we begin the second step about a week after the recording in the first step had begun. This involves learning progressive muscle relaxation. This is accomplished via taped instruction. This exercise is done once a day and takes about 15-20 minutes. The purpose of it is to focus oneself and to try to reduce some of the tension. After about 2 weeks most people become fairly proficient at relaxing their bodies and regulating their breathing. At this point, they are given as abbreviated relaxation tape in which they compress their relaxation skills into a roughly 60 second period. This is then practiced several times a day while learning the third step. 

The third step is training in the use of diaphragmatic breathing. This is taught in the office, with practice a home to follow. It is very similar to the type of breathing used in the practice of yoga and meditation. It aids in achieving relaxation and in centering and focusing the individual, so that they may be more aware of their bodies and the sensations they are experiencing, as well as in reducing high levels of stimulation that can lead to pulling.

The fourth step is the acquiring of a muscle tensing activity which is somewhat opposite to, and incompatible with hair pulling. It is known as a 'competing response'. In this step, patents are taught to make a clenched fist with the hand that they use to pull hair, to bend the arm at the elbow 90 degrees and to press the arm and hand firmly against their side at about waist level. This position is then held for one minute. This is practiced in the office, and then at home over the following week. I usually recommend around three practice periods per day, of ten repetitions each.

Finally, steps two, three, and four are assembled into a complete habit reversal response. Patients are instructed that as a first priority, whenever and wherever they get the urge to pull, they are to (1) relax themselves, and simultaneously (2) Breathe from the diaphragm for 60 seconds, and when this is done, (3) clench their fist and press their arm to their side for 60 seconds. If they find themselves already in a hair pulling episode, they are as a second priority, to interrupt the episode while it is in progress with their habit reversal response. As a third and lowest level priority, they are to practice the response even if they have already stopped pulling and the episode had just ceased.

The HRT is fairly discreet and can be practiced in most situations without attracting attention. This does not turn out to be a serious problem as most with TTM seem to do the majority of their pulling when they are alone. The one main exception to the above instruction concerns handling urges to pull when driving a car. In such a case, patients are instructed to just do the diaphragmatic breathing and to clench their hands on the wheel instead. This can obviously be adapted to other situations where HRT is not possible or advisable. HRT appears to be adaptable to treating all types of hair pulling from different parts of the body.

It is vitally important from the beginning to explain the need for patience and persistence in working to develop HRT and SC skills! Some will practice them for a few days and pessimistically conclude that it won't work and that they will never recover. I like to point out that they have probably practiced hair pulling hundreds or thousands of times, versus the few dozen times they have used their behavioral skills. It is also important to remember that those with TTM can get easily discouraged at first. They have probably tried to stop many times in the past, without success, and have gotten into the habit of visualizing themselves as failures and people who cannot control themselves. They have often had to face the ridicule and criticism of others. Trichotillomania seems to them to be more powerful than they are.

The other major component that is used in treating TTM is Stimulus Control (SC). HRT is very useful as a habit blocker, but as mentioned earlier, it cannot account for all the different inputs that lead to pulling. In my opinion, it should not be relied upon as your only technique in treating TTM. SC is a behavioral treatment that seeks to help sufferers first identify, and then eliminate, avoid, or change the particular activities, environmental factors, routines, states, or circumstances that have become associated with and that trigger hair pulling. A good deal of hair pulling is habitual and occurs predictably in many locations and situations. Over time, just being in these places or situations can trigger pulling episodes. The goal is to become aware of and consciously control. these triggers that lead to pulling and create new learned connections between the urge to pull and new, non-destructive behaviors. SC includes the use of substitute (nondestructive) forms of stimulation, and the rearrangement of routines and environments.

There are two other techniques we often employ along with HRT Plus. One is the use of covert self statements in which patients are encouraged to practice telling themselves things which will help them resist or cope. Examples to help someone cope would include, "Pulling doesn't help; it only makes things worse", "I CAN control my pulling if I just keep trying", "Every hair counts," or "I don't have to give myself permission to pull". Self-instruction statements to help in carrying out treatment could be "You're getting close to a risky situation - keep your hands down", or "Get ready to use HRT; you have a choice". The other technique which is more of short term help is the use of physical aids such as white cotton waiter's gloves sold in restaurant supply stores, or acrylic nail tips. When self-awareness problems remain strong, these act as reminders to interrupt pulling, and also can prevent it. As self-management improves, they are usually outgrown.

