Behavioral and Pharmacological Treatment of ...

Behavioral and Pharmacological Treatment of Trichotillomania Ruth M. T. Stemberger, PhD Dan J. Stein, MD, PhD Charles S. Mansueto, PhD

Hair pulling, known as trichotillomania (TTM), has become increasingly recognized as an often chronic problem for a large number of individuals, most of whom are women. This paper discusses current conceptualizations of TTM with particular focus on the medical and behavioral approaches. The relationship of TTM to other disorders is discussed and issues in pharmacotherapy that are unique to TTM are reviewed. A comprehensive behavioral model (ComB) that explains the environmental, motoric, sensory, cognitive, and affective patterns involved in hair pulling is presented. This model is used to describe how a clinician can develop treatment plans tailored to individual patients, including specific strategies for hair pulling reduction. Potential pitfalls and complications that may occur during treatment are also discussed. [Brief Treatment and Crisis Intervention 3:339–352 (2003)] KEY WORDS: trichotillomania, hair pulling, obsessive-compulsive spectrum, cognitive behavior therapy.

What Is Trichotillomania? The first medical report on chronic pulling was written in 1889 (Hallopeau), but ancient texts suggest that it has occurred for at least several thousand years (Christenson & Mansueto, 1999). It was not until relatively recently, however, that trichotillomania (TTM) gained sufficient attention and became better understood by clinicians, researchers, and the “pullers” themselves. Essentially, TTM is diagnosed when an individual repeatedly pulls his or her hair and suffers the physical, emotional, and social

consequences associated with this often chronic condition (American Psychiatric Association, 2000). Hair is usually pulled from the scalp, but the eyebrows, eyelashes, and pubic area are other common sites. Less frequent sites include beard, legs, mustache, sideburns, arms, and underarms (Thomas, Stemberger, MacGlashon, Witte, & Mansueto, 1999). Hair loss can range from minimal, with little noticeable hair loss, to severe, where most, if not all, hair at the pulling site is gone. Pulling occurs across the age range, from infants and young children, to adolescents and adults. While hair pulling in very young

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children is often temporary, it is usually a chronic condition when present in later years. Seemingly bizarre to those unfamiliar with the syndrome, it is estimated that TTM actually occurs in approximately 2% of the population, with females constituting 90% of adult sufferers (Christenson, Pyle, & Mitchell, 1991; Rothbaum, Shaw, Morris, & Ninan, 1991). Although hair pulling only poses health risks in rare circumstances—when the individual either swallows large quantities of hair, damages the skin to the point of infection, or avoids necessary contact with medical caregivers because of shame and embarrassment—the emotional and social consequences of pulling can be severe. “Pullers” report that the depression, anxiety, shame, embarrassment, feelings of unattractiveness, and low-self esteem associated with pulling can be significant. In addition, marked avoidance of social activities is characteristic of TTM sufferers who wish to maintain secrecy and avoid embarrassment. Commonly avoided activities include hair cuts, physical activities such as sports and dancing, being in the outdoors or in public, and sexual intimacy (Stemberger, Thomas, Mansueto, & Carter, 1999). Although pulling is not considered to be a sign of a more severe disorder, the comorbidity of TTM with other disorders—such as anxiety, affective, and personality disorders—is significant and ranges from 20 to 50% of clinical samples (Christenson, Mackensie, & Mitchell, 1991; Christenson, Chernoff-Clementz, & Clementz, 1992; Schlosser, Black, Blum, & Rise, 1994). It is

From the Behavior Therapy Center of Greater Washington, Silver Spring, Maryland (Stemberger); University of Stellenbosch, Cape Town, and University of Florida, Gainesville (Stein); Behavior Therapy Center of Greater Washington, Silver Spring, Maryland, and Bowie State University, Bowie, Maryland (Mansueto). Contact author: Ruth M. T. Stemberger, PhD, The Behavior Therapy Center, 11227 Lockwood Drive, Silver Spring, MD 20901. E-mail: [email protected]. © 2003 Oxford University Press

