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Recent Advances in the Understanding and Treatment of Trichotillomania



Trichotillomania (TTM), or chronic hair pulling, is associated with significant levels of distress and impairment. While research is in its infancy, more data are accumulating regarding the impact, phenomenology, maintaining variables, etiology, and treatment of TTM. Behavior therapy and clomipramine have been moderately effective in reducing TTM symptoms in clinical trials. Enhancing behavior therapy with techniques designed to address TTM patients' emotional control tendencies (e.g., acceptance-based procedures) represents a promising direction in treating TTM.
Journal of Cognitive Psychotherapy: An International Quarterly
Volume 24, Number 1 • 2010
46 ©
2010 Springer Publishing Company
DOI: 10.1891/0889-8391.24.1.46
Recent Advances in the Understanding
and Treatment of Trichotillomania
Michael R. Walther, BS
Emily J. Ricketts, BA
Christine A. Conelea, MS
Douglas W. Woods, PhD
University of Wisconsin-Milwaukee
Trichotillomania (TTM), or chronic hair pulling, is associated with significant levels of dis-
tress and impairment. While research is in its infancy, more data are accumulating regarding
the impact, phenomenology, maintaining variables, etiology, and treatment of TTM. Behavior
therapy and clomipramine have been moderately effective in reducing TTM symptoms in clin-
ical trials. Enhancing behavior therapy with techniques designed to address TTM patients’
emotional control tendencies (e.g., acceptance-based procedures) represents a promising
direction in treating TTM.
Keywords: trichotillomania; behavior therapy; acceptance and commitment therapy; obsessive-
compulsive spectrum; impulse-control disorders
This article summarizes existing research on trichotillomania (TTM) in adults and describes
how basic psychopathology research on TTM led to the modification of existing behav-
ioral treatment procedures to create a novel acceptance-based intervention. Issues sur-
rounding the diagnosis of TTM will be discussed first, followed by a brief review of the literature
on TTM’s epidemiology, impact, and phenomenology. After highlighting common assessment
techniques and tools used in TTM, etiology of the disorder will be discussed. Finally, treatments
for TTM are discussed and steps taken to modify these interventions in the light of recent etio-
logical work are described.
Trichotillomania is characterized by repetitive hair pulling that results in noticeable hair loss
Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric
Association [APA], 2000). The DSM-IV-TR also specifies criterion B: tension prior to pulling and
criterion C: relief, pleasure, or reduced tension post pulling, but the validity of these is suspect
because many who pull do not report the presence of both criteria (Hanna, 1997; Reeve, Bernstein,
& Christenson, 1992). Although TTM is included in the DSM-IV-TR as an impulse control dis-
order, researchers have also construed it as an obsessive-compulsive spectrum disorder (Stein,
Lochner, Hemmings, & Kinnear, 2005) or an addictive disorder (Grant, Odlaug, & Potenza, 2007).
Advances in Trichotillomania 47
No rigorous epidemiological studies have been conducted, but estimates suggest a prevalence of
TTM of 0.6% to ~3%, depending on whether full DSM-IV-TR criteria are used (Christenson,
Pyle, & Mitchell, 1991; Stanley, Borden, Bell, & Wagner, 1994). TTM is more common in women
(Cohen, Stein, Simeon, & Spadaccini, 1995; Swedo & Leonard, 1992), and onset is usually in early
adolescence (Christenson, Mackenzie, & Mitchell, 1991). Some researchers have suggested a pos-
sible bimodal age of onset, with a subgroup of individuals, known as “baby trichs,” whose onset
occurs in childhood and whose symptoms may be less enduring and contain fewer comorbidities
(Winchel, 1992). Because “baby trichs” have been hypothesized to have milder symptoms than
those with adolescent onset, some have hypothesized they are more responsive to behavior mod-
ification techniques, whereas adolescents and adults may need a more comprehensive treatment
package like cognitive-behavioral therapy (Wetterneck & Woods, 2007). These hypotheses have
yet to be tested, although research has identified important developmental aspects of TTM that
are consistent with these notions. Flessner, Woods, Franklin, Keuthen, and Piacentini (2009) com-
pared pulling styles and other phenomena in those with TTM across age groups, and reported
that “automatic” pulling, or pulling that occurs outside of one’s awareness, is predominant in
children (age 10–12). Conversely,focused” pulling, which is pulling in response to emotional or
cognitive stimuli, was found to be more prevalent among adolescents and adults.
TTM has a significant impact on the lives of individuals with the disorder. In adults, it leads to deficits
in psychological, social, academic, and occupational functioning. Individuals with TTM commonly
experience negative affect and negative self-evaluations including low self-esteem, feelings of unattrac-
tiveness, embarrassment, shame, guilt, isolation, pain, fear, and concern regarding the concealment of
the disorder (Casati, Toner, & Yu, 2000; Diefenbach, Tolin, Hannan, Crocetto, & Worhunsky, 2006; du
Toit, van Kradenburg, Niehaus, & Stein, 2001; Soriano et al., 1996; Stemberger, Thomas, Mansueto, &
Carter, 2000). Anger and frustration due to an inability to control pulling symptoms is also common
(Casati et al., 2000). A small subset of adults with TTM use alcohol, tobacco, or drugs to reduce nega-
tive feelings associated with hairpulling or to reduce urges to pull (Woods, Flessner, et al., 2006).
TTM also interferes with social functioning, as many individuals experience lowered fre-
quency, quantity, and quality of friendships, dating, and intimate relationships (Keuthen et al.,
2004; Wetterneck, Woods, Norberg, & Begotka, 2006). Many individuals with TTM attempt to dis-
guise the bald patches by wearing certain hairstyles or wigs, or through the use of cosmetics (Casati
et al., 2000; Diefenbach et al., 2006; du Toit et al., 2001). Some avoid visits to the hairdresser for fear
of being exposed (Diefenbach et al., 2006; du Toit et al., 2001; Stemberger et al., 2000; Wetterneck
et al., 2006), and avoid social or recreational activities (i.e., vacations, entertainment, swimming,
sports, going outside on windy days) where hair loss is noticeable (Casati et al., 2000; Diefenbach
et al., 2006; Stemberger et al., 2000; Wetterneck et al., 2006; Woods, Flessner, et al., 2006).
TTM significantly impacts academic and occupational performance and finances. TTM may
lead to school absences, difficulty performing school duties, and difficulty studying (Wetterneck
et al., 2006; Woods, Flessner, et al., 2006). Many individuals with TTM experience occupa-
tional interference, particularly in work productivity, concentration, and career advancement
(Diefenbach et al., 2006; Keuthen et al., 2004; Wetterneck et al., 2006; Woods, Flessner, et al.,
2006). Financially, TTM results in money spent on concealment and treatment (Wetterneck et al.,
2006). Research on the impact of TTM in children indicates that children with the disorder expe-
rience similar interference as adults (Franklin et al., 2008).
There is a paucity of research on the cross-cultural impact of TTM; however findings from
two studies of African American women with TTM show that the individuals experienced feelings
48 Walther et al.
of guilt following a pulling episode, embarrassment due to the effects of pulling, and social avoid-
ance (Neal-Barnett & Stadulis, 2006; Neal-Barnett, Ward-Brown, Mitchell, & Krownapple, 2000).
Individuals with TTM may pull hair from any part of the body, but the scalp is the most common
pulling site, followed by eyelashes and eyebrows (Franklin et al., 2008; Hanna, 1997). Pulling of
pubic hair has also been reported in those who have reached puberty, with reports ranging as high
as above 50% in anonymous surveys (Woods, Flessner, et al., 2006). Men with TTM commonly
pull from the beard or mustache (du Toit et al., 2001). The majority of individuals in TTM sam-
ples report pulling from multiple sites (Christenson, Mackenzie, & Mitchell, 1991; du Toit et al.,
2001). Though the primary method of hair extraction is with the fingertips, those with TTM may
also pull with tweezers, combs, or brushes (Woods, Flessner, et al., 2006).
Trichotillomania is commonly preceded by a number of environmental factors (i.e., anteced-
ents) and is met with a variety of consequences, which are believed to play a role in maintaining
the disorder.
Antecedents to pulling have been discovered across multiple phenomenological domains, includ-
ing sensory stimulation, emotions, and cognitions.
