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Help children and teens stop impulsive hair pulling
Trichotillomania (TTM) is distressing to pediatric patients who pull their hair and to their parents who feel helpless to stop the destructive behavior. Hair-pulling with psychiatric comorbidity requires comprehensive assessment and treatment, but we have found that cognitive-behavioral therapy (CBT) alone can help children and adolescents with uncomplicated TTM.
This article describes a typical patient with adolescent-onset mild-to-moderate TTM and the three-step CBT approach—awareness training, stimulus control, and habit reversal—that we find effective in reducing pediatric hair pulling.
Jane, age 12, was referred to our clinic by her primary doctor after an 8-week trial of fluoxetine, 80 mg/d, failed to stop her hair pulling. Jane, who is right-handed, has been pulling her hair for 2 years, mostly in the right front scalp. Her shame over the hair loss makes her reluctant to participate in social activities. A dermatologist found no medical cause for her behavior, such as alopecia or folliculitis.
Jane’s parents say she has no history of a major mood disorder or anxiety. Her hair pulling causes significant “tension and stress” for all family members.
WHY DO PATIENTS PULL HAIR?
Cognitive-behavioral theory suggests that chronic TTM originates as a normal response to stress that often escapes personal and social awareness but gradually increases in frequency and severity (Box).1-8 Thus, hair pulling becomes associated with internal and external cues through conditioning and is maintained primarily by positive reinforcement. Hair-pulling urges that are reinforced by pulling intensify the need to pull, perpetuating the behavioral cycle.
A genetic link? Familial research has associated TTM with increased rates of obsessive-compulsive disorder (OCD) or other excessive habits—such as nail biting or skin picking—among first-degree relatives.6,9,10 Neuroimaging of persons with TTM has shown hyperactivity in the left cerebellum and right superior parietal lobe11 as well as possible structural abnormalities in the left putamen,12 left inferior frontal gyrus, and right cluneal cortex.13
These findings do not necessarily indicate pre-existing brain pathology, however. Perhaps TTM leads to changes in brain structure or function, or both TTM and the brain abnormalities may be caused by another as-yet-unknown variable.
Decreased pain sensitivity. Patients with TTM often report that hair pulling is not painful,2 though we suspect that persons without TTM would disagree and derive no pleasure from it. Changes in pain sensitivity may influence the reinforcing quality of pulling behavior. One possible mechanism for such alterations is upregulation of the endogenous opioid system; some intriguing evidence suggests that opioid receptor antagonists such as naltrexone may reduce pulling.14
Trichotillomania (TTM) is an impulse control disorder characterized by repetitive hair pulling,1 which typically emerges during adolescence. In a large clinical sample of adult hair pullers, mean age of onset was 13.2 Very-early onset (before age 5) may be a more benign form of TTM that tends to abate spontaneously and requires little or no therapeutic intervention.3
Despite the absence of body hair in prepubertal children, their pulling patterns are consistent with those of adults. The scalp is the most common pulling site, followed by eyelashes and eyebrows.4
Psychiatric comorbidity. In two studies evaluating psychiatric comorbidity in pediatric clinical samples, 60% to 70% of children and teens with TTM had at least one comorbid axis I disorder.5,6 Disruptive behavior disorders were most common in one study,6 whereas overanxious disorder was most common in the other.5 In a large clinical sample of adults with TTM, 51% met criteria for comorbid depression.2
Early identification and treatment of TTM are recommended because of the disorder’s distressing nature and social stigma. Early interventions also may help prevent later adult psychiatric comorbidity and functional impairment, although no studies have been done to demonstrate this benefit.7,8
Pain tolerance at the preferred pulling site has not been studied, however. For patients who feel pain from hair pulling, the pain itself may reinforce the behavior by distracting the individual from negative emotional or physiologic states.15
CASE CONTINUED: COUNTING THE WAYS
Jane and her parents agree that she pulls her hair 5 to 8 times daily, one hair at a time with her right index finger and thumb while doing homework or watching TV. The trigger, she says, is “an itch” on her scalp; “sometimes pulling relieves the itch.” She fails to resist pulling her hair 9 out of 10 times.