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important to understand that while TTM is a separate condition, the comorbid disorders can complicate the nature and severity of the pulling and the impact it has on an individual’s life. Furthermore, it is important that to understand hair pulling is to understand what it is “not.” Despite the fact that to onlookers it seems like a form of self-injurious behavior, no evidence suggests that it is related to parasuicidal behaviors such as cutting. This finding is consistent with the fact that the majority of those who pull do not report that the goal of pulling is to hurt or even numb themselves, as is the case with cutting (Thomas et al., 1999). It is also important to note that no research has produced evidence to support a causative relationship between childhood sexual or physical abuse and hair pulling (although the two can certainly cooccur). Another condition to which hair pulling has been compared is obsessive-compulsive disorder—that is, because individuals with TTM feel compelled to pull. However, studies comparing the two conditions point to the conclusion that they are distinct syndromes requiring different treatment approaches (Stanley, Swann, Bowers, Davis, & Taylor, 1992; Stanley, Borden, Mouton, & Breckenridge, 1995). In fact, TTM is classified in the DSM-IV-TR as an impulse control disorder, along with intermittent explosive disorder, pathological gambling, pyromania, and kleptomania. The extent to which TTM shares features with these disorders has yet to be determined; but because these disorders do not tend to co-occur with TTM as frequently as do other conditions, such as depression or OCD, the likelihood that they are closely related to TTM is low. Moreover, the diagnostic grouping of these disorders with TTM has been criticized (Christenson & Mansueto, 1999). What may provide a useful avenue for understanding TTM is the categorization of TTM within a cluster of presumably related disorders termed “obsessive-compulsive spectrum disorders” (OCSDs). In this view it is hypothesized

Brief Treatment and Crisis Intervention / 3:3 Fall 2003

Treatment of Trichotillomania

that a spectrum of disorders exists on a continuum that ranges from impulsive disorders at one extreme to compulsive disorders at the other (Stein et al., 1995). In this organizational scheme, at one end are the relationships among and within the obsessional syndromes, such as OCD, hypochondriasis (in which the individual obsessively fears having a disease), and body dysmorphic disorder (in which the individual obsessively fears that some aspect of their appearance is repulsive). At the other end are the seemingly “impulsive” tic disorders, such as Tourette’s syndrome (in which multiple motor and vocal tics occur). TTM can be conceptualized as belonging somewhere in the middle of this continuum (Ninan, Mansueto, Rothbaum, O’Sullivan & Nemeroff, 1998). In some respects it is like a tic, in that it is rarely triggered by obsessional thoughts and can occur without conscious awareness. In other respects, it is like a compulsion, in that it often involves a more complex set of behaviors and is often associated with some sense of relief from consciously experienced discomfort.

Treatment of Trichotillomania A variety of approaches have been used to help those who suffer from TTM, including psychotherapy, hypnosis, pharmacotherapy, and behavior therapy. Among these, the two most promising, from limited clinical trials, are pharmacotherapy and behavior therapy. Thus, these two approaches and their current applications will be described in more detail. Pharmacotherapy of Trichotillomania Earlier views of TTM as a possible OCD subtype led to the first controlled examination of the effectiveness of medication for alleviating hair pulling. Given that OCD patients respond more

robustly to serotonin reuptake inhibitors (SRIs) like clomipramine than to noradrenaline reuptake inhibitors such as desipramine, the efficiency of clomipramine was compared with that of desiprimine. In that study, clomipramine was found to be significantly more effective than desipramine for patients with hair pulling (Swedo et al., 1989), which not only offered a new treatment possibility for patients with this disorder, but it also provided some evidence for the hypothesis that trichotillomania lies on a spectrum of OCD-related disorders. A newer family of antidepressant medications, the selective serotonin reuptake inhibitors (SSRIs), have proven to be better tolerated than clomipramine, and each of these agents has now been shown to be more effective than placebo for the treatment of OCD. Nevertheless, the data for the efficacy of these agents in TTM is less convincing. Thus, the use of medication in the treatment of TTM deserves a more detailed examination than might be necessary if it were more similar to the treatment of OCD. Uncontrolled studies have suggested that SSRIs such as fluoxetine, fluvoxamine, and citalopram are useful in the treatment of TTM; in addition, controlled studies have shown efficacy for fluoxetine (Piggott, L’Heueux, & Grady, 1992) and venlafaxine, a serotonin and noradrenaline reuptake inhibitor (Ninan et al., 1998). However, a number of placebo-controlled trials of SSRIs have been negative (O’Sullivan, Christenson, & Stein, 1999). Furthermore, studies examining the maintenance of gains in patients receiving SSRIs have found relapse of symptoms even in patients receiving maintenance pharmacotherapy (Pollard et al., 1991; Benaroche, 1991). Disappointing results with SSRI treatment for TTM have led to attempts to use other kinds of medication, either as monotherapy or as a way to augment serotonin reuptake inhibitors. Dopamine blockers are known to be useful in Tourette’s disorder and are used as augmenting


