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Trichotillomania: identification and treatment.

Counselors must be prepared to work with clients with diverse symptoms and educate themselves regarding clients' presenting problems to best serve their clients (American Counseling Association, 2005). Trichotillomania (TTM) is an underrecognized disorder associated with both distress and impaired functioning (Odlaug, Kim, & Grant, 2010). This article serves to provide introductory information to counselors working with clients with TTM.

* Description of the Disorder

Current prevalence estimates for TTM are largely established through college student surveys and vary between 1% and 13.3% (Duke, Keeley, Geffken, & Storch, 2010). Duke et al. (2010) estimated that three million individuals in the United States are affected by TTM (using the conservative 1% frequency). According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000), TTM is distinguished by repeated hair pulling to reduce anxiety. The DSM-IV-TR requires five criteria for the diagnosis of TTM: (a) "recurrent pulling out of one's own hair that results in noticeable hair loss," (b) "increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior," (c) "pleasure gratification or relief when pulling out the hair," (d) "the diagnosis is not given if the hair-pulling is better accounted for by another mental disorder," and (e) "the disturbance must cause significant distress or impairment in social, occupational, or other important areas of functioning" (American Psychiatric Association, 2000, p. 677). There is some contention about the second (tension before pulling) and third (reduction of tension after pulling) criteria, and there is a proposed revision for the DSM-5 (scheduled for publication in 2013) to exclude these two criteria (American Psychiatric Association, 2010; Stein et al., 2010). Studies have been published using the strict DSM-IV-TR criteria as well as the more lenient definition proposed for the DSM-5 (Duke et al., 2010).

Some assessments have been created to help evaluate the impairment of TTM. The Trichotillomania Impact Survey (Neal-Barnett et al., 2010), for example, is designed to identify the phenomenology as well as the impact of hair pulling and the treatment outcome. The Massachusetts General Hospital Hairpulling Scale (Keuthen et al., 2007) is another survey designed to assess the severity and impact of hair pulling on the life of the individual.


The ways individuals pull hair can vary. Hair-pulling sites are most commonly the scalp, but pulling may occur anywhere on the body, including the common pull sites of the face and pubic region (Duke et al., 2010). There is a difference in pull sites among ethnic lines: Caucasians have reported pulling from lashes and eyebrows more often than racial/ethnic minorities (Neal-Barnett et al., 2010). Age is also a factor in the phenomenology of TTM; the number of places that clients with TTM pull from increases with age (Flessner, Woods, Franklin, Keuthen, & Piacentini, 2008). Hair may be pulled one strand at a time (most common) or in clumps (Duke et al., 2010) and is most often pulled with fingers, tweezers, combs, or brushes (Walther, Ricketts, Conelea, & Woods, 2010).

Researchers have identified three subsets of hair pulling: early onset, automatic, and focused. Early onset TTM occurs in children 8 years or younger and is generally self-correcting without therapeutic intervention (Duke et al., 2010). Automatic hair pulling is unconscious and happens while the individual is focused on something else (e.g., watching television or reading), whereas individuals with focused hair pulling are aware of the pulling. Focused hair pulling is characterized by urges and tension often associated with obsessive-compulsive disorder (OCD; Duke et al., 2010). These three subsets are not exclusive; an individual may have co-occurring hair-pulling types (Duke et al., 2010).


Obvious physical impairments include skin infections, bleeding, and irritation. Some of the most serious physical impairments are a result of the ritualistic behaviors that are often associated with TTM (Duke et al., 2010). Forty-eight percent of individuals with TTM manipulate their hair orally (e.g., run their hair over their lips and tongue; Christenson, Mackenzie, & Mitchell, 1991), which can cause serious dental erosion. Ingestion of the hair can cause fatal trichobezoars (hair balls).

Individuals with TTM are affected by decreases in psychological, social, academic, and occupational functioning (Flessner, Conelea, et al., 2008; Walther et al., 2010). They may avoid going to social or recreational events that may expose hair loss (e.g., swimming, being outside in the wind). Participants in Flessner, Conelea, et al.'s (2008) study reported participating in fewer social events as well as having lower quality and quantity of friendships and romantic relationships. Individuals who reported high levels of focused and automatic hair pulling also "reported greater severity, psychological impact, and functional impact" (Flessner, Conelea, et al., 2008, p. 345) than did those with lower levels of hair pulling. People with TTM may have difficulty focusing, which may affect academic or occupational work and career advancement (Wetterneck, Woods, Norberg, & Begotka, 2006).