Sensory Antecedents. Some adults with TTM pull hairs that are different from others in terms
of hair thickness, length, or location (Stein, Christenson, & Hollander, 1999). These hairs may be tar-
geted by engaging in prepulling behaviors such as scanning for the “right” hair (Mansueto, Townsley-
Stemberger, McCombs-Thomas, & Goldfinger-Golomb, 1997). Physical sensations on the scalp, such as
itchiness, irritation, and skin sensitivity may serve as antecedents to pulling (Christenson & Manuseuto,
1999). A study containing a college sample suggested that African American women may be more likely
than others to pull in response to skin irritation (McCarley, Spirrson, & Ceminsky, 2002).
Emotional Antecedents. A number of studies using patient self-report have identified anxiety as
a trigger to pulling. For example, 83% of an adult TTM sample reported anxiety prior to pulling (du
Toit et al., 2001). Other emotional states, such as boredom, tension, and anger (Christenson, Ristvedt,
& Mackenzie, 1993; Diefenbach, Mouton-Odum, & Stanley, 2002; Diefenbach, Tolin, Meunier, &
Worhunsky, 2008), have been associated with increased pulling in adults. In children and adoles-
cents, findings for antecedent tension are mixed, with some studies finding the majority of children
and adolescents endorsing tension (Franklin et al., 2008; King, Scahill et al., 1995) and others finding
no link between tension and pulling (Hanna, 1997; King, Zohar et al., 1995; Reeve et al., 1992).
Cognitive Antecedents. Thoughts about hairs or about pulling hairs, such as “this hair is out
of place” or “I just need to pull a little to relieve my stress” may precede pulling (Mansueto et al.,
1997). Other cognitions that may be involved in the maintenance of TTM include rigid thinking
patterns (e.g., “Wiry hairs are bad”) and cognitive errors, such as catastrophizing (e.g., “I cannot
feel better until this hair is gone”) and overgeneralizing (e.g., This funny-looking hair is notice-
able to everyone”). In addition, beliefs about appearance and fears of negative evaluation are
associated with TTM severity (Norberg, Wetterneck, Woods, & Conelea, 2007). It is unclear how
closely related thoughts like these are to obsessions found in obsessive-compulsive disorder, but
from a behavioral conceptualization, cognitions like these may function as conditioned aversive
stimuli that evoke behaviors for removing the aversive thought (Wetterneck & Woods, 2007).
Environmental variables also follow pulling, and these consequences have been broken down into
sensory, emotional, and cognitive factors. Sensory consequences can be broken down into two
categories, tactile and visual consequences.
Advances in Trichotillomania 49
Tactile Consequences. Tactile consequences involve reinforcement resulting from physical
touch, typically produced by the manipulation of pulled hair (Rapp, Miltenberger, Galensky,
Ellingson, & Long, 1999). As mentioned previously, certain types of hairs may be targeted by an
individual for pulling. These may include coarse hairs or those of differing length. Many individu-
als with TTM report engaging in postpulling activities that produce physical sensations that func-
tion as reinforcers (i.e., rubbing the hair between one’s fingers or rubbing the hair across one’s
face). Though relatively rare, some with TTM ingest the hair after it has been pulled (Bouwer &
Stein, 1998). More commonly, at least half of individuals with TTM engage in other oral behavior
such as biting off the root of the hair or rubbing the hair along one’s lips or mouth (Christenson,
Mackenzie, & Mitchell, 1991; Christenson & Manuseuto, 1999).
Visual Consequences. After the hair has been pulled, the individual may engage in behav-
iors such as scanning the hair, looking at the root, looking at the thickness of the hair, or other
visual behaviors. These behaviors likely produce visual stimulation that reinforces the pulling. For
example, finding the hair that was “out of place,” gray, or possessed some “important” physical
feature (thickness, etc.), may function to strengthen pulling.
Emotional Consequences. Some individuals report pleasure while pulling (Mansueto et al., 1997),
whereas others report a reduction of aversive emotional states, such as anxiety, sadness, boredom, ten-
sion, or stress (Diefenbach et al., 2002, 2008). However, an increase in some of those emotions, such as
sadness or guilt, has been observed from during- to postpulling (Diefenbach et al., 2002).
Cognitive Consequences. Cognitions associated with the emotional consequences discussed
above may also result from pulling. For example, cognitions associated with sadness or guilt may
assist in terminating a pulling episode (Mansueto et al., 1997).
Accurate and thorough assessment of TTM symptoms in adults and children is essential to both
understanding and treating TTM. Several methods of assessment have been utilized in treatment,
including direct observation, clinician rating scales, and self-report measures.
Direct observation of hairpulling by an independent rater is often only utilized with children
or individuals with mental retardation. Though such approaches provide objective measures of
hair pulling, adults’ and adolescents’ tendency to pull in private and the embarrassment they ex-
perience surrounding the direct observation strategy usually prevents the use of this method in
such populations. As a result, self-monitoring involving the detection and recording of instances
of hairpulling during certain periods of the day is commonly used in older children and adults.
Methods of self-monitoring include saving and counting the pulled hairs, rating urges to pull,
recording instances of hand-to-hair contact, or noting the context in which pulling behavior
occurs. Self-monitoring is especially helpful in increasing awareness of pulling in those who lack
awareness of their behavior (Diefenbach, Reitman, & Williamson, 2000; Rothbaum & Ninan,
1994; Stanley, Bowers, Swann, & Taylor, 1991).
Clinician rating scales are completed by a therapist or independent evaluator and consist
of questions directed toward the client regarding hairpulling symptoms. The most commonly
used clinician rating scale for TTM is the National Institute of Mental Health Trichotillomania
Symptom Severity and Impairment Scale (NIMH-TSS and NIMH-TISS; Swedo et al., 1989). The
NIMH-TSS is a five-item measure assessing average hairpulling episode duration during the past
week and on the previous day, thoughts preceding the pulling episode, resistance to urges, distress,
and interference. The NIMH-TIS is an 11-point scale assessing overall patient impairment. The
psychometric properties of the NIMH scales are mixed, demonstrating good interrater reliability,
concurrent validity, and sensitivity to hairpulling symptom changes post treatment, but more
moderate internal consistency (Diefenbach, Tolin, Crocetto, Maltby, & Hannan, 2005; Rothbaum,
1992; Stanley, Breckenridge, Snyder, & Novy, 1999; Swedo et al., 1989).
Objective self-report measures are completed by the patient and/or their caregiver. The most
commonly used self-report measure is the Massachusetts General Hospital Hairpulling Symptom
50 Walther et al.
Severity Scale (MGH-HS; Keuthen et al., 1995), a seven-item measure assesses urge frequency,
intensity, controllability, hairpulling frequency, resistance, controllability, and associated distress
during the prior week. The MGH-HS possesses the strongest psychometric properties of any cur-
rent TTM measure for adults (Diefenbach et al., 2005; Keuthen, Flessner, et al., 2007; O’Sullivan
et al., 1995). TTM severity in children can be assessed with the psychometrically acceptable
Trichotillomania Scale for Children (Tolin et al., 2008).
Most existing measures of TTM have focused on the assessment of pulling severity. However,
recent studies have placed an emphasis on the development of assessments that distinguish
between the specific pulling subtypes: focused and automatic. The child and adult versions of
the Milwaukee Inventory for Styles of TTM (Flessner et al., 2007; Flessner, Woods, et al., 2008)
have demonstrated adequate internal consistency and good construct and discriminant validity
in preliminary research.
The precise etiology of TTM has yet to be determined, but possible etiological factors from sev-
eral theoretical perspectives have been proposed. These factors are highlighted below.
Animal Models
Plucking and pulling behaviors have been observed across many species in captivity, including
rodents, birds, and mammals (Reinhardt, 2005). In one of the more promising animal models,
researchers have postulated that the phenomenon of “barbering” in mice is homologous to TTM
(Garner, Weisker, Dufour, & Mench, 2004). Barbering has been found to be about 1.5 times more
likely in female mice and 5 times more likely in breeder mice, consistent with the notion that
TTM is more common in females. Research on the etiology of barbering has revealed several pos-
sible environmental and pathophysiological mechanisms. Barbering seems to be elevated in ani-
mals that endure social stress in the form of isolation or crowding and in animals with heightened
stress reactivity (Dufour & Garner, in press). Neuropsychological tests of barbering mice have
revealed a selective deficit in “set shifting,” a function controlled by the prefrontal corticostriatal
loop (Garner, Meehan, Famula, & Mench, 2006), and the severity of barbering was correlated
with the severity of this deficit. Interestingly, research on the neuropsychological profiles of those
with TTM has revealed deficits in the same brain region (Stanley, Hannay, & Breckenridge, 1997).
Given the numerous similarities between barbering and TTM, further research on the etiology of
treatment of barbering may benefit models of TTM in humans.
