What is Trichotillomania?

Trichotillomania, otherwise known as Hair-Pulling Disorder, is a psychological disorder that is characterized by the “recurrent pulling out of one’s own hair” (APA, 2013). Individuals with trichotillomania are unable to stop engaging in hair-pulling behavior despite attempts to stop and experience significant distress or impairment as a result of this behavior (APA, 2013).

Trichotillomania is estimated to impact 0.5-2% of the general population, and while there are no significant sex differences in childhood, adult women are four times more likely to experience trichotillomania than adult men (Grant and Chamberlain, 2016). Many individuals with trichotillomania also meet the criteria for another psychological disorder such as Depression or Anxiety. Symptoms of trichotillomania are often first observed in early adolescence and, without treatment, can remain present throughout an individual’s lifetime (Grant and Chamberlain, 2016).

Is Trichotillomania treatable?

Yes. Despite the fact that trichotillomania can persist if left untreated, research has shown that with treatment, full recovery is possible for individuals with trichotillomania. Research has tested the effectiveness of various psychotherapeutic interventions and has found that multiple approaches are effective in treating trichotillomania. Behavioral therapy has been found to be the most effective treatment, particularly habit reversal training, Acceptance and Commitment Therapy, and Dialectical Behavioral Therapy.

Habit reversal training is considered to be the first-line treatment for trichotillomania and many studies have found it to be effective at reducing hair-pulling behavior in individuals with trichotillomania (Rahman et al., 2017; Franklin et al., 2011; Bate et al., 2011). However, more recent research has focused on how effective habit reversal training is at treating trichotillomania when enhanced with techniques from Dialectical Behavioral Therapy or Acceptance and Commitment Therapy. 

What is Habit Reversal Training?

Habit reversal training is a behavioral therapy composed of 3 core elements: awareness training, stimulus control, and competing responses. The goal of the awareness training element of HRT is to help the client gain awareness of their hair-pulling behaviors and to identify patterns. In order to develop this insight, clients are asked to keep a detailed log recording every incident of hair- pulling. Clients will be asked to log details of each hair-pulling behavior such as the time and situation in which it occurred, the amount of hair pulled and location from which the hair was pulled.

The client will also be asked to document the physical sensations, emotions and thoughts experienced before and after he or she engaged in the hair-pulling behavior. Individuals will then review the log with their therapist to help identify situations in which they feel most compelled to engage in this behavior. Keeping and reviewing a log also helps clients gain insight into the frequency of their hair-pulling behavior and its subsequent consequences. The second aspect of habit reversal therapy is to help the client develop stimulus control strategies. Based on the data from the self-report log, an individual may notice that they tend to engage in hair-pulling behaviors in specific contexts.

Overtime, these situations (either external situations or internal thoughts or feelings) can turn into triggers for hair-pulling. Therefore, if the client is able to avoid or manage these triggers, they will be less likely to engage in hair-pulling behaviors. The third aspect of habit reversal training is to help clients develop and utilize competing responses when they feel the urge to engage in hair-pulling. For example, when a client has the urge to pull their hair, they can instead make a tight fist or play with a toy. Clients will continue to practice competing responses until the urge to pull hair is no longer present. Utilizing competing responses teaches clients that they are able to tolerate urges without acting on them and that overtime these urges will subside (Morris et al., 2013). 

 What is Acceptance and Commitment Therapy?

Acceptance and Commitment Therapy (ACT) is a type of behavioral therapy designed to help clients improve their psychological flexibility. Psychological flexibility is the ability to be mindful of one’s internal and external experiences while still living in alignment with one’s core values. ACT is comprised of six components: acceptance, cognitive defusion, contact with the present moment, self as context, values, and committed action. These processes are not sequential steps, but rather interrelated processes that help individuals increase their psychological flexibility (Harris, 2019).

ACT is considered to be an evidence-based treatment for a variety of psychological concerns such as anxiety and mood disorders, but research has also found that ACT is also effective at treating trichotillomania (Avdagic et al., 2014; Forman et al., 2007). ACT is shown to be an effective treatment approach for trichotillomania both as a stand alone treatment and when integrated with habit reversal training (Lee et al., 2018; Twohig et al., 2004; Woods et al., 2006). Research suggests that ACT may be effective in treating trichotillomania due to its efficacy in reducing experiential avoidance and improving mindfulness and acceptance skills (Woods et al., 2006; Crosby et al., 2012).

What is Dialectical Behavioral Therapy?

Dialectical Behavioral Therapy is a type of behavioral therapy that combines aspects of Zen practices with traditional behavioral therapy in order to create a method of treatment that is centered around the dialectic of acceptance and change. A large aspect of DBT is teaching clients skills that are grouped into four categories: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness (Chapman and Dixon-Gordon, 2020).

While DBT is most popular for being the first-line treatment for Borderline Personality Disorder, DBT has been proven effective in treating a variety of psychological disorders. Research has shown that DBT can be an effective component of trichotillomania treatment as it can provide clients with the emotion regulation and distress tolerance skills necessary to resist the urge to engage in hair-pulling behavior and manage any related emotions. Studies have found that DBT enhanced habit reversal training is effective in reducing hair-pulling behaviors, and also increasing client’s emotion regulation skills (Kethuen et al., 2010; Kethuen et al., 2010; Kethuen et al., 2012).

Does NYBH offer treatment for Trichotillomania?