Knowledge regarding the etiology of TTM is largely speculative (Duke et al., 2010), which means that risk factors are equally unclear. Multiple theories have been proposed, and it is generally agreed that the manifestation of TTM is a result of some combination of biological, psychological, and social factors. One case study, for example, claimed that TTM was amphetamine induced (Hamalian & Citrome, 2010), but this is the only case that makes the claim that TTM can be induced by stimulants. Trauma and posttraumatic stress disorder are proposed to have a role in the etiology of TTM, but research is limited on this potential etiology (Gershuny et al., 2006). Research has supported the negative reinforcement model of TTM. Specifically, an increase in negative emotions (e.g., tension, anxiety, boredom, and sadness) often occurs before pulling, pleasurable emotions occur during pulling, and there is again an increase in negative emotions (e.g., guilt, anger, and sadness) after pulling (Diefenbach, Mouton-Odum, & Stanley, 2002; Diefenbach, Tolin, Meunier, & Worhunsky, 2008; Shusterman, Feld, Baer, & Keuthen, 2009). In other words, the emotional experience of hair pulling is a cyclical process that may set the stage for future hair pulling. This provides even more support of the model of negative reinforcement. Pulling hair may be a strategy for managing undesirable emotions (Diefenbach et al., 2002). Diefenbach, Reitman, and Williamson (2000) proposed that TTM may be modeled and learned from peers and family members. Although it is unlikely that all the theories proposed are evident in an individual,

It is clear that multiple independent or interrelated factors contribute to TTM. For example, it is likely that genetic influences impose a vulnerability to emotional dysregulation through biological processes; hair-pulling is learned to reduce associated discomfort ..., rewarding a behavior pattern that becomes classically conditioned to associated stimuli over time. (Duke et al., 2010, p. 186)

Multicultural Considerations

TTM is underrecognized in the general population (Odlaug et al., 2010) and in racial/ethnic minority individuals (Neal-Barnett et al., 2010). There is little research on the cross-cultural impact of TTM (Walther et al., 2010) and multicultural considerations that multiculturally competent counselors should take into consideration. This is reflective of research in psychopathology and is due, in large part, to the limited access to racial/ethnic minority participants (Neal-Barnett et al., 2010). There is some literature, however, on the impact that race/ethnicity, sex, and age may play.

Race/ethnicity. Neal-Barnett et al. (2010) conducted one of the only large-scale studies (an online study that included a comparison of 103 racial/ethnic minorities and 1,290 Caucasians). Results of the study found that racial/ethnic minorities reported more interference of home management as a result of TTM and were less likely to participate in treatment. Caucasians reported more interference of academic life compared with minorities. There was no significant difference reported between racial/ethnic minorities and Caucasians with regard to the efficacy of treatment (Neal-Barnett et al., 2010).

Sex. Research indicates that TTM is disproportionally represented by women (e.g., Chamberlain, Odlaug, Boulougouris, Fineberg, & Grant, 2009; Diefenbach et al., 2008; Flessner, Busch, Heideman, & Woods, 2008; Neal-Barnett et al., 2010). There are some potential explanations for this discrepancy: (a) women may seek out treatment more often, (b) men may blame TTM on socially acceptable male-pattern balding, and/or (c) men can avoid TTM effects by shaving their heads (Duke et al., 2010).

Age. Typical age of onset (13 years) may be important in treatment planning; "later onset is considered to be of increased severity, more treatment resistant, and more often associated with comorbid psychopathology" (Duke et al., 2010, p. 184). Duke et al. (2010) suggested that TTM is equally distributed between the sexes in early childhood but that as age increases, so does the distribution of TTM in women (i.e., more adult women have TTM).


One element worth noting again is that the criteria of anxiety or tension before hair pulling and reduction of tension after hair pulling are currently required for a diagnosis of TTM. It is likely that these variables, which are currently criteria for differential diagnosis, may not be a point for differentiation in the next edition of the DSM. As mentioned earlier, the proposed revision for the DSM-5 is to exclude these two criteria (American Psychiatric Association, 2010).