Biological Factors
Genetics. A specific TTM gene has not been identified in humans, although genetic research in
animals and humans has yielded results suggesting that TTM may have a genetic basis. Novak,
Keuthen, Stewart, and Pauls (2009) recently compared TTM concordance rates in 24 monozy-
gotic and 10 dizygotic twin pairs. Using DSM-IV-TR criteria, TTM concordance rates were sig-
nificantly higher in monozygotic pairs (38%) than in dizygotic pairs (0%, p = .047).
The search for a particular gene(s) involved in TTM has produced interesting findings.
Compulsive grooming behaviors have been observed in some knockout mice, such as those defi-
cient of the postsynaptic synapse-associated protein 90/postsynaptic density-95-associated pro-
tein 3 (SAPAP3). Zuchner, Wedland, et al. (2009) resequenced SAPAP3 in unrelated individuals
with TTM (N = 77), TTM and obsessive-compulsive disorder (OCD; N = 44), and normal con-
trols (N = 48). Heterozygous variants in SAPAP3 were found in 4.2% of those with TTM/OCD
and in only 1.1% of controls, leading researchers to conclude that this genotype may increase
susceptibility for OCD spectrum behaviors, including TTM. Mutations in the slit and trk like
1 (SLITRK1) gene, which has been implicated in other repetitive behavior disorders (Abelson
et al., 2005), were examined in 44 TTM nuclear families by Zuchner, Cuccaro, et al. (2009). Rare
Advances in Trichotillomania 51
variants in SLITRK1 were found in 4.5% of the sample, suggesting that this gene may play a role
in some cases of TTM. Other possible genes that may contribute to TTM susceptibility include
those associated with the encoding of components in the serotonergic and dopaminergic neu-
rotransmitter pathways (e.g., T102T-genotype; Hemmings et al., 2006) and genes expressed in
cortico-basal ganglia circuits (e.g., Hoxb8; Greer & Capecchi, 2002).
Neuroanatomy and Neurochemistry. Abnormal repetitive behaviors, including TTM, are
thought to involve dysregulation of parallel, segregated cortico-striato-thalamocortical circuits
(Graybiel & Rauch, 2000; Mink, 2001). These circuits regulate the selection and sequencing of
behavior and include a direct pathway that initiates movements and an indirect pathway respon-
sible for motoric inhibition. Disinhibition of the indirect pathway is thought to be particularly
important in the etiology of repetitive behavior disorders, and TTM in particular seems to
be associated with altered function of the prefrontal corticostriatal loop (Stanley et al., 1997).
Imaging research has revealed several neurostructural deficits in individuals with TTM, includ-
ing increased grey matter densities in areas associated with habit learning, cognition, and affect
regulation (e.g., left striatum, left amygdalo-hippocampal formation, multiple cortical regions;
Chamberlain et al., 2008); reduced cerebellar volumes (Keuthen, Makris, et al., 2007); and reduced
basal ganglia volumes (O’Sullivan et al., 1997).
Research has not linked a specific neurochemical deficit with pulling severity. Based on out-
come research suggesting favorable response to pharmacotherapy, some researchers have hypoth-
esized that pulling severity is related to dysregulations of the serotonergic, noradrenergic, and/or
dopaminergic systems (e.g., Swedo et al., 1989; Winchel, Jones, Stanley, Molcho, & Stanley, 1992).
Hormones. As mentioned earlier, increased barbering behavior in animals has been
observed in mice that are reproductively active, leading some to conclude that TTM symptoms
may be impacted by hormonal changes (Garner et al., 2004). In a cross-sectional study of 1,471
women with TTM, Flessner et al. (2009) found that fluctuations in “focused” pulling coincided
with typical ages of important hormonal and biological changes, such as pubertal onset and
perimenopause. Despite these findings, little experimental research has examined the relation-
ship between hormones and TTM. In one small study, Epperson, McDougle, and Price (1996)
conducted a double-blind controlled study comparing the effects of intranasal oxytocin and
saline placebo on TTM symptoms in two women. TTM symptoms did not change acutely or
after 7 days; however, the intranasal administration may not have enabled the hormone to cross
the blood–brain barrier, which may explain why the hormone did not affect repetitive behavior.
Clearly, more research is needed to understand if and how hormonal changes impact pulling.
Neuro-Cognitive Factors. The cortical-striatal pathways implicated in TTM appear to play a
key role in the acquisition and retrieval of motor sequences (Graybiel, 1998). Thus, hair pulling
may be conceptualized as involving difficulties inhibiting abnormal repetitive action repertoires
that are driven by tension or urges (i.e., response inhibition) and engaging in novel tasks which
compete with the repetitive action repertoires (i.e., cognitive flexibility).
To examine whether TTM is characterized by difficulties with response inhibition, 17 indi-
viduals with TTM were compared to 20 healthy controls and 20 individuals with OCD on a Stop-
Signal task. Those with TTM exhibited greater response inhibition deficits than either the OCD
or healthy control group, and the degree of inhibitory deficit was moderately correlated with pull-
ing severity (Chamberlain, Fineberg, Blackwell, Robbins, & Sahakian, 2006). In another study, 21
individuals with TTM were compared to 17 normal controls on a Stroop test (Stanley et al., 1997).
The TTM group again demonstrated deficient performance in comparison to the control group.
Deficits in cognitive flexibility have also been observed in persons with TTM. In one study,
23 individuals with TTM were compared to 21 individuals with OCD and 26 healthy controls
on the Object Alternation Task (Bohne et al., 2005). Those with TTM showed a greater number
of perseverative errors when compared to the healthy controls, suggesting greater difficulties in
changing response patterns. Similarly, Stanley et al. (1997) demonstrated that adults with TTM
performed worse on the Trails B test than normal controls, suggesting impaired cognitive flexibil-
ity in persons with TTM. In contrast, other studies demonstrated that those with TTM were no
52 Walther et al.
different than healthy control participants on a measure of cognitive flexibility (Intradimensional-
Extradimensional Shift Task Score; Chamberlain, Blackwell, Fineberg, Robbins, & Sahakian, 2006;
Chamberlain, Fineberg, et al., 2006). Although data on flexibility are still contradictory, evidence
for impaired flexibility in persons with TTM is consistent with a problematic habitual motor pat-
tern of behavior.
Behavioral Factors. Behavioral theories of TTM focus on the role of conditioning in pulling
etiology and maintenance. Azrin and Nunn (1973) proposed that pulling may initially develop
as a stress-coping behavior reinforced by tension reduction. The notion that pulling may be
maintained by negative reinforcement via reduction of aversive private experiences (i.e., not just
tension or anxiety) has since garnered more support. In an examination of the affective states
associated with pulling, Diefenbach et al. (2002) found that negative emotions such as tension,
anxiety, boredom, and sadness may immediately precede pulling. Temporary reductions in these
emotions were reported immediately following pulling. However, a later increase in unpleasant
emotions such as guilt, anger, and sadness was observed, suggesting that emotional reactions to
pulling may also set the occasion for future pulling episodes. In another study, Diefenbach et al.
(2008) compared the emotional experience of hair pulling in individuals with TTM to nonclini-
cal controls. At the onset of the pulling, the TTM group reported larger decreases in boredom,
sadness, tension, and anger and larger increases in relief and calm. The TTM group also reported
higher pleasure during pulling and greater guilt, sadness, and anger following pulling. These
results further support the negative reinforcement model.
Pulling may also be maintained by positive reinforcement (Rapp et al., 1999). Positive rein-
forcers for pulling may include emotions of gratification, pleasure, or satisfaction experienced
as a consequence of pulling; visual stimulation produced by particular hairs (e.g., plump roots,
hairs of a particular thickness, texture, or color); and tactile stimulation created by prepulling hair
twisting or stroking, pulling hairs out (e.g., sensation of popping), or postpulling manipulations
(e.g., rubbing hairs against body, face, lips; running hair between fingers).
Pulling “triggers,” internal and external cues that increase the likelihood of pulling, may
acquire their function via classical and operant conditioning processes (Diefenbach et al., 2000).
Over time, the urge and/or pulling behaviors may become associated with many stimuli, such as
specific settings, times of day, locations, or particular objects, which increases the likelihood that
pulling will occur in the presence of those stimuli.
Emotional Regulation. As described above, research has demonstrated reductions in aver-
sive emotions following pulling (Diefenbach et al., 2002), supporting the notion that pulling
may function as an emotion regulation strategy. There is also growing evidence to show that
the relationship between specific emotional states and TTM severity may be moderated by an
individual’s history of escaping or avoiding unpleasant emotions or cognitions. This response
tendency, termed experiential avoidance (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), may
be particularly important in the analysis of TTM. Begotka, Woods, and Wetterneck (2004) first
demonstrated a significant relationship between pulling severity (as measured by the MGH-HS),
and experiential avoidance (as measured by the Acceptance and Action Questionnaire; Hayes
et al., 2004). Experiential avoidance has also been shown to significantly moderate the relation-
ship between hair-pulling severity and negative cognitions, including dysfunctional beliefs about
appearance, fears of negative evaluation, and shameful cognitions (Norberg et al., 2007).