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agents in treatment refractory OCD. Indeed, some data suggest that these agents have a role in the pharmacotherapy of TTM (Stein & Hollander, 1992; Van Ameringen & Mancici, 1996). New generation antipsychotics, such as risperidone and ziprasidone, have a better tolerability and safety profile than do older ones, such as haloperidol. Nevertheless caution is warranted, as these agents can have important adverse events, and placebo-controlled trials showing efficacy in TTM have not been done. A number of other agents have also been examined as potential pharmacotherapentic agents for TTM: naltrexone, an opioid antagonist; lithium, a mood stabilizer; and inositol, a carbohydrate. However, certainty about the benefits of these agents is limited because of methodological shortcomings, such as small sample size and inadequate controls. Therefore, these agents cannot be recommended for routine clinical use at the present time. Indeed, given that behavior therapy is often effective for the treatment of TTM, it can be considered as the first-line intervention. Despite these limitations, pharmacotherapy can play an important role for some hair pullers, especially when comorbid mood and anxiety disorders are present. Given that such comorbidity is so common and that many mood and anxiety disorders respond to SSRIs, the use of these agents seems reasonable for the treatment of patients who present with such features. Guidelines for dosing and duration have often drawn on work with OCD (i.e., relatively high dose over long treatment intervals), although some patients are likely to respond at lower SRI doses than is expected for patients with OCD (O’Sullivan et al., 1999). Other agents may be useful for patients with different patterns of comorbidity. Because of the accumulating evidence that both behavior therapy and pharmacotherapy are beneficial for treatment of TTM, many clinicians are disposed to recommending combined

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therapy in which both treatments are provided. Furthermore, some evidence suggests that in naturalistic settings, patients with TTM derive benefits from combined treatments that incorporate pharmacotherapy as well as other behavioral and cognitive behavioral modalities (Keuthen et al., 1998). Further work is needed, however, to specifically confirm the effectiveness of pharmacotherapy in naturalistic settings where comorbidity of TTM may be common. Research on the optimal sequencing and combination of psychotherapy and pharmacotherapy is another area where additional work is required. The Case of Susan Susan is a 34-year-old accountant who is happily married and has two children. She presents as an energetic, outgoing woman with appropriate social skills and demeanor. The only complaint for which she is seeking treatment is what she describes as a “stress-related condition.” Since the age of 12, she has pulled her scalp hair, eyebrows, and eyelashes. She has done so to the point where she often has bald spots on her scalp—up to two inches in diameter—and few, if any, lashes or brows. She denies any other significant psychiatric symptoms, besides the depressed mood, shame, and low self-esteem that she believes are a result of her chronic pulling. Although her pulling has waxed and waned over the years, she has never gone more than one month without pulling and has at times spent one to two hours a day pulling. When she was a teenager, her parents sent her to a dermatologist and to “talk therapy,” but her hair pulling continued. Susan has recently heard that her condition has a name, trichotillomania, and that some effective treatments are available, so she is seeking help again Susan had never received pharmatherapy for her hair pulling and, like many patients, was wary of the possible side effects. Upon her ini-



