What is Trichotillomania (TTM)?
Trichotillomania (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—they may pull from single or multiple sites, which may shift over time. Often the number of pulling sites increases with age, and 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 estimated to affect between 1 to 3% of the general population. and it is often an underdiagnosed and mistreated. 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, with a 9:1 ratio 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. TTM can cause significant distress and impairment.
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.
Treatment for Trichotillomania
The consensus amongst practitioners and existing treatment studies indicate that CBT is the first-line treatment intervention for Trichotillomania (Hair Pulling Disorder). 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
- social support
In addition to CBT, stimulus control procedures targeted at reducing stimuli or situations that trigger hair pulling are also used to treat Trichotillomania; these procedures may cue the individual when they are engaged in the hair pulling, and/or provide substitutes for sensory reinforcement.
Unfortunately, HRT alone does not help all pullers and many pullers do not achieve complete abstinence from pulling with this treatment. The current line of thinking suggests that habit-like (or automatic) pulling is more responsive to HRT than 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, reductions in hair pulling were 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.
Few controlled medication treatment trials exist for hair pulling disorder. 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). Existing single case reports and case studies demonstrate efficacy for nearly every class of psychiatric medication with hair pulling disorder, though randomized, controlled trials are needed to replicate these findings on a larger scale.
Little research has looked at the combined efficacy of CBT and medications in treating this disorder. One existing study 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. There is a gap in the literature 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” their disorder.
For more general information regarding treatment, please read our Treatment Approaches page on our website.
How our program can help:
Our program specializes in evidence-based treatment for Trichotillomania (Hair Pulling Disorder) with cognitive behavioral therapy (CBT) and medication. For more information, please contact our intake coordinator at 617-726-6766.
Trichotillomania (TTM) Clinic and Research Unit
The Massachusetts General Hospital Trichotillomania (TTM) Clinic and Research Unit has been directed by Nancy Keuthen Ph.D. 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 is currently a site PI for the TLC Foundation for Body Focused Repetitive Behavior Precision Medicine Initiative. The aim of this project is to identify potential subtypes of body-focused repetitive behaviors to enhance treatment outcomes. Dr. Keuthen 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. Dr. Keuthen has authored over 100 journal articles and chapters during her career. She serves as the Vice-Chair (Former Chair) of the Scientific Advisory Board of the TLC Foundation for Body-Focused Repetitive Behaviors and is a member of the Scientific Advisory Board of the International OCD Foundation.
Darin Dougherty, M.D. 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, empirically-based treatment for hair pulling symptoms and the alleviation of suffering. Our clinic is committed to advancing the current treatments for TTM through our program of research. For more information, please read our Treatment Approaches page on our website or contact our intake coordinator at 617-726-6766.