The treatment of TTM has taken a circuitous path. The development of such treatments has
historically proceeded in the absence of information on the basic psychopathology of the disor-
der. Despite this, effective treatments for TTM do exist. Studies demonstrating treatment efficacy
have been reported with pharmacological and nonpharmacological interventions, and the vast
majority of this research has been conducted with adults. Research from randomized controlled
trials on the efficacy of pharmacotherapy in children and adolescents does not exist, and research
Advances in Trichotillomania 53
on the effectiveness of behavioral procedures is very limited (e.g., Tolin, Franklin, Diefenbach,
Anderson, & Meunier, 2007). Because the thrust of this article is on psychological intervention
and because the data on TTM treatment in children are so limited, we only provide a brief review
research on pharmacotherapy, followed by a more extensive discussion on the development and
outcome data for nonpharmacological interventions in adults.
Research on medication for TTM has been mixed, with no one drug having been demonstrated
efficacious in replicated randomized controlled trials. Of the medications that have been tested,
two types predominate. Selective serotonin reuptake inhibitors (SSRIs), including fluoxetine and
sertraline, have been tested extensively in both crossover and randomized placebo controlled
designs. Results have generally failed to demonstrate benefits of SSRIs over placebo (Christenson,
Mackenzie, Mitchell, & Callies, 1991; Streichenwein & Thornby, 1995) or wait-list control (van
Minnen, Hoogduin, Keijsers, Hellenbrand, & Hendriks, 2003), thereby raising questions about
the validity of neurochemical theories on the etiology of TTM. Clomipramine has also been
tested, with mixed results. One of the first pharmacotherapy treatment studies in TTM compared
clomipramine to desipramine and showed superiority for clomipramine (Swedo et al., 1989).
However, a more recent comparison between clomipramine, placebo, and behavior therapy failed
to show separation between clomipramine and placebo (Ninan, Rothbaum, Martsteller, Knight,
& Eccard, 2000). In a recent meta-analysis of medication studies for TTM, Bloch et al. (2007)
noted that clomipramine was likely effective for TTM, whereas SSRIs were not. In the most recent
controlled pharmacological treatment study of TTM, Grant, Odlaug, and Kim (2009) compared
pill placebo to N-Acetylcysteine, a glutamate modulator, in 50 adults with TTM. Using a dou-
ble-blind randomized trial design, results clearly showed that following 12 weeks of treatment,
N-Acetylcysteine yielded significantly greater reduction in pulling severity than placebo. Overall,
56% of the active group was considered treatment responders compared to 16% of the placebo
condition. This finding is novel and promising, but awaits replication by an independent research
Behavior Therapy for TTM
Recent surveys of practitioners and persons with TTM suggest the most common form of non-
pharmacological treatment for TTM involves one of many psychotherapies that have not been
empirically tested (e.g., supportive therapy, hypnosis, psychoanalysis, or eye movement desen-
sitization and reprocessing; Marcks, Wetterneck, & Woods, 2006; Woods, Flessner, et al., 2006).
Behavior therapy, another nonpharmacological approach with more empirical support, has also
been used. Although a variety of behavioral procedures have been attempted as treatments for
TTM (Altman, Haavik, & Cook, 1978; Rapp, Miltenberger, Long, Elliott, & Lumley, 1998), only
one behavioral treatment, habit reversal therapy (HRT), has been studied in a rigorous fash-
ion. Despite promising results, HRT’s utility as a durable and stand-alone treatment for TTM is
Brief Description of HRT. HRT has been used to treat TTM and a host of other conditions
including Tourette’s Disorder (e.g., Woods, Twohig, Flessner, & Roloff, 2003), excessive nail biting
(e.g., Twohig, Woods, Marcks, & Teng, 2003), and self-injurious skin picking (e.g., Teng, Woods,
& Twohig, 2006). HRT combines awareness training, competing response training, and social
support. Awareness training involves increasing the participant’s awareness of specific pulling
episodes and the cognitive/emotional phenomena that precede pulling (e.g., specific situations,
cognitions, or urges). In competing response training, the participant is taught to engage in a
“competing response” that is physically incompatible with the pulling. Participants are instructed
to do the competing response (i.e., making a fist) for 1 min contingent on the specific pulling
behavior or on an occurrence of the preceding cognitive/emotional phenomena. Social support
54 Walther et al.
involves the recruitment of a significant other in the participant’s life who is instructed to prompt
the participant to use the competing response when necessary and to praise him or her when
the competing response is implemented correctly. In addition to awareness training, compet-
ing response training, and social support, HRT often includes a “stimulus control” component.
Stimulus control refers to specific strategies that can be implemented to reduce the likelihood that
pulling will occur. For example, if tweezers are used to pull hair in front of a mirror, the partici-
pant may be asked to remove tweezers from the home and cover the mirror. Examples of stimulus
control techniques are endless, but primarily involve a direct individualized modification of the
environment to reduce the likelihood of pulling.
Data on the Efficacy of HRT for TTM. A number of uncontrolled case studies (Rosenbaum
& Ayllon, 1981), controlled single-subject designs (e.g., Rapp et al., 1998; Tarnowski, Rosen,
McGrath, & Drabman, 1987), and uncontrolled group designs (Lerner, Franklin, Meadows,
Hembree, & Foa, 1998; Mouton & Stanley, 1996) provide preliminary support for the efficacy of
HRT for TTM, but lack of experimentally controlled group designs weakens these claims.
Only three randomized controlled trials have been conducted to evaluate the efficacy of HRT
for TTM, all of which involved adult samples of limited size. Azrin and colleagues found that HRT
was more effective than another behavioral approach, negative practice, but the study was limited
by exclusive reliance on patient self-report and substantial attrition (7 of 19) during the follow-up
phase (Azrin, Nunn, & Frantz, 1980). In a second randomized controlled trial, 23 persons with TTM
were randomly assigned to one of three conditions: HRT+cognitive therapy, clomipramine, or pla-
cebo. Treatment efficacy was measured via clinician ratings. Results showed that HRT+cognitive
therapy was more effective than the placebo or clomipramine (Ninan et al., 2000). Specifically,
HRT+cognitive therapy showed a 90% decrease in pulling at posttreatment compared to a 38%
decrease for clomipramine and a 10% decrease for placebo. These data are promising, but limited
by the fact that initial sample sizes were very small (n = 6–10 per group), the dropout rate high
(40% for clomipramine, 29% for HRT+cognitive therapy, and 17% for placebo), and the follow-up
assessment inadequate. The third, and perhaps most well-designed, study involved 43 persons (16
years and older) who were randomly assigned to wait-list (N = 15), fluoxetine (N = 13), or behavior
therapy (N = 15; van Minnen et al., 2003). Individuals assigned to the wait-list condition did not
receive treatment for 12 weeks. Those assigned to the fluoxetine condition had their dosage titrated
to 60 mg/day, and those assigned to behavior therapy received stimulus control and HRT proce-
dures across 6 sessions held every other week. Dropout rates were relatively low, with a 6% dropout
rate for behavior therapy, 15% rate for fluoxetine, and 0% for wait-list. Results showed that the
behavior therapy procedures produced a significantly greater reduction in MGH-HS scores when
compared to the wait-list and fluoxetine groups at posttreatment. However, when using the inde-
pendent hair damage ratings as the dependent variable, effect sizes were considerably smaller, and
no longer significant. The Beck Depression Inventory (Beck, Steer, & Brown, 1996) and Symptom
Checklist-90 (SCL-90; Derogatis, Lipman, & Covi, 1973) were also administered at pre- and post-
treatment, but the groups did not differentially improve on these measures. A later study by the
same research group looked at a 2-year follow-up of the behavioral treatment (Keijsers et al., 2006).
Results showed a 70% reduction in effect size from posttreatment to the 2-year follow-up.