tial evaluation, her options for medication were fully explained, and the potential benefits of combining medication and behavior therapy were discussed. Given that Susan had never attempted treatment before and had no comorbid symptoms that might benefit from medication, she decided to try behavior therapy without pharmacotherapy, with the knowledge that she could add medication in the future if she desired. Behavioral Treatment of Trichotillomania The first published attempt to systematically describe and treat TTM from a behavioral perspective was conducted by Azrin and Nunn (1973), who developed the habit reversal method. In their view, TTM was primarily a motor habit maintained by excessive practice and chaining of behaviors. An essential element of this treatment employed a motor response that was incompatible with hair pulling (i.e., holding the arms straight down and clenching the fists). Subsequent variants added features such as self-monitoring, social support, awareness training, and relaxation training (Mouton & Stanley, 1996; Rapp, Miltenberger, Long, Elliott, & Lumley, 1998; Rapp, Miltenberger, & Long, 1998; Rogers & Darnley, 1997). Although initial reports were promising, it became apparent that the effectiveness of this approach was mixed and that relapse was a significant problem (Azrin, Nunn, & Franz, 1980; Lerner, Franklin, Meadows, Hembree, & Foa, 1998). Subsequently, further work was conducted to address other aspects of TTM to enhance treatment effectiveness. Cognitive aspects of TTM were identified (Gluhoski, 1995; Thomas et al., 1999) and thus argued to be significant factors for some hair pullers. These included (a) the low level of awareness before and during pulling often reported by hair pullers, and (b) rigidly held ideas about hair and pulling that can contribute

to the problem in some individuals (e.g., that gray hairs are not acceptable or that hair lines should be straight and symmetrical). Suggested ways to boost treatment effectiveness included therapeutic tactics to increase awareness, such as record keeping or self-monitoring, as well as cognitive therapy to moderate the rigid beliefs about hair (Gluhoski, 1995). In addition, the behavioral theory of classical conditioning has been applied to TTM. This theory posits that environmental cues trigger an urge to pull, which has led therapists to the use of environmental strategies such as stimulus control—for example, avoiding or removing stimuli that trigger pulling, such as being alone, looking in a mirror in the bathroom, or seeing tweezers available (Rothbaum, 1992). In cases where sensory cues trigger pulling—such as itching at the pulling site or the sight of gray or uneven hairs—systematic exposure to these cues as well as practice at preventing the pulling response have also been used as treatment components (Brondolo, 2000). In Susan’s case, being in the bathroom, looking in the mirror, and applying makeup were cues for her to pull. In addition, the sight of curly or gray hair, or an out of place lash or brow hair, triggered her urge to pull. Ideas drawn from operant conditioning have also been useful with pulling. First, it seems clear that hair pulling can be facilitated or inhibited by environmental variables. Examples of these include (a) whether the individual is alone or with others, (b) whether they have a free hand to pull with, and (c) whether their posture makes it likely that their hand will be near the pulling site (e.g., when driving a car). Thus, strategies to minimize facilitating conditions and maximize inhibiting conditions have been used. The second idea from operant conditioning, that pulling is somehow reinforcing, has also been useful in understanding its nature. Thus, using reinforcers to increase the use of alternatives to pulling, such as habit reversal or


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relaxation strategies, has been useful—particularly with children and adolescents where a third party is available to encourage the behavior and provide the reward, but also in selfreinforcement strategies for adults. In addition, the recognition that pulling can be reinforcing in a variety of ways—including the relief of boredom, avoidance of frustrating situations, or relief from itching or tingling at the site— has provided the impetus to seek other means to provide this reinforcement or tolerate these aversive situations (Rapp et al., 2000). For Susan, what facilitated her pulling was being alone, having her hand in her hair or on her face (i.e., when applying makeup), and driving with one hand on the wheel. She would be able to resist the urge when others were present, but if alone, with a free hand that was near her face or hair, she found it very difficult to resist. A Comprehensive Behavioral Model for Trichotillomania (ComB/TTM) Clearly, the cognitive behavioral approaches have offered a wide variety of alternative treatment strategies for hair pulling that were not in use 20 years ago. However, as treatment strategies and “packages” have been developed and tested, a dilemma for “pullers,” clinicians, and researchers remains. With what can seem like a hodgepodge of strategies available from standard cognitive behavioral therapy, how can the most efficient and effective treatment plan be developed for any one individual? In fact, Mansueto, Stemberger, Thomas, and Golomb (1997) have described a comprehensive behavioral (ComB) model for understanding individual cases of hair pulling and for choosing the most effective treatment strategies for a particular person. In addition to systematically organizing the knowledge applied from existing cognitive behavioral theory and methods, this model introduces the variable of sensory function, which seems to play an important role in many

