Trichotillomania (TTM; Hair Pulling Disorder) is estimated to affect between 1 to 3% of the general population. Unfortunately, it is often an underdiagnosed and mistreated disorder.
TTM can start at any age though the mean age of onset is in early adolescence between 11-13 years old. Clinical experience and research findings indicate that TTM more often affects women than men. In clinical settings, the female to male ratio of occurrence is 9:1 or higher. Reports of female predominance in the disorder can possibly be attributed to hormonal differences between genders, greater likelihood for females to seek treatment, and/or greater ease of camouflaging the associated hair loss in males. In younger hair pullers the gender ratio may be more equivalent; it is unclear if hair pulling in younger children is the same phenomenon as hair pulling in adults. Regardless of whom it affects, TTM can cause significant distress and impairment.
TTM is characterized by repeated pulling of one’s hair for non-cosmetic reasons from any body area, most often the scalp, eyelashes, eyebrows, beard, or pubic area. Pullers can report an urge prior to, or when attempting to resist, pulling. They often also endorse pleasure, relief or gratification upon pulling. Individual hair pullers can vary considerably in their clinical presentation. An individual may pull hair from single or multiple sites. The pulling site(s) may shift over time. Often the number of pulling sites increases with age. Pullers can use their hands or instruments to extract hair. The pulling may result in bald spots or noticeable loss in affected areas; other pullers extract hair in a distributed fashion to avoid noticeable physical damage. Efforts are often made to camouflage the loss with hairstyles, scarves, wigs, makeup, or clothing. Individuals with the disorder are often ashamed and make great efforts to hide their behavior from family, friends and healthcare providers.
Many people describe not being aware of their pulling behavior while it occurs. This style of pulling has been termed “automatic pulling”. This can happen when one is engaged in tasks or absorbed in thought, such as while watching television, talking on the phone, reading or lying in bed. Another style of pulling is “focused pulling”. This is often associated with thoughts of pulling or a compulsion to pull that may be in response to a negative emotional state, physical sensations or an intense urge. The latter style of pulling is often binge-like and results in higher frequency of hairs pulled. These styles of pulling are not mutually exclusive. Most pullers generally exhibit both styles of pulling.
TTM is currently listed in the Obsessive-Compulsive and Related Disorders Section of the 5th edition of the Diagnostic and Statistic Manual of Mental Disorders (DSM-5). It also shares features with obsessive-compulsive disorder and other obsessive-compulsive spectrum disorders (such as Tourette Syndrome, Body Dysmorphic Disorder, and pathologic skin picking). Some refer to TTM as an OCD spectrum disorder; others categorize it as a body-focused repetitive disorder (BFRB) or grooming disorder.
The current DSM-5 (APA, 2013) diagnostic criteria for TTM include:
- Recurrent pulling out of one’s hair, resulting in hair loss.
- Repeated attempts to decrease or stop hair pulling.
- The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
- The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).
Cognitive-Behavioral Treatment (CBT)
Both consensus amongst practitioners and review of existing treatment studies indicate that CBT is the first-line treatment intervention for TTM. CBT for this disorder has traditionally consisted of habit reversal training (HRT). HRT is a multi-component treatment package designed to treat motor habits. It includes the following:
- habit awareness training
- incompatible response training with implementation of an action (such as fist-clenching) that is incompatible with the hair pulling response
- relaxation techniques and
- social support
Stimulus control procedures targeted at reducing stimuli or situations that trigger hair pulling, cueing the individual when engaging in the behavior, and/or providing substitutes for sensory reinforcement are also often used to treat TTM.
Unfortunately, HRT alone does not help all pullers and many pullers do not achieve complete abstinence from pulling with this treatment. Current thinking is that the more habit-like (or automatic) pulling is more responsive to HRT than the focused pulling. HRT alone may not be effective in addressing negative affective states or intense sensations that trigger focused pulling. One randomized controlled study has suggested that supplementing HRT with another treatment approach, known as Acceptance and Commitment Therapy (ACT), can be effective. In this study reduction in hair pulling was associated with improved tolerance for uncomfortable inner experiences. Another adjunctive treatment to HRT, known as Dialectical Behavior Therapy (DBT), has also been demonstrated to be effective for pullers when used in conjunction with HRT.
Psychopharmacological (Medication) Treatment
Few controlled medication treatment trials exist for TTM. Historically practitioners often prescribed serotonin reuptake inhibitors (SRIs). Currently, these medications are prescribed less often due to conflicting reports of efficacy and uncomfortable side effects. However, these medications may be appropriate, especially if there is a comorbid disorder (such as depression) that also requires treatment.
Other medications with some evidence of success in treating this disorder include glutamatergic agents (N-acetylcysteine), dopamine-blocking neuroleptics and opiate antagonists (naltrexone). Single case reports and case studies exist demonstrating efficacy for nearly every class of psychiatric medication with TTM though randomized, controlled trials are needed.
Little research has looked at the combined efficacy of CBT and medications in treating this disorder. The one study that does exist suggests better outcomes with combined treatment (CBT and medication) than monotherapy (CBT or medication alone). In cases in which pulling severity, distress and/or associated impairment is severe, combined treatment may be warranted. The literature lacks studies examining outcomes with medication withdrawal. It is likely that pulling symptoms can recur once medications are discontinued, especially in the absence of any CBT. CBT would be indicated when individuals are unwilling to take medications or cannot tolerate medication side effects. It is important to note that CBT requires considerable commitment to monitor symptoms, practice coping skills and tolerate urges and discomfort, while working to reduce hair pulling symptoms.
Relapse is a significant problem for this disorder. Medications may lose their efficacy over time and it may be difficult to maintain the long-term commitment to CBT. It is important that pullers have reasonable expectations when embarking on treatment and understand that the goal of treatment is “symptom management” and not “cure” for their disorder.
MGH Trichotillomania Clinic and Research Unit
The TTM Clinic and Research Unit has been directed by Nancy Keuthen PhD for the past 20 years. Dr. Keuthen has conducted cutting edge research in this field including neuroimaging studies, scale development, exploration of neuropsychological functioning, medication and CBT studies, and large-scale Internet studies examining TTM clinical phenomenology. She has received foundation and benefactor support for her extensive research portfolio. She is the first author of the self-help book Help for Hair Pullers and an editor of the text Trichotillomania, Skin Picking and Other Body-Focused Repetitive Behaviors. She has authored 100 journal articles and chapters during her career. She serves as the Vice-Chair (Former Chair) of the Scientific Advisory Board of the Trichotillomania Learning Center and member of the Scientific Advisory Board of the International Obsessive-Compulsive Disorder Foundation. Darin Dougherty MD serves as Director of Psychopharmacology in the TTM Clinic and Research Unit. Dr. Dougherty does extensive neuroimaging and treatment outcome research in TTM and other disorders.
Our mission involves the provision of state-of-the-art clinical care for the treatment of symptoms and the alleviation of suffering. Our clinic is committed to advancing the current treatments for TTM through our program of research. We offer both cognitive-behavioral treatment and medication management approaches reflecting the latest advances in treatment outcome studies.
For more information about our clinical services, please contact Barbara Davidson at (617) 726-6766.