Across all trials examining behavior therapy for TTM, findings suggest that behavior therapy
may be useful for treating TTM. However, problems remain with the existing literature. First,
there is a significant lack of a well-designed large-scale randomized controlled trial with psycho-
metrically sound assessment strategies administered by a blinded independent evaluator. Second,
there has been a lack of follow-up assessment or unacceptable recurrence of symptoms. Finally,
the treatments that have been tested have not been developed on a model of TTM etiology and
maintenance that is grounded in empirically supported theory. From a blind efficacy perspective
this latter criticism may be unimportant, but the development of a treatment based on an empir-
ically derived theoretical account not only provides an opportunity to advance knowledge about
therapeutics for a particular problem, but also provides the opportunity to advance knowledge
about the psychopathology of the disorder (Foa & Kozak, 1997).
Advances in Trichotillomania 55
Building Behavior Therapy for TTM from the Ground Up
To move beyond the limitations of HRT, Mansueto and colleagues (1997) first acknowledged the
need for a more comprehensive model of TTM to guide treatment development. As suggested by
Mansueto and et al., to develop a therapeutic procedure, it would be useful to utilize existing lit-
erature on the phenomenology of TTM, make informed decisions about how these factors may
contribute to symptom expression, and combine into one integrated treatment package those treat-
ment components that either have been found or are believed to impact these specific factors.
Important Factors to Consider in the Treatment of TTM. In the development of a compre-
hensive treatment for TTM, it is important to recognize a number of factors that contribute to
symptom severity and overall life impairment. By systematically combining treatment strategies
designed to address these factors, a comprehensive and integrated treatment for TTM may be
designed. Below, these factors are described and the steps taken in the creation of a comprehen-
sive and integrated treatment are presented.
1. Idiosyncratic factors in the maintenance of pulling: As described earlier, TTM can be evoked
and reinforced by a host of different environmental stimuli. To address this factor, it would
be helpful to systematically identify evocative and reinforcing stimuli for a client and create
a particular set of therapeutic recommendations with the goal of reducing or eliminating
these stimuli from the client’s environment. This is typically what is done in the therapeutic
technique for TTM known as stimulus control.
2. Feelings of isolation and embarrassment: One of the primary distressing symptoms expe-
rienced by those with TTM involves feelings of social isolation and a lack of understanding
about their disorder (Wetterneck et al., 2006). The impact of these events is unknown, but it
is plausible that these factors contribute to anxiety and depressive symptoms, and thus pos-
sibly an increase in TTM pulling severity. To counter this particular factor, psychoeduca-
tion about TTM may be useful in reducing feelings of isolation and improve one’s sense of
control over the disorder as it has with chronic pain (Lefort, Grey-Donald, Rowat, & Jeans,
1998) and body-image issues (Cash & Hrabosky, 2003). Although psychoeducation may
provide some benefit, it is expected that education alone would be insufficient to produce
substantial and maintainable gains in pulling severity.
3. Training response inhibition and cognitive flexibility: Individuals with TTM appear to have
difficulties preventing, and once initiated, stopping or changing unwanted or inappropriate
motor patterns (i.e., flexibility and inhibition). To address this deficit, it may be useful to spe-
cifically train the inhibition and disruption of the pulling. Although the mechanism of HRT
is unclear (Miltenberger, Fuqua, & Woods, 1998), the treatment is designed to teach the indi-
vidual to become aware of antecedents to pulling, engage in an alternative response to pulling
when those antecedents are present or when pulling starts, and to reinforce this behavior.
4. Focused pulling: More recent research has suggested an emotional/cognitive regulation
function served by some episodes of pulling. Unfortunately, traditional behavior therapy
does not appear to address the emotional or cognitive factors that may contribute to this
function of pulling (van Minnen et al., 2003). To address this issue, various treatment com-
ponents may be useful. For example, cognitive therapy procedures (e.g., cognitive restruc-
turing, thought stopping) have been used to reduce emotional or cognitive factors, and
dialectical behavior therapy strategies have been used with other psychiatric disorders to
teach emotional regulation skills (Linehan, 1993). Another therapeutic strategy, based on
principles of acceptance and commitment therapy, have also begun to be employed in the
treatment of a variety of different disorders, including OCD (Twohig, Hayes, & Masuda,
2006a), excessive skin picking (Twohig, Hayes, & Masuda, 2006b), and psychosis (Bach &
Hayes, 2002), as well as food cravings (Forman et al., 2007). Given that TTM severity has
been linked to experiential avoidance (the process specifically targeted in acceptance-based
therapies), we believe it may be particularly useful to utilize an acceptance based treatment
to address pulling episodes potentially impacted by experiential avoidance.
Summary of the Integration. Given this background work, our lab has combined the four
aforementioned elements of treatment into an integrated treatment package for TTM, termed
56 Walther et al.
acceptance-enhanced behavior therapy for trichotillomania (AEBT-T). Although the HRT, stim-
ulus control, and psychoeducation components (described above) are relatively common ele-
ments to traditional behavior therapy for TTM, the integration of acceptance and commitment
therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is novel, and thus worth a brief description.
ACT is a therapeutic approach designed to (a) promote the rejection of emotional control
strategies that interfere with working toward valued life goals; (b) increase one’s willingness to
accept the occurrence of private experiences such as urges, thoughts, feelings, or cravings; (c)
create defusion from the literal meaning of language; (d) encourage the participant to experience
the discomfort created by unpleasant private experiences while behaving in a way that is consis-
tent with one’s valued life direction; and (e) encourage participants to refrain from behaviors
with pleasurable consequences if that behavior disrupts one’s progression toward one’s valued
goals (Hayes, Strosahl, et al., 1999). ACT was derived from basic experimental research on human
language and cognition (Relational Frame Theory; Hayes, Barnes-Holmes, & Roche, 2001). The
overarching goal of ACT is to alter the context of human language from one that accepts private
events as causes for behavior to one that promotes the experience of having private events (pleas-
ant or unpleasant) while moving in a valued life direction. Although a comprehensive descrip-
tion of the procedure is not possible here, ACT achieves this goal through the use of experiential
exercises and metaphors. Specific attempts to alter or change the content of thoughts or emotions
are avoided. It is believed that by changing the context of language surrounding private events,
one may continue to experience unpleasant urges, thoughts, emotions, or cravings but that such
events will no longer have an impact on psychological well-being or overt behavior.
As evidence accrues on the efficacy of acceptance-based interventions for various problems,
data are beginning to demonstrate clearly that ACT decreases experiential avoidance. For exam-
ple, studies on pain tolerance have shown that an acceptance-based intervention results in signif-
icantly greater pain tolerance in a cold-pressor task when compared to various control conditions
(Guitierrez, Luciano, & Fink, 2004; Hayes, Bissett, et al., 1999). Additional support showing that
acceptance-based interventions decrease experiential avoidance come from a study by Levitt,
Brown, Orsillo, and Barlow (2004). In this study, participants with panic disorder listened to
either a brief acceptance rationale, suppression rationale, or neutral narrative prior to under-
going a carbon dioxide challenge, which consisted of exposure to 5.5% CO2-enriched air for 15
min. Subjective ratings of anxiety during the task did not differ between groups; however, those
in the acceptance group did not evaluate the anxiety as negatively as did those in the other groups
and were more willing to participate in an additional challenge. Finally, in two studies specific to
TTM, results showed that experiential avoidance decreased significantly from pre- to posttreat-
ment following a course of ACT and HRT, and that this decrease was strongly correlated with
reductions in pulling (Marcks et al., 2006; Woods, Wetterneck, & Flessner, 2006).
Developing a Treatment for TTM. Based on these theoretical considerations, our group
crafted an initial treatment manual, which was evaluated and revised in a systematic process. To
date we have conducted a feasibility trial, which resulted in a revision of the original manual. This
revised manual was then tested in a small randomized controlled pilot study and subsequently
further revised. Currently, we are conducting a large randomized controlled trial comparing
AEBT-T to a psychoeducation/supportive therapy condition (PI: Woods; R01MH080966). Below,
we outline the results and manual modifications stemming from the feasibility and pilot trials.
Feasibility Study of AEBT-T. In the initial feasibility trial (Twohig & Woods, 2004), a 7-ses-
sion treatment manual was implemented with 6 adult participants, utilizing two separate multi-
ple baseline across subjects designs. The first 4 sessions involved ACT components, and the final 3
sessions were dedicated to HRT and stimulus control. The dependent variable was self-report of
hairs pulled per day, collected and reported daily to the experimenters. Pre- and postphotographs
of the affected area were also collected and scored by independent evaluators.
Sessions Occurred Weekly. The first 5 sessions were 1 hr in duration and the final 2 each
lasted 30 min. The therapists had been trained in ACT by Steven Hayes, and both therapists had
Advances in Trichotillomania 57
extensive experience in implementing HRT. During the four ACT-focused sessions, treatment
centered on (a) abandoning strategies used to control urges to pull, thoughts, emotions, or other
aversive private experiences; (b) acceptance of, or willingness to experience, one’s private events;
(c) defusion from the literal meaning of language; and (d) heading in a valued life direction. HRT
and stimulus control was implemented in the fifth session and reviewed in sessions 6 and 7, which
occurred during the three weeks following the ACT-only sessions.