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cases of pulling but has yet to be included in previous treatment approaches. Specifically, ComB addresses the role that five variables or modalities play in pulling: environment, motor response, sensation, affect, and cognition. ComB assumes that although certain patterns of pulling can be identified, a wide range of variability exists with respect to the nature of pulling and the factors that influence pulling (see Mansueto, Stemberger, Thomas, & Golomb, 1997). Therefore, to effectively treat any particular case, the therapist must identify a detailed description of the individual’s pattern. Consistent with a “generic” behavioral model, a critical first step in this approach is to employ a “functional analysis” in which three categories of components play a role in each case of pulling: antecedents, behaviors, and consequences. First, antecedents to pulling are elements that either trigger or facilitate pulling, and they can be identified as such: • Environmental—a place where pulling typically occurs, such as in front of a bathroom mirror • Motoric—simple motor habits, often without full awareness, that may predispose one to pull, like twirling or stroking the hair during sedentary activities • Sensory—enjoying the sensations associated with the pulling of hair or with afterpull; self-stimulating activities like nibbling on the hair root • Affective—being calmed by or, conversely, energized by hair pulling • Cognitive—“weeding out” unwanted hairs that are believed to be ugly or otherwise unacceptable For some individuals only one or two types of antecedents play a role; for others, the list of antecedents is lengthy. Table 1 presents the possible types of antecedents and their associated



Table 1. ComB Model: Possible Antecedents Listed by Their Associated Modalities Modality

Type

Common examples

Environment Social Implements

Bedroom, car, living room, bathroom, work, kitchen

Motor

Setting Being alone, presence of others Tweezers, wall mirrors, hand mirrors, magnifying mirrors Behavior

Sensation

Site sensation

Tactile

Affect

Hair qualities including coarse, rough, curly, short, knotted, sharp, straight, dirty/gritty, fine, oily, long Hair qualities including gray or white, knotted, dark, light Affect

Cognition

Thoughts

Awareness

Full, partial, or no awareness

Visual

Studying/reading, watching TV, talking on phone, working, on computer, driving, getting ready for bed, trying to sleep, using toilet, resting/napping, riding in car, groom/ applying makeup Sensitivity/tingling, irritation, discomfort, itching, burning/ glowing, pressure

Indecision, tension/anxiety, boredom, frustration, loneliness, anger, guilt, tired/sluggish, happiness/excitement, sexual arousal I don’t want certain types of hairs; it is important for hair to be even, symmetrical, uniform; skin will heal better if I pull; I’ll just pull this one

Note. From Thomas et al. (1999).

Table 2. ComB Model: Possible Behavioral Components Listed by Their Associated Modalities Modality

Type

Environment

Going to a setting Securing implements Choosing site: Head, pubic, brows, lashes, beard, legs, mustache, sideburns, arms; 20% pull from 1 site; 26%, 2 sites; 14%, 3 sites; 14%, 4 sites; 26%, 5+ sites Handedness: right, left, or both Dispose of hair quickly or save hair Tactile search for hair Visual search for hair Manipulate hair (twirl, twist, play) Traction (gentle, quick) Examine hair or root after pulling Stimulate skin or mouth after pulling Swallow hair or root

Motor

Sensation

Note. From Mansueto et al. (1997) and Thomas et al. (1999).


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modalities, as well as examples of each type of antecedent, listed from the most frequently reported to the least frequently reported (Thomas et al., 1999). The antecedents typically offer good potential for change because if the antecedents can be modified, pulling can be stopped before it starts. As mentioned, Susan’s antecedents included (a) environmental stimuli (the bathroom or mirror) and sensory stimuli (seeing gray or curly hair, or “out of place” lashes or brows), (b) the thought that she must get rid of the gray, curly, or “out of place” hairs, and (c) facilitators, such as having her hands free or being alone. The next phase of this approach addresses the behaviors associated with the act of pulling. Again it is assumed that understanding the specific behaviors involved for any one individual is critical in developing an effective treatment plan. The components include preparatory behaviors, such bringing tweezers and a magnifying mirror into the bathroom; the pulling itself; and analyzing the disposition of the hair or root, such as pulling the root off of the hair shaft and rubbing it between the fingers. Table 2 provides examples of these behaviors and their associated modalities. As with the antecedents, the individuals will vary