It seems that the element of tension places TTM in the classification of an impulse control disorder, but "many consider the disorder to be in the spectrum of obsessive-compulsive disorder (OCD) due to its similar phenotypical, neurobiological, and clinical features" (Corse & McGeary, 2008, p. 1136). Central to this argument are the two concepts of impulsivity and compulsivity. The compulsions of OCD are motivated by invasive cognitions, whereas the intrusive thoughts are not a part of the criteria for TTM. Additionally, whereas completion of compulsions may bring pleasure to those with TTM, there is no pleasure in the compulsions of those with OCD (Stein et al., 2010). There is a request to revise the criteria for TTM diagnosis in the DSM-5; this revision would result in a movement of TTM from an impulse control disorder to the obsessive-compulsive spectrum (Chamberlain et al., 2009; Stein et al., 2010).

Pathological skin picking shares similarities in phenomenology (e.g., high incidence in women) and clinical symptoms (e.g., repetitive and compulsive grooming behaviors; Bohne, Keuthen, & Wilhelm, 2005). However, some important differences exist between the two diagnoses. The onset of TTM is in adolescence whereas pathological skin picking has a bimodal onset, and TTM is less common than pathological skin picking (Odlaug & Grant, 2008). Comorbidity of bipolar disorder and borderline personality disorder has also been found to be more common in individuals who have pathological skin picking than in individuals with TTM (Odlaug & Grant, 2008).

Some have drawn a similarity between TTM and tics. There are important differences in the symptomatology of these two diagnoses. Specifically, "tics typically involve abrupt movement of one or more muscle groups and occur in response to a sensory urge, whereas hair-pulling always involves complex movements and several muscle groups having specific purpose (grooming)" (Duke et al., 2010, p. 185).


Comorbidity with TTM is limited because the research on TTM is limited, due in part to the small number of known cases and studies (Duke et al., 2010). Although there is no single diagnosis found to be consistently comorbid with TTM, TTM has been found to be comorbid in clients along with mood, anxiety, eating, and substance abuse disorders (Ferrao, Miguel, & Stein, 2009) as well as skin picking (Odlaug & Grant, 2008). A positive correlation between TTM and depression has been found (Duke, Keeley, Ricketts, Geffken, & Storch, 2009), as has a correlation between TTM and anxiety for women (Duke et al., 2009).

* Current Treatment Approaches

Pharmacological Approaches

Although counselors cannot prescribe medication, they are called to be aware of pharmacological approaches to identify the best treatments for each client. With the ethical charge of working with clients to identify the most effective treatment, a brief discussion of pharmacology is presented here. Serotonergic pharmacological approaches were ineffective (Dufour et al., 2010; Swede, Lenane, & Leonard, 1993) and pushed researchers to consider other potential pharmacological approaches. Medications considered are an atypical antipsychotic (olanzapine); a dopamine blocker (pimozide); an opioid antagonist (naltrexone); carbohydrate inositol (Duke et al., 2010); and the tricyclic antidepressant, clomipramine (Walther et al., 2010). Unfortunately, to date, alternative pharmacological approaches have been researched on individual case studies and uncontrolled trials (Duke et al., 2010). Counselors should encourage clients to engage in critical dialogue with the prescribing physician about medications. An excellent source of information on potential psychopharmacological treatment of TTM can be found in Chamberlain et al.'s (2009) article, which presents a thorough description of controlled trials with strong methodologies with regard to pharmacology use for individuals with TTM.

Behavioral Approaches

Behavioral approaches to addressing TTM work from the framework that TTM is learned and preserved with classical and operant conditioning (Duke et al., 2010). According to some researchers, randomized trials have indicated that treatment including behavioral interventions has been found to be superior to pharmacotherapy (Duke et al., 2010). Other researchers caution counselors that the efficacy of behavioral treatment of TTM is still largely unknown (Walther et al., 2010). Although there is no standard cognitive behavior therapy (CBT) outlined for the treatment of TTM, a study by Flessner, Penzel, and Keuthen (2010) found that CBT was overwhelmingly the line of first defense in a study of counselors' treatment of TTM (despite a lack of research to document efficacy). Bloch et al. (2007) found that habit reversal training is currently considered the most effective intervention and should be the first intervention considered.