Table 1
Defining hair pulling: What to ask the pediatric patient
| Response description | How many times do you pull your hair each day? |
| How many hairs do you pull each time? | |
| From what body areas do you pull hair? | |
| What are all the steps involved in pulling (Touching the head before pulling? Pulling one hair at a time with the thumb and index finger)? | |
| Response detection | Under what circumstances do you sense the urge to pull? |
| How strong is the urge on a scale of 1 to 10, with 10 being the greatest intensity you ever felt? | |
| How do you try to resist and overcome the urge to pull? | |
| Precursors | External cues (Do you pull when you look at yourself in a mirror?) |
| Internal cues (Do you pull when you are nervous?) | |
| High-risk situations | What are you usually doing when you get the urge to pull? (reading, talking on the telephone, watching TV, using a computer, etc.) |
| Consequences that reinforce the behavior | Do you pull to reduce physical sensations (such as itching) at the site of pulling? |
| Does pulling relieve sadness or worry about problems at home or in school? | |
| Do you pull to create a more even hairline? |
Psychiatric comorbidity is common—if not the norm—in adults with TTM. Although axis I comorbidity is also seen in children and adolescents, their hair pulling is frequently uncomplicated. Jane meets criteria for TTM, as determined by the Trichotillomania Diagnostic Interview,16 but her history does not support a comorbid disorder. After discussing the diagnosis with Jane and her parents, the psychiatrist begins treatment with CBT alone.
MEDICATION OR CBT?
SSRIs. Literature on TTM pharmacotherapy is very limited and equivocal. Medications that have helped adults with TTM have been described,17 but the lack of a single, randomized, controlled trial in pediatric TTM severely limits treatment recommendations for children.
Selective serotonin reuptake inhibitors (SSRIs) have shown efficacy for treating anger and other impulse control problems but not for TTM. Some practitioners use SSRIs for TTM because of the belief that TTM is a variant of OCD. However, TTM may be maintained by positive reinforcement rather than compulsive tendencies and thus may not respond to SSRIs.
CBT. Evidence on CBT justifies cautious recommendations for pediatric TTM. In randomized trials, CBT reduced hair pulling in adults and was more effective than SSRIs or placebo.18,19
REDUCING THE URGE
Obtain detailed information about a child or adolescent’s hair-pulling episodes (Table 1), as recognizing triggers and reactions is vital to effective CBT. Explain to the patient that:
- the pleasure or satisfaction she derives from pulling reinforces the urge to pull
- she can reduce the urge by learning and using awareness training, stimulus control, and habit reversal (Table 2).
Awareness training involves patient self-monitoring to gain awareness of urges to pull and of pulling behavior. The child must become alert to every hair pulled and to response precursors, such as placing her hand on her head. For a patient such as Jane, a useful technique is to post reminders on the TV and school notebook and in the bedroom and bathroom—wherever pulling typically occurs.
A “PULLING CALENDAR”
Jane begins a daily “pulling calendar” in which she records each time she pulls a hair while watching TV or doing homework. She is asked to include the total number of hairs pulled and the intensity of the “itch to pull” on a scale of 1 to 10.
Stimulus control. Most patients can identify high-risk situations, such as time in the bathroom, talking on the phone, watching TV, driving, reading, or while falling asleep. Boredom, frustration, anxiety, and sadness may serve as pulling cues.
With stimulus control, the patient tries to reduce her ability to freely engage in pulling behavior in high-risk situations. For instance, you might encourage a child who pulls hairs while doing homework to stick Band-Aid®-type adhesive strips on her thumb and index finger tips before she starts studying as an impediment to gripping hairs. Such “speed bumps” may allow her to delay pulling and reach for tools that assist in habit reversal.
TREATMENT THAT APPEALS
Jane agrees to apply adhesive strips to her fingers and understands why. Because she is a fan of Peter Pan, we place Peter Pan stickers on her books and notebooks and on the TV remote control as reminders not to pull.
Table 2
CBT strategies to reduce the hair-pulling urge
| Awareness training | Increases patient’s awareness of pulling |
| Stimulus control | Establishes an environment less conducive to pulling |
| Habit reversal/ response | Patient develops alternate activities that provide competing positive reinforcement comparable to that gained from pulling |
Habit reversal and competing response procedures provide pleasurable physical stimulation as an alternative to pulling. The most effective methods engage the same motions as used in hair pulling. Examples include sculpting with clay, hulling sunflower seeds, and playing with Koosh® balls—small rubbery balls filled with a jellylike plasma and covered with hundreds of soft “tentacles.”
