Trichotillomania:Trichotillomania:An Introduction to Compulsive Hair-An Introduction to Compulsive Hair-

PullingPulling

Bruce A. Sellars, Psy.D.Bruce A. Sellars, Psy.D.Licensed Clinical PsychologistLicensed Clinical PsychologistPsychological Health-RoanokePsychological Health-Roanoke

3 Greek words:3 Greek words:

trich (hair)trich (hair) tillo (pull)tillo (pull)mania (madness ormania (madness or

excessive activity)excessive activity)

TrichotillomaniaTrichotillomania

Commonly known as Commonly known as ““trichtrich”” or or““TTMTTM””

First named by FrenchFirst named by Frenchphysician Francois Henriphysician Francois HenriHallopeau in 1889Hallopeau in 1889

TTMTTM

TTM is currently classified as an ImpulseTTM is currently classified as an ImpulseControl Disorder in DSM-IVControl Disorder in DSM-IV together with kleptomania, pyromania,together with kleptomania, pyromania,

pathological gamblingpathological gambling has little in common with thesehas little in common with these shares more common traits with OCD andshares more common traits with OCD and

BDDBDD

DSM-IV DiagnosticDSM-IV Diagnostic

CriteriaCriteria Recurrent pulling out of oneRecurrent pulling out of one’’s hairs hair

resulting in noticeable hair loss.resulting in noticeable hair loss. Feeling of tension immediately beforeFeeling of tension immediately before

pulling out or when attempting to pull hairpulling out or when attempting to pull hairout.out.

Sense of pleasure, gratification, or reliefSense of pleasure, gratification, or reliefwhen pulling out the hair.when pulling out the hair.

DSM-IV DiagnosticDSM-IV Diagnostic

CriteriaCriteria Hair pulling is not better explained by theHair pulling is not better explained by the

presence of some other disorder.presence of some other disorder. Hair pulling causes significant distress and anHair pulling causes significant distress and an

impairment of the ability to function in animpairment of the ability to function in animportant area of oneimportant area of one’’s life.s life.

(Note: Many researchers have found a significant(Note: Many researchers have found a significantnumber of patients do not meet thenumber of patients do not meet thetension/relief criteria.)tension/relief criteria.)

Clinical Presentation ofClinical Presentation of

TTMTTM

Usual age of onset- pubertyUsual age of onset- puberty Gender- female (90% of adult patients)Gender- female (90% of adult patients) Hair-pulling sites:Hair-pulling sites:

Scalp (67-77% of cases)Scalp (67-77% of cases) EyebrowsEyebrows EyelashesEyelashes Pubic areasPubic areas LimbsLimbs FaceFace

Common Hair-PullingCommon Hair-Pulling

BehaviorsBehaviors

Focused vs. Automatic PullingFocused vs. Automatic Pulling Searching for certain types ofSearching for certain types of

hair to pullhair to pull CoarseCoarse Different colorDifferent color ThinThin Out of placeOut of place

Body FocusedBody Focused

Repetitive BehaviorsRepetitive Behaviors

(BFRBs)(BFRBs) Trichotillomania (compulsive hair-pulling)Trichotillomania (compulsive hair-pulling) Dermatotillomania (compulsive skin-Dermatotillomania (compulsive skin-

picking)picking) Onychophagia (compulsive nail-biting)Onychophagia (compulsive nail-biting) Compulsive nose-pickingCompulsive nose-picking Compulsive biting of inside of cheekCompulsive biting of inside of cheek Lip-biting or pickingLip-biting or picking Tongue chewingTongue chewing

Prevalence In Non-Prevalence In Non-

clinical College Samplesclinical College Samples

TTM: 3.6% females, 1.5% malesTTM: 3.6% females, 1.5% males Skin-picking: 4.6%Skin-picking: 4.6% Nail-biting: 6.4%Nail-biting: 6.4% Mouth, lip, cheek chewing: 5.7%Mouth, lip, cheek chewing: 5.7%

Comorbidity in TTMComorbidity in TTM

Major depression-Major depression-51.6%51.6%

Generalized anxietyGeneralized anxietydisorder- 27.0%disorder- 27.0%

Alcohol abuse- 19.4%Alcohol abuse- 19.4% Other substance abuse-Other substance abuse-

16.1%16.1% OCD- 13.4%OCD- 13.4% Social phobia- 11.3%Social phobia- 11.3%

Bulimia- 8.1%Bulimia- 8.1% Chronic motor tics-Chronic motor tics-

3.2%3.2% Anorexia- 1.6%Anorexia- 1.6% TouretteTourette’’s Disorder-s Disorder-

0.005%0.005%

(Christenson et al., 1995;(Christenson et al., 1995;N=186)N=186)

TrichobezoarTrichobezoar

Potential serious medical disorder canPotential serious medical disorder canresult if patient eats her hair resulting in aresult if patient eats her hair resulting in amatted hair blockage. This can result inmatted hair blockage. This can result inabdominal pain, vomiting, and weightabdominal pain, vomiting, and weightloss. This may have to be surgicallyloss. This may have to be surgicallyremoved.removed.