Habit reversal training. Habit reversal training is grounded by a landmark 1973 study by Azrin and Nunn (as cited in Duke et al., 2010). Habit reversal training is the most researched and is considered the most effective intervention for TTM (Duke et al., 2010). It consists of three main elements: awareness training, competing response training, and social support. Awareness training is simply empowering the client to be cognizant of the hair pulling as well as the thoughts and emotions that precede the pulling. Competing response training is the act of doing something that is incompatible with the pulling, which makes pulling impossible (e.g., balling up the hand into a fist for 60 seconds instead of pulling hair). Social support is brought in for the client to have support to identify hair pulling and for the social support to encourage and redirect the client to participate in the competing response training. Counselors also often add stimulus control to habit reversal training (Walther et al., 2010). If the client, for example, stands in front of the mirror in the hallway and pulls hair with tweezers, then the mirror would be covered and the tweezers taken out of the house. Other components added to habit reversal training are increasing the number of sessions, monitoring of the self, and relaxation exercises (Duke et al., 2010). Walther et al.'s (2010) article provides a concise description of habit reversal training. The article also summarizes research on the efficacy of habit reversal training.

Acceptance and commitment therapy. The basic premise of acceptance and commitment therapy is acceptance of thoughts rather than trying to reduce or eradicate thoughts and urges to pull (Walther et al., 2010). There are four main tenets to acceptance and commitment therapy: (a) acceptance and awareness of thoughts, urges, and feelings that may cause discomfort; (b) rejection of emotional control that prevents growth toward life goals; (c) addressing behaviors that prevent growth toward life goals; and (d) cognitive defusion (Walther et al., 2010). Walther et al.'s (2010) article is an excellent introductory source of information on this acceptance-based intervention use for TTM. It provides information about the purpose, goals, and language surrounding the use of this intervention.

Adjunct and Emerging Approaches

Combination approach: Pharmacotherapy and behavioral therapy. Dougherty, Loh, Jenike, and Keuthen (as cited in Chamberlain et al., 2009; Duke et al., 2010) conducted a study to see if monotherapy (either behavioral therapy or pharmacotherapy) or a combination of psychotherapy and pharmacotherapy was more effective in the treatment of TTM. (Unfortunately, the 2006 study by Dougherty et al. is not widely available to counselors, as evidenced by the fact that I saw it cited in other resources but was unable to retrieve it through the university databases; Dougherty provided the article to me via e-mail per my request.) Once again, the participant pool was small (N=26) and the attrition rate high (44 began, 26 completed), but there were promising results that a combination of pharmacotherapy and psychotherapy may be effective. Participants receiving both therapies had greater reduced symptoms than did participants receiving only one of the treatments (Dougherty et al. as cited in Chamberlain et al., 2009; Duke et al., 2010). Similarly, a case study resulting in successful cessation of pulling (and consumption of pulled hair) also used pharmacotherapy in conjunction with behavioral therapy (Jones, Coutinho, Anjaria, Hussain, & Dholakia, 2010). The treatment plan included an antidepressant (quetiapine), removal of hair extensions, family assistance, and a psychiatric program that had significant therapeutic group interactions.

Because case studies are not generalizable, combination approaches are being presented as emerging approaches. Chamberlain et al.'s (2009) article provides valuable information about combination approaches, including research with placebo trials, habit reversal training, CBT, sertraline, and fluoxetine.

Acceptance-enhanced behavioral therapy. Acceptance-enhanced behavioral therapy was presented as a way to address hair pulling with awareness and habit reversal training (Woods, Wetterneck, & Flessner, 2006). Woods et al. (2006) hypothesized that habit reversal training would be effective for those with automatic pulling, because it brings awareness to those who are unconsciously pulling. Those people who pull consciously (focused pulling) are already keenly aware of their pulling; awareness is not necessary. Acceptance-enhanced behavioral therapy is a combination approach, combining habit reversal training, psychoeducation, and acceptance and commitment therapy. Although this approach would fit neatly under the combination approach, the efficacy of acceptance-enhanced behavioral therapy has not been tested (Flessner, Busch, et al., 2008).