‘CALMER, HAPPIER’
We explain habit reversal to Jane and instruct her to use the Koosh ball a few times a day. She enjoys pulling its rubber strands, an action that uses the same muscles as hair pulling. Because she will need Koosh balls during all identified high-risk situations, we instruct her to buy one for her book bag and to leave one near the couch where she watches TV.
Over time, Jane reports a gradual decrease of hair pulling with the use of awareness training and stimulus control techniques. Using the Koosh ball (habit reversal) helps her improve. By the 10th week, Jane and her parents report a 70% decrease in hair pulling, based on the pulling calendar entries and other objective evidence of treatment response. All report feeling “calmer and happier.”
CONCLUSION
Cognitive and behavioral strategies are useful and safe for treating pediatric TTM. Enlisting the parents and patient in identifying problem situations and applying creative solutions may increase the chances of success.
Follow-up is important for maintaining new cognitive and behavioral patterns. We recommend that you see patients monthly for at least 3 months, depending on how the patient feels about additional sessions. We encourage families to call and report on progress or relapses. Booster CBT sessions can help deal with setbacks.
Related resources
- Trichotillomania Learning Center, Inc.; devoted to improving TTM understanding and providing access to treatments and support groups. www.trich.org. Accessed Sept. 17, 2004.
- Golomb RG, Vavrichek SM. The hair pulling “habit” and you: how to solve the trichotillomania puzzle (rev ed). Silver Spring, MD: Writer’s Cooperative of Greater Washington; 2000. Book for children and teenagers.
Drug brand names
- Fluoxetine • Prozac
- Naltrexone • Depade, ReVia
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
Preparation of this article was supported in part by a grant from the National Institute of Mental Health (MH61457).
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed., text rev. Washington, DC: American Psychiatric Association Press; 2000;674-7.
2. Christenson GA, Mackenzie TB, Mitchell JE. Characteristics of 60 adult chronic hairpullers. Am J Psychiatry 1991;148:365-70.
3. Swedo SE, Leonard HL. Trichotillomania: an obsessive compulsive spectrum disorder? Psychiatr Clin North Am 1992;15:777-90.
4. Reeve E. Hair pulling in children and adolescents. In: Stein DJ, Christenson GA, Hollander E, eds. Trichotillomania. Washington, DC: American Psychiatric Association Press, 1999;201-24.
5. Reeve EA, Bernstein GA, Christenson GA. Clinical characteristics and psychiatric comorbidity in children with trichotillomania. J Am Acad Child Adolesc Psychiatry 1992;31:132-8.
6. King RA, Scahill L, Vitulano LA, et al. Childhood trichotillomania: clinical phenomenology, comorbidity, and family genetics. J Am Acad Child Adolesc Psychiatry 1995;34:1451-9.
7. Franklin ME, Bux DA, Foa EB. Pediatric trichotillomania: conceptualization and treatment implications. In: Orvashel H, Faust J, Hersen M, eds. Handbook of conceptualization and treatment of child psychopathology. Oxford, UK: Elsevier Science; 2001;379-98.
8. Keuthen NJ, Franklin ME. Trichotillomania: psychopathology and treatment development [presentation]. Reno, NV: Association for the Advancement of Behavior Therapy annual meeting, 2002.
9. Bienvenu OJ, Samuels JF, Riddle MA, et al. The relationship of obsessive-compulsive disorder to possible spectrum disorders: results from a family study. Biol Psychiatry 2000;48:287-93.
10. Lenane MC, Swedo SE, Rapoport JL, et al. Rates of obsessive compulsive disorder in first degree relatives of patients with trichotillomania: a research note. J Child Psychol Psychiatry 1992;33:925-33.
11. Swedo SE, Rapoport JL, Leonard HL, et al. Regional cerebral glucose metabolism of women in trichotillomania. Arch Gen Psychiatry 1991;48:828-33.
12. O’Sullivan RL, Rauch SL, Breiter HC, et al. Reduced basal ganglia volumes in trichotillomania measured via morphometric magnetic resonance imaging. Biol Psychiatry 1997;42:39-45.
13. Grachev ID. MRI-based morphometric topographic parcellation of human neocortex in trichotillomania. Psychiatry Clin Neurosci 1997;51:315-21.
14. Carrion VG. Naltrexone for the treatment of trichotillomania: a case report. J Clin Psychopharmacol 1995;15:444-5.
15. Christenson GA, Mansueto CS. Trichotillomania: descriptive characteristics and phenomenology. In: Stein DJ, Christenson GA, Hollander E, eds. Trichotillomania. Washington, DC: American Psychiatric Press, 1999;1-41.