Data were interpreted using visual inspection procedures. The intervention produced pre-post
decreases in hair pulling to zero levels for four of the six participants. Results were maintained for
three of the four at follow-up. Moderate decreases were seen in the pulling of the remaining two
participants. MGH-HS scores collected at pretreatment, posttreatment, and follow-up showed a
63% reduction at posttreatment, with gains maintained at the 3-month follow-up. Independent
photograph ratings confirmed the self-report findings. All participants evaluated the treatment
Modification of the Original AEBT-T Protocol. The initial 7-session protocol demonstrated
promising results. Nevertheless, based on therapist experiences and feedback from the partici-
pants, the treatment was modified in four ways: (a) the number of sessions was increased from
7 to 10 to provide more time for ACT content, as therapists and participants reported feeling
rushed on the ACT material; (b) the values component of ACT was placed at the beginning of
treatment to allow the participant to be working toward a clear and valued goal; (c) some of the
metaphors used during the initial pilot test were not well-received and dropped in the revised
manual; and (d) relapse prevention techniques were added into the final 2 sessions to improve the
maintenance of the treatment gains.
Initial Controlled Pilot Study Comparing AEBT-T to Wait-List Control. The modified man-
ual was tested in a small randomized controlled trial funded by the Trichotillomania Learning
Center (a national patient support organization; Woods, Wetterneck, et al., 2006). Twenty-eight
participants were randomly assigned to one of the two conditions (14 AEBT-T and 14 wait-list
control). Two from the AEBT-T and one from the wait-list condition dropped out for reasons
unrelated to the study. A blinded independent evaluator assessed the participants at pretreat-
ment and posttreatment. At the end of the posttreatment assessment, the wait-list participants
were offered AEBT-T and reassessed at the end of treatment. All individuals in the initial AEBT-T
condition were reassessed at a 3-month follow-up. In addition to assessing pulling severity with
self-report (MGH-Hairpulling Scale) and independent evaluator rating (NIMH-TIS Rating),
depression and anxiety measures were taken, as was a measure of experiential avoidance at all
Results showed that pulling severity across both indices decreased for the AEBT-T group,
but not for the wait-list group (Between Group Differences: dMGH = 1.71, dNIMH-Impairment = 1.38).
Likewise, after the wait-list group received treatment, they also showed significant decreases in
all indicators of pulling severity. Overall, 66% of treatment recipients were deemed “treatment
responders, and these results maintained at the 3-month follow-up. In addition, significant
reductions were seen for the AEBT-T group in measures of anxiety and depression, but these
decreases were not seen in the wait-list group.
Additional analyses investigating potential mechanisms of change indicated that pre-post
decreases in the measure of the experiential avoidance (as measured by the Acceptance and Action
Questionnaire) were moderately and significantly correlated with pre-post decreases in MGH-HS
scores (r = .59). Treatment compliance ratings completed by both clinician and participant were
also positively and significantly correlated with reduction of symptoms at posttreatment (r =
At the end of the pilot study, participants also rated the perceived utility of each treatment
component on a 1–5 scale, with 1 being not at all useful and 5 being extremely useful. No specific
claims can be made about the actual contribution of each component to symptom improvement,
but the data on perceived utility suggested that greater emphasis should be placed on particular
58 Walther et al.
treatment components over others. The HRT components of awareness training and competing
response training, along with stimulus control techniques, were perceived as very useful, Social
support was perceived to be of little utility. In terms of ACT components, extensive work on
clarifying participant values was not perceived as particularly useful relative to other ACT com-
ponents. Based on these and other data, the manual tested in this randomized controlled trial
was further revised. The primary revisions included (a) introducing HRT and stimulus control
techniques earlier in therapy; (b) deemphasizing the values work while increasing the focus on
control, willingness, and defusion; (c) further trying to integrate the ACT and HRT components
by encouraging the use of specific ACT defusion and willingness components during HRT imple-
mentation; and (d) removing the formal social support component from the treatment manual.
The revised manual (Woods & Twohig, 2008) is being tested in the aforementioned federally
funded study.
Preliminary Evidence for the Independent Contributions of ACT and HRT. Given the struc-
ture of AEBT-T and the absence of dismantling studies, it is difficult to ascertain the separate and
unique impact of the ACT and HRT interventions. Nevertheless, three streams of preliminary
evidence suggest that both interventions are likely to have an independent effect on TTM. First, in
the feasibility study, the implementation of ACT alone reduced pulling to near-zero levels with no
additional decreases seen following HRT for three participants. One participant, however, showed
a slight impact following ACT, but more substantial change with the addition of HRT. Second,
in the AEBT-T pilot study, session by session MGH-HS data showed that 45% of the observed
reduction in the MGH-HS scores occurred between Sessions 1 and 8, which corresponded to the
implementation of ACT. The remaining percentage of symptom reduction took place following
Session 9, which corresponded to HRT+stimulus control components. Third, in a recently com-
pleted multiple-baseline pilot study (Flessner, Busch, Heideman, & Woods, 2008), two individuals
with TTM received 7 sessions of ACT and then HRT was added, and one individual received HRT
first, followed by the implementation of ACT. With all three participants, the greatest benefit did
not occur until both treatment components had been implemented. Although such data are no
substitution for a well-conducted dismantling study, existing evidence supports the idea that ACT
and HRT may independently contribute to symptom reduction and suggests that the greatest
benefit may be achieved from a combination of the two interventions.
Trichotillomania is a relatively prevalent and debilitating mental health condition that has received
comparatively little attention from either behavioral or biological researchers. The availability of
well-established interventions for the disorder in adults is limited, with only HRT-based behavior
therapy and clomipramine appearing to be efficacious in replicated trials. Despite the support
for these interventions, they are limited in their efficacy, maintenance, and scope. Not all patients
improve; many of those who improve do not stay improved; and preliminary results suggest that
improvements may be limited to the pulling behavior itself and do not necessarily impact many
of the problematic co-occurring symptoms such as anxiety and depression.
Given these limitations, researchers have begun to explore treatments tailored to a more
nuanced understanding of the disorder. Multiple tailored approaches could be used. Modular
approaches (i.e., Franklin & Tolin, 2007; Mansueto et al., 1997) would attempt to match a patient’s
particular pulling profile with specific therapeutic techniques. Other strategies could employ
standard-package behavior therapy techniques (i.e., HRT and stimulus control) with treatment
strategies (i.e., dialectical behavior therapy, ACT) designed to address what is not addressed in tra-
ditional behavior therapy for TTM (i.e., emotional control function of pulling). Having identified
at least two distinct styles of pulling often present in persons with TTM, we have developed an
acceptance-based behavior therapy approach to treat adults with the disorder. As with traditional
Advances in Trichotillomania 59
behavioral techniques, our treatment employs HRT and stimulus control procedures to target
“automatic pulling” and based on the research suggesting that experiential avoidance moder-
ates the relationship between negative cognitions and pulling severity, we add ACT to aid in the
treatment of “focused pulling.” Preliminary research from our group suggests that this combined
intervention is effective, the results maintained, and the two individual treatment components
make independent contributions to improvement. Despite these results, there is clearly a need for
more research, not only on ACT-enhanced behavior therapy for TTM, but on the disorder itself.
It is only through a more thorough understanding by the biological and behavioral mechanisms
underlying the disorder that we will be able to develop the most efficacious treatments.
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Acknowledgments. This research was supported, in part, by a National Institute of Mental Health Grant
MH080966 to Douglas W. Woods.
Correspondence regarding this article can be directed to Douglas W. Woods, PhD, 2441 E. Hartford Avenue,
Room 358, University of Wisconsin, Milwaukee, WI 53211. E-mail:
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... Conclusions focused on research limitations, and a tentative suggestion of HRT as promising (Chamberlain et al., 2009). In 2010 two reviews were published (Duke et al., 2010;Walther, Ricketts, Conelea, & Woods, 2010controlled studies, one uncontrolled and six case studies, in an attempt to synthesise the evidence of pharmacological treatment in TTM. Again the ineffectiveness of SSRIs was emphasised with further support for the superiority of HRT. ...