in the nature and importance of each of these components. Susan’s pulling almost always involved looking in the mirror and visually examining the hair to be pulled; a quick pull to remove it; and then a visual and tactile examination of the hair, particularly if it was gray or curly. She would pull scalp hairs between her fingers to feel how coarse it was and to check that she got one that was truly gray or curly. Finally, the consequences of pulling serve the important function of maintaining the cycle of pulling by affecting the duration any individual hair-pulling episode, as well as by influencing the likelihood that future episodes will occur. Thus, consequences are critical elements that influence the chronic nature of pulling for suffers of TTM. It is important to note, however, that pullers often suffer punishing consequences for pulling, which may serve to end an episode of pulling and which also may have limited the severity of pulling over the course of the individual’s history. Examples of these and their associated modalities are listed in Table 3. These components can also play an important role in treatment. The consequences of Susan’s pulling were (a) a sense of satisfaction upon removing the

Table 3. ComB Model: Possible Consequences of Pulling, Listed by Their Associated Modalities Modality

Type

Example

Environment

Reinforcer Punishment Punishment Reinforcer

Attention (e.g., from parent) Criticism/disapproval Fatigue Increase sensation at site (e.g., invigorating/energizing; pain that is pleasurable) Decrease sensation at site (e.g., relief from itching/burning/glowing) Increase tactile sensation on finger tips (i.e., interesting to touch) Increase visual sensation (i.e., interesting to look at) Pain or bleeding Distraction from obligations, relief from stress/boredom/urge, pleasure Upset/anxious/depressed due to pulling Achieve goal Regain self-control, “coming to senses”

Motor Sensation

Affect Cognition

Punishment Reinforcer Punishment Reinforcer Punishment

Note. From Mansueto et al. (1997).

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unwanted hair, and (b) sensory satisfaction upon feeling the coarse or curly hair. However, pulling also seemed to increase the urge to pull subsequent hairs; so, as is the case for many who pull, she often found herself pulling many more than she had originally intended. She also felt acutely embarrassed and ashamed when she feared that anyone saw her pulling. Assessment of the antecedents, behaviors, and consequences can be conducted through two primary means: semistructured interview and self-monitoring. A semistructured interview can be drawn from the list of factors in Tables 1, 2, and 3. In addition, self-monitoring or record keeping involve the individual’s noting episodes of pulling and relevant factors, such as the setting, degree of awareness, affect, sensations, associated cognitions, and the consequences of pulling. Both the interview and the self-monitoring are often very enlightening for individuals who pull by enhancing their understanding of the predictable patterns in their behavior. A template for the development of a selfmonitoring form can be found in Mansueto, Golomb, Thomas, and Stemberger (1999). Before discussing how this assessment is used to identify the treatment strategies most likely to be effective, two additional factors are worthy of discussion. The first is the uniquely important role of the sensory modality in hair pulling. Individuals who work with the developmentally disabled or with children are likely familiar with individual differences in the desire for sensory stimulation. These differences seem to exist in the general population, with people either seeking out sensory stimulation, actively avoiding it, or (perhaps most common) displaying each pattern at different times. Clinical and research experience suggests that this variable often plays an important role in TTM (Golomb & Vavrichek, 1999; Thomas et al., 1999). Specifically, hair pulling, and its associated preparatory and postpulling behaviors, provides tactile stimulation on the fingers, at the site of the

pulling, and in some cases, on the lips, mouth, or skin after pulling. In addition, it often provides visual stimulation or interest before and after pulling, which is more likely to be true for those who have greater degrees of awareness of their hair pulling. Another potential function of hair pulling has been recently elaborated upon by Penzel (2002). He suggests that individuals who pull have a relatively narrow range of acceptable levels of internal comfort or arousal, such that too much or too little sensation, affect, or cognitive activity is aversive. Thus, they are motivated to relieve the over- or underarousal. Pulling and the stimulation it provides are uniquely suited to either soothe the individual when he or she is overaroused or invigorate the individual when he or she is underaroused. This scenario may in fact account for the occurrence of pulling when, possibly by accident, these individuals find pulling to be uniquely reinforcing and always available. It is probably true that when this pattern is present in children, treatment is often a more straightforward process—that is, find and encourage the use of other sensory methods to achieve the goal of maintaining the comfort level. However, when an individual has been pulling into adulthood, the complexity of other environmental, affective, and cognitive variables that have become associated with the pulling might complicate the picture significantly and thus require a more complex treatment plan. Susan’s therapist developed a self-monitoring form in which Susan noted times when she pulled; where she was when she pulled; and what she did and how she felt before, during, and after pulling. She was instructed to take particular note of whether she sought the sensory stimulation during pulling and whether she was “under- or overaroused” prior to and after pulling. Through the method, she and her therapist realized that she was more likely to pull when she felt hurried and stressed (e.g.,