One of the major misconceptions about behavior therapy is that is that it doesn't take feelings into account, but any behavior therapist who doesn't take the feelings that patients with TTM have into account will face many treatment failures. Coaching and encouragement are very important. The procedure is really not a difficult one to learn, but practicing it like a discipline takes stubborn persistence. I have seen the time it takes to master HRT Plus range from a few weeks to a few months. It varies with how strong the urges are and how persistent the person is in facing their symptoms.

One of the greatest stumbling blocks can be seen with the TTM sufferer who says "What is the point of my practicing so hard and letting my hair grow back, if in one slip-up I pull it all out again? I feel like such a failure when this happens." My answer to them goes something like, "Look, I know how difficult it must be in sticking with a treatment where hours of effort can seem to be undone in a few minutes. I'm sure you are feeling very disappointed with yourself at the moment. Remember though, it's more important to take the long term view, rather than just concentrating on where you are at this moment. Your hours of practice haven't been wasted. Eventually, if you keep picking yourself up each time you fall down, the accumulated force of all your practice will add up to behavioral change. Focus instead on crediting yourself for not pulling all those other times you usually would have. Don't measure your progress right now in terms of hairs you have or haven't pulled. Concentrate on learning the HRT and using SC and you'll reach your goal. It isn't possible to learn a new skill without some setbacks here and there, If you simply quit, then we can be sure you won't make any progress. As long as you keep trying, you're making progress.

I also believe in integrating cognitive therapy with the behavioral. This centers around teaching TTM sufferers that disturbed emotions are the result of illogical beliefs and distorted reasoning - that they cause their own upsets, but can also control them by learning to spot these errors and vigorously challenge them and change them. Beliefs such as "I must get the results I desire without discomfort or frustration", or Getting over TTM should be easy", or "I shouldn't have TTM, It's unfair and therefore I shouldn't have to work hard to recover from it." I like to use tapes and reading material to help my patients learn to challenge these ideas and to learn to think more sensibly in ways that will help them. One of the chief goals is to teach patients to quit rating themselves as human beings (which is impossible) and to stick to rating their behavior (which is something they CAN rate and change) - that doing badly, at times, does NOT mean that they themselves are bad or worthless.

Even when HRT and SC have been mastered and logical thinking is established, the work has not yet ended. I tell people that getting well is 50% of the job; staying well is the other 50%. TTM is best viewed as a chronic problem that you can recover from, but never be cured of. Long term maintenance is the key to keeping gains. We do this via a program called "relapse prevention". There are four steps to this. They are:

  1. Know your high risk situations.
  2. Be prepared for slip-ups; take immediate action.
  3. Accept that slip-ups do occur and are only temporary; don't downplay your efforts.
  4. Live a balanced life to reduce the role of stress, both physical and psychological.

Does everyone maintain their recovery and stay free of TTM following therapy? The answer is of course no. Because people aren't perfect, because life can be stressful, and because we are talking about recovery versus cure, a certain number of people will run into trouble from time to time. We expect this. Using their relapse prevention steps, however, or even returning for a few booster sessions of therapy, most can get back on the track in a short term.

To conclude, there are many useful techniques for treating TTM - no one must suffer needlessly anymore. Be a wise consumer in seeking proper therapy from a trained and competent therapist. The rest is up to you.

If you would like to read more about what Dr. Penzel has to say about Trichotillomania, take a look at his self-help book, "The Hair-Pulling Problem: A Complete Guide to Trichotillomania," (Oxford University Press, 2003). You can learn more about it at



Please Note: Then information in this site is presented as a public service to our patients and friends. It is not a substitute for a careful evaluation by a qualified mental health professional.  If you are already under treatment, do not make any changes in your regimen without consulting your doctor.

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