16. Rothbaum BO, Ninan PT. The assessment of trichotillomania. Behav Res Ther 1994;32(6):651-62.
17. Lundt LP. Trichotillomania: a heads-up on severe cases. Current Psychiatry 2004;3(5):89-105.
18. Ninan PT, Rothbaum BO, Marsteller FA, et al. A placebo-controlled trial of cognitive-behavioral therapy and clomipramine in trichotillomania. J Clin Psychiatry. 2000;61:47-50.
19. Azrin NH, Nunn RG, Frantz SE. Treatment of hairpulling (trichotillomania): a comparative study of habit reversal and negative practice training. J Behav Ther Exp Psychiatry 1980;11:13-20.
Trichotillomania (TTM) is distressing to pediatric patients who pull their hair and to their parents who feel helpless to stop the destructive behavior. Hair-pulling with psychiatric comorbidity requires comprehensive assessment and treatment, but we have found that cognitive-behavioral therapy (CBT) alone can help children and adolescents with uncomplicated TTM.
This article describes a typical patient with adolescent-onset mild-to-moderate TTM and the three-step CBT approach—awareness training, stimulus control, and habit reversal—that we find effective in reducing pediatric hair pulling.
Jane, age 12, was referred to our clinic by her primary doctor after an 8-week trial of fluoxetine, 80 mg/d, failed to stop her hair pulling. Jane, who is right-handed, has been pulling her hair for 2 years, mostly in the right front scalp. Her shame over the hair loss makes her reluctant to participate in social activities. A dermatologist found no medical cause for her behavior, such as alopecia or folliculitis.
Jane’s parents say she has no history of a major mood disorder or anxiety. Her hair pulling causes significant “tension and stress” for all family members.
WHY DO PATIENTS PULL HAIR?
Cognitive-behavioral theory suggests that chronic TTM originates as a normal response to stress that often escapes personal and social awareness but gradually increases in frequency and severity (Box).1-8 Thus, hair pulling becomes associated with internal and external cues through conditioning and is maintained primarily by positive reinforcement. Hair-pulling urges that are reinforced by pulling intensify the need to pull, perpetuating the behavioral cycle.
A genetic link? Familial research has associated TTM with increased rates of obsessive-compulsive disorder (OCD) or other excessive habits—such as nail biting or skin picking—among first-degree relatives.6,9,10 Neuroimaging of persons with TTM has shown hyperactivity in the left cerebellum and right superior parietal lobe11 as well as possible structural abnormalities in the left putamen,12 left inferior frontal gyrus, and right cluneal cortex.13
These findings do not necessarily indicate pre-existing brain pathology, however. Perhaps TTM leads to changes in brain structure or function, or both TTM and the brain abnormalities may be caused by another as-yet-unknown variable.
Decreased pain sensitivity. Patients with TTM often report that hair pulling is not painful,2 though we suspect that persons without TTM would disagree and derive no pleasure from it. Changes in pain sensitivity may influence the reinforcing quality of pulling behavior. One possible mechanism for such alterations is upregulation of the endogenous opioid system; some intriguing evidence suggests that opioid receptor antagonists such as naltrexone may reduce pulling.14
Trichotillomania (TTM) is an impulse control disorder characterized by repetitive hair pulling,1 which typically emerges during adolescence. In a large clinical sample of adult hair pullers, mean age of onset was 13.2 Very-early onset (before age 5) may be a more benign form of TTM that tends to abate spontaneously and requires little or no therapeutic intervention.3
Despite the absence of body hair in prepubertal children, their pulling patterns are consistent with those of adults. The scalp is the most common pulling site, followed by eyelashes and eyebrows.4
Psychiatric comorbidity. In two studies evaluating psychiatric comorbidity in pediatric clinical samples, 60% to 70% of children and teens with TTM had at least one comorbid axis I disorder.5,6 Disruptive behavior disorders were most common in one study,6 whereas overanxious disorder was most common in the other.5 In a large clinical sample of adults with TTM, 51% met criteria for comorbid depression.2
Early identification and treatment of TTM are recommended because of the disorder’s distressing nature and social stigma. Early interventions also may help prevent later adult psychiatric comorbidity and functional impairment, although no studies have been done to demonstrate this benefit.7,8
Pain tolerance at the preferred pulling site has not been studied, however. For patients who feel pain from hair pulling, the pain itself may reinforce the behavior by distracting the individual from negative emotional or physiologic states.15
CASE CONTINUED: COUNTING THE WAYS
Jane and her parents agree that she pulls her hair 5 to 8 times daily, one hair at a time with her right index finger and thumb while doing homework or watching TV. The trigger, she says, is “an itch” on her scalp; “sometimes pulling relieves the itch.” She fails to resist pulling her hair 9 out of 10 times.