... There are three main reasons for the execution of a systematic review investigating efficacy of treatments for TTM. Firstly, in recent years there has been a call by TTM researches and experts for more methodologically rigorous randomised controlled trials to be carried out (Bloch et al., 2008;Chamberlain et al., 2009;Elliott & Fuqua, 2000;Flessner et al., 2010;Walther et al., 2010;Woods, Flessner, Franklin, Keuthen, et al., 2006). Secondly, the bulk of reviews have not been systematically performed. ...
The aim of this systematic review and meta-analysis was to assess the efficacy of psychological and pharmacological interventions compared to a range of control groups. Participants were adults who have been diagnosed with trichotillomania. A systematic search was conducted of the Cochrane library, EBSCOhost, MEDLINE before 1966 and Google Scholar for randomised controlled trials addressing the aim. Of the total 462 records identified, 12 studies were included in the quantitative synthesis and 9 studies were included in meta-analyses. Analyses revealed that behaviour therapy showed superior efficacy when compared to a passive control group. However, when behaviour therapy was compared to an active control group both behaviour therapy and active controls show similar efficacy in treating trichotillomania. It was concluded that the psychological mechanisms for the efficacy of behaviour therapy in trichotillomania treatment are more complex than what the behavioural model indicates. A lack of efficacy was found for fluoxetine. However, N-acetyl cysteine, clomipramine and olanzapine show potential for the treatment of trichotillomania.
... Prevalence was largely unknown for decades; the first large epidemiological survey examining prevalence in a USA general population sample (4) revealed 1.7% of participants as having current TTM, with the lifetime TTM rate at 2.5%. There is a dearth of qualitative enquiry around TTM with cross-cultural research being limited (5). ...
Full-text available
Trichotillomania (TTM) is a poorly understood disorder with no consensus on aetiology or epidemiology; often overlooked due to high comorbidity rates. Cross-cultural qualitative research is sparse; therefore, an international qualitative study was conducted. A generic qualitative approach with thematic analysis was used to explore data from asynchronous email interviews. The aim of this article is to report participant experiences of seeking treatment. Using a sample of 20 adults (18–55 years) from 15 different countries, this article highlights lack of access and unmet healthcare needs signifying an inadequate supply of TTM expertise globally and the need for more robust clinical guidance.
... In another review, it was acknowledged that evidence of brain regions associated with TTM was limited to either single studies or conflicting multiple studies; the authors of that review surmised that the cognitive domains of visuo-spatial learning and response inhibition were impaired in a proportion of people with TTM while set shifting appeared intact (Chamberlain, Odlaug, Boulougouris, Fineberg, & Grant, 2009). Six studies that explored neuropsychological function in TTM were reviewed byWalther, Ricketts, Conelea, and Woods (2010). While acknowledging contradictory findings, the authors noted that impaired cognitive flexibility is consistent with repetitive habitual motor patterns in TTM. ...
Objectives: Existing models of trichotillomania (TTM; hair pulling disorder) rely heavily on a biological predisposition or biological pathogenesis of the disorder, but fail to capture the specific neuropsychological mechanisms involved. The present systematic review aims to scope existing neuropsychological studies of TTM to explore gaps in current models. Methods: A systematic literature search was conducted to detect all published primary studies using neuropsychological and neuroimaging measures in a cohort of individuals experiencing TTM. Studies addressing neuropsychological function were divided into domains. Findings from imaging studies were considered within brain regions and across methodology. Results: Thirty studies with a combined 591 participants with TTM, 372 healthy controls and 225 participants in other types of control group were included. Sixteen studies investigated neuropsychological parameters, and 14 studies pursued neuroimaging technologies. Available studies that used neuropsychological assessments and reported a statistically significant difference between those with TTM and controls ranged in effect size from 0.25 to 1.58. All domains except verbal ability and visual ability reported a deficit. In neuroimaging studies, several structural and functional brain changes were reported that might be of significance to TTM. Only tentative conclusions can be made due to the use of multiple methodologies across studies, a major limitation to meaningful interpretations. Conclusions: Positive neuropsychological and neuroimaging results require replication, preferably with multi-site studies using standardized methodology. Increased standardized testing and analyses across the literature, as a whole, would improve the utility and interpretability of knowledge in this field. (JINS, 2017, 23, 000-000).
... Trichotillomania (TTM) is an impulse-control disorder characterized by pulling hair from the scalp, eyebrows, eyelashes, pubic regions, or other areas, resulting in noticeable hair loss. TTM is associated with significant functional impairment and has high rates of psychiatric comorbidity that appear to increase with age Walther et al. 2010;Woods et al. 2006). In terms of prevalence, estimates of TTM in late adolescents and young adults range from 0.6 to 3.5 %, with a greater preponderance in girls and women. ...
Trichotillomania (TTM) is an impulse-control disorder characterized by the pulling of scalp, facial, and/or body hair, resulting in noticeable hair loss. It is associated with significant functional impairment, such as poor school and work performance, disruption in family functioning, and social impairment. This chapter will focus on adults with TTM through a review of the relevant research, an overview of the nature of the problem, and a description and assessment of a clinical case. A detailed treatment overview will follow, describing the use of habit reversal training (HRT) for reducing symptoms and improving functioning, along with a discussion of complicating factors. Finally, the chapter will highlight key practice points for clinicians treating adult TTM patients.
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Background: Trichotillomania and skin picking appear to be compulsory and chronic. The present study attempts to investigate the effectiveness of this type of treatment in improving the symptoms of adolescents. Methods: This study used single case design scheme of multi stepped on four patients (two patients for each disorder) with 10 sessions over the course of three month follow up. Data was gathering through Skin Picking, trichotillomania Scale, Milwaukee Inventory for Subtypes of Skin Picking and hair pulling. Results: The intervention had significant effects in the reduction of symptoms of focused and automatic skin picking and trichotillomania and follow-up over three month revealed that the treatment effects were maintained. Conclusion: The AEBT could be effective in treating patients with trichotillomania and skin picking, and follow-up over three month revealed that the treatment effects were maintained.
Compulsive hair pulling is a serious and debilitating psychological disorder lasting on average 20 years. Using multiple research approaches that included qualitative interviews, psychological measures, systematic literature review and functional brain imaging, a comprehensive picture of how reward and punishment drive the behavior of hair pulling was created. The model of hair pulling disorder developed in this research can guide the application of current treatments and inform the development of new ones. The implications of this research may be relevant to any health condition that features impulsive behaviors that are driven by the experience of reward.
Trichotillomania (TTM) involves the chronic pulling out of hair to the point of hair loss or thinning, which continues despite repeated attempts to stop. Behavior therapy is a promising treatment for the condition, but studies have been limited by the lack of a credible control condition, small sample sizes, follow-up periods of short duration, and low participation by underrepresented populations. In the current article, the authors describe the theoretical rationale for an acceptance-enhanced form of behavior therapy for TTM in adults and describe the methodology used to test the efficacy of this intervention against a psychoeducation and supportive control condition. In addition, the authors discuss the importance of and difficulties encountered with enrolling minority participants into TTM research, as well as strategies used to enhance minority recruitment. Finally, the authors discuss the instruments, procedures, and related outcomes of the fidelity measures used in the randomized controlled trial.
A Transdiagnostic Approach to Obsessions, Compulsions and Related Phenomena - edited by Leonardo F. Fontenelle January 2019
Background: Not all patients suffering from trichotillomania (TTM) recover completely using CBT and of those that do, only a few maintain their recovery over time. Aims: The purpose of the present study was to investigate the effectiveness of metacognitive methods combined with habit reversal (MCT/HRT) in trichotillomania with a relatively long-term follow-up. Method: A case series (n = 8) and a randomized wait-list controlled trial (n = 34) design were conducted in this study. In the case series, three of the eight patients dropped out of the study. Therefore, TTM-related symptoms were evaluated in five patients suffering from TTM before and after brief metacognitive plus habit reversal therapy during 1-month, 6-month, and 12-month follow-ups. The treatment consisted of detached mindfulness (DM) techniques, ritual postponement and habit reversal training (HRT) in eight sessions. Results: All patients were responders at post-treatment in case series. After the 12-month follow-up, the results were associated with higher pre-treatment levels of self-esteem and global functioning and lower pre-treatment levels of depression and anxiety with nearly complete abstinence from hair pulling immediately after treatment. A randomized wait-list controlled trial with experimental (n = 17) and waiting list group (n = 17) was then conducted to confirm the case series results. There were significant differences between the two groups regarding changes in MGH-HPS, Y-BOCS-TM, RSES, GAF, BDI, BAI and self-monitoring. Therefore, the MCT/HRT treatment was found to be more effective than the waiting list group. Conclusions: A combined treatment including metacognitive and habit reversal techniques is remarkably effective in patients with TTM.