Several case studies with treatment plans for TTM have been presented in the literature. Dia (2008), for example, used numbing cream on pull sites in conjunction with behavioral therapy (e.g., stimulus control, habit reversal, competing response training, replacement behaviors, relaxation strategies, and cognitive restructuring).

Decoupling. Moritz and Ruler (2011) presented a self-help technique that they called decoupling. The premise behind decoupling is similar to those presented in habit reversal training. The basic idea is that the individual shifts the behavioral movement of pulling to another movement. Where habit reversal training focuses on stopping the behavior (e.g., clenching a fist instead of pulling), decoupling deviates the behavior (e.g., instead of pulling at the scalp, massage the scalp; Moritz & Rufer, 2011). Moritz and Rufer presented decoupling as an alternative to habit reversal training when the client may be unwilling or not ready to seek professional help. Their article provides a clear description of the decoupling technique, including pictures for reference.

* Clinical Summary

Individuals with TTM experience a lower quality of life in comparison with control groups regardless of the severity of the symptoms (Odlaug et al., 2010), suggesting that all TTM symptomatology should be addressed to improve wellness. Unfortunately, TTM is underdiagnosed, and when it is diagnosed, it is often treated ineffectively (Duke et al., 2010). There is a dearth of counselors who are trained, let alone specialize, in the treatment of TTM (Duke et al., 2010), which means that clients with TTM are likely underserved. Counselors can better serve clients by being competent to correctly assess, diagnose, and treat TTM.

Treatment for TTM has largely focused on pharmacological or behavioral treatments, but counselors do have a number of intervention options when working with individuals with TTM. Given that there is no standard treatment, counselors should use caution when implementing these approaches and keep ethical considerations in mind with regard to clients' rights to evidence-based practices (e.g., American Counseling Association, 2005). Current treatment approaches should be replicated or adapted with the knowledge that treatment approaches have largely been mixed, have used small samples, and have been limited to short-term results (Corso & McGeary, 2008; Duke et al., 2010). In their article, Walther et al. (2010) provided a useful list of considerations when choosing a treatment for clients with TTM.

A clinical best practice is the use of clinical outcome research. It helps counselors identify the effectiveness of treatment with a client. The Trichotillomania Impact Survey or the Massachusetts General Hospital Hairpulling Scale, for example, can be used in outcome research as pre/post assessments. These assessments can be used to help the client and counselor to evaluate potential progress and efficacy of the treatment.

* Research Summary

There are significant biopsychosocial impacts of TTM (Flessner, Conelea, et al., 2008; Walther et al., 2010). Some research exists on race and ethnicity, sex, and age with regard to TTM, but future research is needed regarding racial/ ethnic minority populations and cross-cultural implications of individuals with TTM. Further research is needed to help support or reject potential comorbid diagnoses and to evaluate the etiology of TTM.

Chamberlain et al. (2009) argued that there is a need for more research to be conducted in the area of treatment of TTM. In their view, the research is sparse and there is a lot of unchartered territory regarding potential treatment of TTM. Specifically, they mentioned potential psychopharmacological treatments to be researched concerning atomoxetine, a selective noradrenaline reuptake inhibitor (Chamberlain et al., 2009). A case study published mere months after Chamberlain et al.'s publication did look at the potential for glutamatergic agents (Asemota, 2010). Although the results were successful (asymptomatic with regard to the desire to pull), this was one case study, so the results should not be generalized to other cases. Replication studies are also needed to provide support for current treatment approaches. Behavioral approaches in particular use different implementation elements, making it inappropriate to compare results from different studies (Duke et al., 2010).

Received 09/07/11

Revised 10/08/11

Accepted 11/01/11

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K. Elizabeth McDonald, School of Counseling and Social Service, Walden University. Correspondence concerning this article should be addressed to K. Elizabeth McDonald, School of Counseling and Social Service, Walden University, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401 (e-mail:
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Title Annotation:Theory
Author:McDonald, K. Elizabeth
Publication:Journal of Counseling and Development
Article Type:Report
Geographic Code:1USA
Date:Oct 1, 2012
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