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Table 4. ComB Model Possible Treatment Strategies Associated with Each Modality Modality

Treatment Strategy

Environmental

Stimulus control (avoiding settings and implements) Seek out inhibitors, such as people Contingency management (rewards for using strategies) Competing response training, as in habit reversal (e.g., clenching fist, cross-stitch, holding koosh ball) Response prevention during risky behaviors (e.g., band-aids or gloves on fingers, wet or oily hair, hats or hair pulled back) Use other means to meet sensory needs (e.g., touch dental floss, wire, feathers or doll hair; nibble sunflower seeds; brush hair) Numb site sensations with cortisone cream or lacrilube/remove visual sensation with dyed hair or pull hair back Use other means to soothe or invigorate (e.g., baths, massages, facial masks, “aromatherapy”) Relaxation, controlled breathing Emotive: assertiveness training, journal writing, exercise Imagery: positive visualization, self-hypnosis Medication to moderate affect Cognitive restructuring Coping self-statements (e.g., “I’ll feel much better if I resist”; “If I start, it will be

Motoric

Sensory

Affective

Cognition

harder to stop”) Note. From Mansueto et al. (1998).

when she was getting ready to go somewhere) and when she was daydreaming and relatively still (e.g., when driving). Choosing a Treatment Strategy With regard to the ComB model, once the antecedents, behaviors, and consequences for an individual have been identified and listed by modality, the relative importance of each modality will be apparent. As discussed, for some individuals, the sensory modality will be primary; for others, the motoric and environmental modalities will be most important; and for others, the cognitive modality will play a central role. Most individuals will display a mix of contributions from a number of modalities. The relative importance of each modality will determine the choice of treatment strategy selected from the variety of treatment options available.

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A sample of treatment options for each modality is listed in Table 4. Several principles regarding this approach to treatment should be kept in mind. First, the most critical aspect of treatment is the assessment of the antecedents, behaviors, and consequences; and their associated modalities. Unsatisfactory effects of previous treatments were possibly due in part to the fact that no one treatment is best for all hair pullers. Rather, it is best to tailor the treatment based on the detailed assessment to each individual. Second, a guiding principle in all behavioral therapies is that each attempt at treatment represents a single case study in which the outcome of a particular strategy must be evaluated and in which the strategy should be modified, augmented, or discarded if the effect is less than satisfactory. Together, Susan and her therapist selected three primary methods for treatment. First, she



was instructed to use several strategies to reduce the visual and environmental cues associated with pulling: covering all mirrors whenever possible and strictly reducing the amount of time she could spend in front of a mirror to groom. Second, she chose to use the wire from a kitchen scrubber to satisfy her desire for sensory stimulation, and she kept some of this in her car so she could use it when driving. Finally, she identified ways to plan ahead and feel less pressured when getting ready to go somewhere. Although there are a number of other possible treatment strategies, these are the three that Susan and her therapist felt would be most likely to achieve the most change. After a trial of several weeks—during which Susan will return for weekly updates and support—her pulling will be reevaluated, and the plan will be augmented or modified if necessary. Complications in Treatment Although a logical and systematic plan can be developed from ComB and the treatment strategies that have been developed over many years, it is often true that treatment does not follow a textbook story line. A number of complications may be present that require adjustments to the standard approach. Two variables that will affect treatment are the patient’s level of motivation and the nature of their goals. Individuals vary widely in their desire to change their pulling. Some are ready to make pulling the number one priority in their life; others are more interested in keeping their pulling on the back burner, while using any strategies that might not require extraordinary effect. Additionally, some have the rigid goal of completely eliminating the pulling, whereas others are willing to accept some pulling—for example, if it results in only minimal cosmetic damage or if other negative consequences are experienced as tolerable. It seems to make little sense for the clinician to push clients in either