Associated Hair-Associated Hair-

related Behaviorsrelated Behaviors Playing with hair/winding around a fingerPlaying with hair/winding around a finger Stroking hair against mouth, face, or tongueStroking hair against mouth, face, or tongue Biting/chewing hair or pulling it between theBiting/chewing hair or pulling it between the

teethteeth Swallowing hairSwallowing hair Saving itSaving it Rolling it in a ballRolling it in a ball Tying hair into a knotTying hair into a knot

Psychological EffectsPsychological Effects

of TTMof TTM Low self-esteemLow self-esteem Diminished sense of attractivenessDiminished sense of attractiveness Shame, embarrassmentShame, embarrassment Tension, anxietyTension, anxiety DepressionDepression Avoids social situationsAvoids social situations

Theoretical Models ofTheoretical Models of

TTMTTM Addiction ModelAddiction Model -small study found -small study found

naltrexone (opiate-blocking drug) reducednaltrexone (opiate-blocking drug) reducedpulling by 50%pulling by 50%

Behavioral ModelBehavioral Model - seen as learned habit - seen as learned habitdisorder where pulling is associated withdisorder where pulling is associated withtension reductiontension reduction

Ethological ModelEthological Model - animals can display - animals can displaydisplacement behavior and stereotypy indisplacement behavior and stereotypy inresponse to stress; TTM seen as excessiveresponse to stress; TTM seen as excessivegroominggrooming

Theoretical Models ofTheoretical Models of

TTMTTM Neurobiological ModelNeurobiological Model - brain imaging - brain imaging

studies are not consistent; TTMstudies are not consistent; TTMsometimes improves with SSRIs orsometimes improves with SSRIs ordopamine-blocking drugsdopamine-blocking drugs

Comprehensive Model (ComB Model)Comprehensive Model (ComB Model) - -multifactorial approach designed to tailormultifactorial approach designed to tailortreatment to each patienttreatment to each patient

Genetic FactorsGenetic Factors

5% of first-degree relatives of TTM probands5% of first-degree relatives of TTM probandswere also found to have TTM (higher thanwere also found to have TTM (higher thanprevalence rate of general population)- Swedoprevalence rate of general population)- Swedo& Rapoport, 1991& Rapoport, 1991

8% of first-degree relatives of TTM patients8% of first-degree relatives of TTM patientsreported pulling their hair (Christenson et al.,reported pulling their hair (Christenson et al.,1992)1992)

SLTRK1 gene mutations are hypothesized toSLTRK1 gene mutations are hypothesized toaccount for 5% of TTM; Zuchner et al. (2006)account for 5% of TTM; Zuchner et al. (2006)studied 44 families who had members withstudied 44 families who had members withTTMTTM

Treatment OptionsTreatment Options

MedicationMedication Electrolysis or laser hair removalElectrolysis or laser hair removal External treatments (ointments, dandruffExternal treatments (ointments, dandruff

shampoos)shampoos) Acceptance and Commitment Therapy (ACT)Acceptance and Commitment Therapy (ACT) Hypnosis, EMDRHypnosis, EMDR Behavior TherapyBehavior Therapy Interactive online programsInteractive online programs

www.stoppulling.comwww.stoppulling.com; ; www.stoppicking.comwww.stoppicking.com

MedicationsMedications

Advantages:Advantages: May decrease urge to pull, improve ability toMay decrease urge to pull, improve ability to

resist such urgesresist such urges May make behavior therapy more successfulMay make behavior therapy more successful Can relieve depression and anxiety whichCan relieve depression and anxiety which

may increase TTM behaviorsmay increase TTM behaviors Usually recommended if TTM is severe or ifUsually recommended if TTM is severe or if

person has trouble with behavior therapyperson has trouble with behavior therapy

MedicationsMedications

Disadvantages:Disadvantages: May decrease feelings of self-efficiency andMay decrease feelings of self-efficiency and

decrease motivation for behavior therapydecrease motivation for behavior therapy Can lead to sense of hopelessness ifCan lead to sense of hopelessness if

improvement is not seenimprovement is not seen Potential side effectsPotential side effects

Medication OptionsMedication Options

SSRIs have most often been used. Of these, theSSRIs have most often been used. Of these, thepreferred one is Lexapro. Prozac does not appear aspreferred one is Lexapro. Prozac does not appear aseffective.effective.