This chapter discusses available psychosocial interventions used in the treatment of trichotillomania (TTM), as well as the research evidence for each technique. Habit reversal training (HRT) is one of the most commonly utilized behavioral interventions for the treatment of TTM and is often used as part of cognitive-behavioral therapy. Awareness training is an important component to HRT as hair pulling can occur outside of an individual's awareness. Stimulus control is another core component to cognitive-behavior therapy for TTM and is viewed as a key component to HRT. The ultimate goal of stimulus control is to choose interventions and strategies that create barriers to hair pulling by making it more difficult. Focused pulling may benefit most from cognitive or acceptance based strategies aimed at increasing one's ability to regulate their emotions. As such, acceptance and commitment therapy (ACT) may be effective for targeting focused pulling.
Full-text available
Acceptance approaches, which have been receiving increased attention within behavior therapy, seek to undermine the linkage between private events and overt behavior, rather than attempting to control the form or frequency of private events per se. Research comparing control versus acceptance strategies is limited. The present study examined the behavioral and subjective impact of a control-based versus acceptance rationale, using a cold pressor task. Subjects in the acceptance group demonstrated greater tolerance of pain compared to the control-based and placebo groups. Only the control-based rationale targeted the subjective experience of pain but it did not differ across rationales. Results confirmed that acceptance was effective in manipulating the believability of reason giving, a key process measure. By encouraging individuals to distance themselves from their private events, acceptance methods may help reduce the use of emotional reasons to explain behavior and hence shift concern from moderating thoughts and feelings to experiencing the consequences of one's action. Acceptance is a promising new technique. Its effect is all the more surprising given that it teaches principles (e.g., "thoughts do not cause behavior") that run counter both to the popular culture and to the dominant approaches within empirical clinical intervention.
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Background: Few studies have addressed quality of life (QOL) and functional impairment in trichotillomania (TTM). This study empirically documented QOL and its predictors in both non-clinical and clinical TTM samples using generic measures of QOL. Methods: Two TTM samples (conference attendees and treatment outcome study participants) completed standardized QOL measures, the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) or the Quality of Life, Enjoyment, and Satisfaction Questionnaire (Q-LES-Q). Hair pulling severity was assessed with the Massachusetts General Hospital Hairpulling Scale (MGHHPS) and the Psychiatric Institute Trichotillomania Scale (PITS). Depression and anxiety symptoms were assessed with the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). Z-scores compared QOL data for our TTM cohorts with published data for normal control (NC) groups. Regression analyses identified predictors of QOL using illness duration and depression, anxiety, and hair pulling scale scores. Results: Generic QOL measures failed to reveal significant differences between the TTM and NC groups. BDI scores were the strongest predictor of QOL when using the MGHHPS to assess TTM severity. The PITS was a stronger predictor of QOL than the BDI or BAI though the latter scales independently predicted several QOL subscale scores. Conclusions: Hair pulling severity, depression, and anxiety independently contribute to QOL in TTM sufferers. The lack of documented QOL differences between TTM and NC samples strongly suggests a need for TTM-specific QOL measures.
Objective: Problems with inhibiting certain pathological behaviors are integral to obsessive-compulsive disorder (OCD), trichotillomania, and other putative obsessive-compulsive spectrum disorders. The authors assessed and compared motor inhibition and cognitive flexibility in OCD and trichotillomania for the first time, to their knowledge. Method: The Stop-Signal Task and the Intradimensiona/Extradimensional Shift Task were administered to 20 patients with OCD, 17 patients with trichotillomania, and 20 healthy comparison subjects. Results: Both OCD and trichotillomania showed impaired inhibition of motor responses. For trichotillomania, the deficit was worse than for OCD, and the degree of the deficit correlated significantly with symptom severity. Only patients with OCD showed deficits in cognitive flexibility. Conclusions: Impaired inhibition of motor responses (impulsivity) was found in OCD and trichotillomania, whereas cognitive inflexibility (thought to contribute to compulsivity) was limited to OCD. This assessment will advance the characterization and classification of obsessive-compulsive spectrum disorders and aid the development of novel treatments.
An ACT Approach Chapter 1. What is Acceptance and Commitment Therapy? Steven C. Hayes, Kirk D. Strosahl, Kara Bunting, Michael Twohig, and Kelly G. Wilson Chapter 2. An ACT Primer: Core Therapy Processes, Intervention Strategies, and Therapist Competencies. Kirk D. Strosahl, Steven C. Hayes, Kelly G. Wilson and Elizabeth V. Gifford Chapter 3. ACT Case Formulation. Steven C. Hayes, Kirk D. Strosahl, Jayson Luoma, Alethea A. Smith, and Kelly G. Wilson ACT with Behavior Problems Chapter 4. ACT with Affective Disorders. Robert D. Zettle Chapter 5. ACT with Anxiety Disorders. Susan M. Orsillo, Lizabeth Roemer, Jennifer Block-Lerner, Chad LeJeune, and James D. Herbert Chapter 6. ACT with Posttraumatic Stress Disorder. Alethea A. Smith and Victoria M. Follette Chapter 7. ACT for Substance Abuse and Dependence. Kelly G. Wilson and Michelle R. Byrd Chapter 8. ACT with the Seriously Mentally Ill. Patricia Bach Chapter 9. ACT with the Multi-Problem Patient. Kirk D. Strosahl ACT with Special Populations, Settings, and Methods Chapter 10. ACT with Children, Adolescents, and their Parents. Amy R. Murrell, Lisa W. Coyne, & Kelly G. Wilson Chapter 11. ACT for Stress. Frank Bond. Chapter 12. ACT in Medical Settings. Patricia Robinson, Jennifer Gregg, JoAnne Dahl, & Tobias Lundgren Chapter 13. ACT with Chronic Pain Patients. Patricia Robinson, Rikard K. Wicksell, Gunnar L. Olsson Chapter 14. ACT in Group Format. Robyn D. Walser and Jacqueline Pistorello
Trichotillomania (TM) typically is assessed using adaptations of clinician-rated scales for obsessive-compulsive disorder (OCD). The present preliminary study examined the psychometric properties of four OCD-based clinician-rated scales [i.e., the Yale–Brown Obsessive Compulsive Scale—Trichotillomania (YBOCS-TM), the Psychiatric Institute Trichotillomania Scale (PITS), and the NIMH Trichotillomania Severity and Impairment Scales] of TM symptoms. Descriptive data, interrater agreement, internal consistency, and concurrent validity were evaluated in a sample of 22 individuals with a principal diagnosis of TM. Mixed psychometric evidence was found regarding the utility of OCD-based scales for assessing TM symptomatology, although conclusions are limited based on small sample sizes. Interrater agreement generally was acceptable for all PITS items and for both item and summary scores for the YBOCS-TM Behavior Subscale. For all four clinician-rated scales, however, estimates of internal consistency were below minimally acceptable levels. Examination of scale validity was limited given some difficulties with reliability, although data suggested potential support for concurrent agreement between some item and summary scores with external criteria based on self-monitoring of hair pulling. Despite limitations due to the small sample size, the data provide useful preliminary information about the clinical evaluation of TM. Implications for future research, most notably development of new TM scales, are discussed.
Summary “Barbering” is an abnormal behavior in mice. Barbering mice pluck fur and/or whiskers from cage-mates and/or themselves, leaving idiosyncratic patches of hair loss. The behavior is a paradox: barbering is common in laboratory mice, but it is not seen in wild mice, it does not benefit the plucker, and it is costly to the recipient. This chapter will attempt to resolve the barbering paradox by asking how and why barbering behavior occurs. Using Tinbergen's (1963) framework for an ethological analysis, we assess barbering in terms of adaptive function, phylogeny, development, and mechanism. The first section discusses hypotheses of adaptive function. The dominance hypothesis is refuted by several studies; the coping hypothesis remains untested; and the pathology hypothesis is supported by multiple lines of evidence. The pathology hypothesis therefore provides the best resolution to the barbering paradox. Accordingly, throughout, we compare and contrast barbering to trichotillomania (TTM) and other human disorders characterized by repetitive behavior. The second section assesses the phylogenetic underpinnings of barbering by comparing and contrasting hair-plucking behavior across species and between mouse strains. The third section reviews the developmental processes that underlie barbering behavior, particularly developmental risk factors, learning, the laboratory environment, and transgenic effects. The final section reviews the behavioral mechanisms, eliciting stimuli, and physiological mechanisms that might mediate barbering. Here, we outline the role of cortico–striatal circuitry in abnormal repetitive behavior in general, how it can be used to delineate disorders, and insights it provides into barbering.