Therapists at NYBH are well-equipped to treat individuals with trichotillomania. NYBH offers trichotillomania treatment virtually as well as in-person on Long Island and in Manhattan. NYBH therapists utilize habit reversal training, ACT, and DBT techniques when working with individuals with trichotillomania, and many of our providers have received extensive training in these modalities. Your therapist will first conduct a thorough assessment, after which you and your clinician will collaboratively decide which treatment approach is best suited for you.

As mentioned, many individuals with trichotillomania also struggle with other psychological disorders such as anxiety. Your NYBH provider will determine whether any comorbid disorders are present, and work with you to create a comprehensive treatment plan that addresses these concerns in conjunction with your trichotillomania. NYBH therapists will work closely with the parents of children seeking treatment, as well as any other providers such as psychiatrists and school counselors.   

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) https://doi-org.ezproxy.cul.columbia.edu/10.1176/appi.books.9780890425596.dsm01

Avdagic, E., Morrissey, S. A., & Boschen, M. J. (2014). A randomised controlled trial of acceptance and commitment therapy and cognitive-behaviour therapy for generalised anxiety disorder: [1]. Behaviour Change, 31(2), 110-130. 

Bate, K. S., Malouff, J. M., Thorsteinsson, E. T., & Bhullar, N. (2011). The efficacy of habit reversal therapy for tics, habit disorders, and stuttering: A meta-analytic review. Clinical Psychology Review, 31(5), 865–871. https://doi.org/10.1016/j.cpr.2011.03.013 

Chapman, A. L., & Dixon-Gordon, K. L. (2020). Dialectical behavior therapy. American Psychological Association. https://doi-org.ezproxy.cul.columbia.edu/10.1037/0000188-000

Crosby, J. M., Dehlin, J. P., Mitchell, P. R., & Twohig, M. P. (2012). Acceptance and commitment therapy and habit reversal training for the treatment of Trichotillomania. Cognitive and Behavioral Practice, 19(4), 595–605. https://doi.org/10.1016/j.cbpra.2012.02.002 

Forman, E.M., Herbert, J.D., Moitra, E., Yeomans, P.D. and Geller, P.A. (2007) A randomized controlled effectiveness trial of Acceptance and Commitment Therapy and Cognitive Therapy for anxiety and depression. Behaviour Modification, 31: 772–99.

Franklin, M. E., Edson, A. L., Ledley, D. A., & Cahill, S. P. (2011). Behavior therapy for pediatric trichotillomania: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 50(8), 763–771. https://doi.org/10.1016/j.jaac.2011.05.009 

Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania. The American journal of psychiatry, 173(9), 868–874. https://doi.org/10.1176/appi.ajp.2016.15111432

Harris, R. (2019). Act Made Simple: An easy-to-read primer on acceptance and commitment therapy . New Harbinger Publications, Inc.

Morris, S. H., Zickgraf, H. F., Dingfelder, H. E., & Franklin, M. E. (2013). Habit reversal training in trichotillomania: Guide for the clinician. Expert Review of Neurotherapeutics, 13(9), 1069–1077. https://doi.org/10.1586/14737175.2013.827477 

Rahman, O., McGuire, J., Storch, E. A., & Lewin, A. B. (2017). Preliminary Randomized Controlled Trial of Habit Reversal Training for Treatment of Hair Pulling in Youth. Journal of Child and Adolescent Psychopharmacology, 27(2), 132-139. https://doi.org/10.1089/cap.2016.0085

Keuthen, N. J., Rothbaum, B. O., Falkenstein, M. J., Meunier, S., Timpano, K. R., Jenike, M. A., & Welch, S. S. (2010). DBT-enhanced habit reversal treatment for trichotillomania: 3-and 6-month follow-up results. Depression and Anxiety, 28(4), 310–313. https://doi.org/10.1002/da.20778

Keuthen, N. J., Rothbaum, B. O., Fama, J., Altenburger, E., Falkenstein, M. J., Sprich, S. E., Kearns, M., Meunier, S., Jenike, M. A., & Welch, S. S. (2012). DBT-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial. Journal of Behavioral Addictions, 1(3), 106–114. https://doi.org/10.1556/jba.1.2012.003 

Keuthen, N. J., Rothbaum, B. O., Welch, S. S., Taylor, C., Falkenstein, M., Heekin, M., Jordan, C. A., Timpano, K., Meunier, S., Fama, J., & Jenike, M. A. (2010). Pilot trial of dialectical behavior therapy-enhanced habit reversal for Trichotillomania. Depression and Anxiety, 27(10), 953–959. https://doi.org/10.1002/da.20732 

Lee, E. B., Homan, K. J., Morrison, K. L., Ong, C. W., Levin, M. E., & Twohig, M. P. (2018). Acceptance and commitment therapy for trichotillomania: A randomized controlled trial of adults and adolescents. Behavior Modification, 44(1), 70–91. https://doi.org/10.1177/0145445518794366 

Twohig, M. P., & Woods, D. W. (2004). A preliminary investigation of acceptance and commitment therapy and habit reversal as a treatment for Trichotillomania. Behavior Therapy, 35(4), 803–820. https://doi.org/10.1016/s0005-7894(04)80021-2 

Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of acceptance and commitment therapy plus habit reversal for Trichotillomania. Behaviour Research and Therapy, 44(5), 639–656. https://doi.org/10.1016/j.brat.2005.05.006