Anafranil has been tried as well as Lithium.Anafranil has been tried as well as Lithium. NaltrexoneNaltrexone showed reduced hair-pulling in one small showed reduced hair-pulling in one small

study.study. Antipsychotics have also been tried and are notAntipsychotics have also been tried and are not

suggested as a first-line medication.suggested as a first-line medication. Tenex or Tenex or clonodineclonodine may be useful with tic-like pulling. may be useful with tic-like pulling. Medications may serve best as adjunctive treatment.Medications may serve best as adjunctive treatment.

The ComB Model inThe ComB Model in

Treating TTMTreating TTM

Developed by CharlesDeveloped by CharlesMansueto.Mansueto.

Attempts to provide aAttempts to provide acomprehensive behavioralcomprehensive behavioralprogram.program.

Phase I: AssessmentPhase I: Assessment

and Functionaland Functional

AnalysisAnalysis Orientation and Commitment: how will life beOrientation and Commitment: how will life be

different when you dondifferent when you don’’t pull hair? Whatt pull hair? Whatpurpose does it serve? How difficult willpurpose does it serve? How difficult willchange be?change be?

Identification of Functional ComponentsIdentification of Functional Components(SCAMP): Sensory, Cognitive, Affective, Motor(SCAMP): Sensory, Cognitive, Affective, Motorhabits/awareness, Place/environmentalhabits/awareness, Place/environmentaltriggers.triggers.

Self-MonitoringSelf-Monitoring

Phase II: Identify andPhase II: Identify and

Target ModalitiesTarget Modalities Identify potential target modalitiesIdentify potential target modalities Select target modalitiesSelect target modalities Focus awareness on pulling or pickingFocus awareness on pulling or picking

behaviors. Develop alternative modes ofbehaviors. Develop alternative modes oftactile stimulation:tactile stimulation: GlovesGloves Cover mirrorsCover mirrors Fidget toys in handsFidget toys in hands Band aids on fingersBand aids on fingers Playing with yarn, pipe-cleaners, velcroPlaying with yarn, pipe-cleaners, velcro Nibble seeds, uncooked spaghetti, gummy bearsNibble seeds, uncooked spaghetti, gummy bears

Phase III: Identify andPhase III: Identify and

Choose InterventionChoose Intervention

StrategiesStrategies

Use strategies person most likely to useUse strategies person most likely to useand have successand have success

Environmental changes usually done firstEnvironmental changes usually done first Agree on homework assignments andAgree on homework assignments and

document thesedocument these

Phase IV: EvaluationPhase IV: Evaluation

Evaluate effectiveness of strategiesEvaluate effectiveness of strategies Adjust as neededAdjust as needed Develop relapse planDevelop relapse plan

Habit ReversalHabit Reversal

Training (HRT)Training (HRT) Self awareness training (monitoring)Self awareness training (monitoring) Relaxation training, diaphragmaticRelaxation training, diaphragmatic

breathingbreathing Muscle tensing action (competingMuscle tensing action (competing

response)response)

ResourcesResources

Trichotillomania Learning Center-Trichotillomania Learning Center-www.trich.orgwww.trich.org

The Hair-Pulling Problem: A Complete GuideThe Hair-Pulling Problem: A Complete Guideto Trichotillomania.to Trichotillomania. Oxford University Press, Oxford University Press,2003 (a book by Fred Penzel, Ph.D. and2003 (a book by Fred Penzel, Ph.D. andgeared towards professionals)geared towards professionals)

Help for Hair Pullers: Understanding andHelp for Hair Pullers: Understanding andCoping with TrichotillomaniaCoping with Trichotillomania. New Harbinger. New HarbingerPublications, 2001. (in paperback and forPublications, 2001. (in paperback and forsufferers of TTM; by Nancy Keuthen, Ph.D.,sufferers of TTM; by Nancy Keuthen, Ph.D.,Dan Stein, M.D., and Gary Christenson, M.D.)Dan Stein, M.D., and Gary Christenson, M.D.)