direction. There is not anything inherently wrong with hair pulling—that is, unless the client is swallowing large amounts of hair, causing damage to the skin and risking infections, or avoiding medical care altogether (in these cases, they need to be seen by a physician in addition to their therapist). Rather, the clinician needs to be aware of the client’s goal in order to plan appropriate, efficient treatment strategies. However, if a client has the unrealistic goal of eliminating hair pulling in an unreasonable amount of time or with minimal amount of effort, the clinician needs to provide the client with accurate information regarding how unlikely it is that such a goal will be achieved. In Susan’s case, her level of motivation seemed extremely high, but her expectations for stopping quickly seemed unrealistic given the long standing nature of her pulling. As treatment progressed more slowly than she had hoped, she felt disheartened and needed significant support to maintain her motivation. With this support and several minor modifications to her treatment plan, Susan was able to reduce her pulling to minimal levels. A second difficulty can arise in treatment when the client is so emotionally distraught or ashamed about hair pulling and its effects that these issues seriously interfere with the client’s taking action to reduce the pulling. In such cases, the client may be unable to take the essential steps necessary for effective treatment and may not be able to absorb information needed to use treatment strategies effectively. At that point, until pulling-reduction strategies can be implemented, appropriate treatment would include working on acceptance of the current situation, as well as implementing efforts for enhancing self-esteem, reducing depression, addressing relationship problems, and so forth. When rigidly held beliefs about hair and pulling are present, treatment can also be complicated. For example, in some cases hair pulling


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is associated with comorbid body dysmorphic disorder (BDD), in which the individuals are obsessively preoccupied with thoughts that something is wrong with their hair; thus, they spend several hours each day checking and fixing their hair, as well as pulling hair that is gray, crooked, out of place, or somehow unacceptable. In such cases, treatment of the BDD must be incorporated into the entire plan, thus making treatment more time consuming and difficult. In less severe cases, individuals who are perfectionistic about their hair, eyebrows, or eyelashes, but do not have BDD, will often need extra attention in the area of reducing perfectionism and tolerating the discomfort associated with hair that is “out of place” or not symmetrical. Therapists need to be aware of another variety of belief about the pulling that can interfere with progress in therapy. Individuals who have a long history of avoiding social interaction and relationships as a result of their hair pulling may believe that when they stop pulling, their lives will change in ways for which they are not prepared. This belief can create a lot of pressure and may interfere with the goal of pulling cessation. Addressing these beliefs in the course of assessment and treatment will ease the negative impact they might have. In some cases, a secondary pattern can develop, in which pulling becomes a means of maintaining control and individuality in a relationship. In adolescent girls, for example, some parents become so distraught over their daughter’s pulling that that they attempt to use extreme methods of control (e.g., punishment, invasion of privacy) to get her to stop pulling. Children and adolescents who have a need for greater self-control and privacy may become increasingly resistant of their parents efforts and may therefore become unwilling to work to stop the pulling. Unfortunately, parents can not eliminate the pulling without the cooperation of the girl herself. In such cases, a focus on family issues with the goal of supportively helping the

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parents to relinquish control will allow the girl to work toward management of her own hair pulling. Because pulling can co-occur with other disorders—including depression, the anxiety disorders (i.e., social phobia, panic, and agoraphobia), and OCD—it may be that another disorder must be treated before progress can be made with the hair pulling. For example, even mild depression can make it difficult for an individual to employ the strategies necessary to reduce the hair pulling; therefore, the depression may need to be the initial focus of treatment. A comprehensive assessment of other possible comorbid disorders and a frank discussion of how they might affect treatment is always important. In conclusion, much progress has been made in the treatment of TTM over the past 30 years. New strategies are promising, although much room exists for improvement in initial effectiveness and long-term gains. In addition, a great need exists for outcome research that addresses the question of which treatments are most effective and efficient for which individuals. Thus, the specific strategies and approaches available need to be examined in the context of individual patterns of pulling. However, for individuals seeking help for hair pulling, current approaches have much to offer. References American Psychiatric Association (2000). Diagnostic and statistical manual for mental disorders (4th ed., text revision). Washington, DC: author. Azrin, N.H., & Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619–628. Azrin, N.H., Nunn, R. G., & Franz, 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, 1, 13–20. Benarroche, C. L. (1991, May). Discontinuation



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