Table 1
Defining hair pulling: What to ask the pediatric patient
| Response description | How many times do you pull your hair each day? |
| How many hairs do you pull each time? | |
| From what body areas do you pull hair? | |
| What are all the steps involved in pulling (Touching the head before pulling? Pulling one hair at a time with the thumb and index finger)? | |
| Response detection | Under what circumstances do you sense the urge to pull? |
| How strong is the urge on a scale of 1 to 10, with 10 being the greatest intensity you ever felt? | |
| How do you try to resist and overcome the urge to pull? | |
| Precursors | External cues (Do you pull when you look at yourself in a mirror?) |
| Internal cues (Do you pull when you are nervous?) | |
| High-risk situations | What are you usually doing when you get the urge to pull? (reading, talking on the telephone, watching TV, using a computer, etc.) |
| Consequences that reinforce the behavior | Do you pull to reduce physical sensations (such as itching) at the site of pulling? |
| Does pulling relieve sadness or worry about problems at home or in school? | |
| Do you pull to create a more even hairline? |
Psychiatric comorbidity is common—if not the norm—in adults with TTM. Although axis I comorbidity is also seen in children and adolescents, their hair pulling is frequently uncomplicated. Jane meets criteria for TTM, as determined by the Trichotillomania Diagnostic Interview,16 but her history does not support a comorbid disorder. After discussing the diagnosis with Jane and her parents, the psychiatrist begins treatment with CBT alone.
MEDICATION OR CBT?
SSRIs. Literature on TTM pharmacotherapy is very limited and equivocal. Medications that have helped adults with TTM have been described,17 but the lack of a single, randomized, controlled trial in pediatric TTM severely limits treatment recommendations for children.
Selective serotonin reuptake inhibitors (SSRIs) have shown efficacy for treating anger and other impulse control problems but not for TTM. Some practitioners use SSRIs for TTM because of the belief that TTM is a variant of OCD. However, TTM may be maintained by positive reinforcement rather than compulsive tendencies and thus may not respond to SSRIs.
CBT. Evidence on CBT justifies cautious recommendations for pediatric TTM. In randomized trials, CBT reduced hair pulling in adults and was more effective than SSRIs or placebo.18,19
REDUCING THE URGE
Obtain detailed information about a child or adolescent’s hair-pulling episodes (Table 1), as recognizing triggers and reactions is vital to effective CBT. Explain to the patient that:
- the pleasure or satisfaction she derives from pulling reinforces the urge to pull
- she can reduce the urge by learning and using awareness training, stimulus control, and habit reversal (Table 2).
Awareness training involves patient self-monitoring to gain awareness of urges to pull and of pulling behavior. The child must become alert to every hair pulled and to response precursors, such as placing her hand on her head. For a patient such as Jane, a useful technique is to post reminders on the TV and school notebook and in the bedroom and bathroom—wherever pulling typically occurs.
A “PULLING CALENDAR”
Jane begins a daily “pulling calendar” in which she records each time she pulls a hair while watching TV or doing homework. She is asked to include the total number of hairs pulled and the intensity of the “itch to pull” on a scale of 1 to 10.
Stimulus control. Most patients can identify high-risk situations, such as time in the bathroom, talking on the phone, watching TV, driving, reading, or while falling asleep. Boredom, frustration, anxiety, and sadness may serve as pulling cues.
With stimulus control, the patient tries to reduce her ability to freely engage in pulling behavior in high-risk situations. For instance, you might encourage a child who pulls hairs while doing homework to stick Band-Aid®-type adhesive strips on her thumb and index finger tips before she starts studying as an impediment to gripping hairs. Such “speed bumps” may allow her to delay pulling and reach for tools that assist in habit reversal.
TREATMENT THAT APPEALS
Jane agrees to apply adhesive strips to her fingers and understands why. Because she is a fan of Peter Pan, we place Peter Pan stickers on her books and notebooks and on the TV remote control as reminders not to pull.
Table 2
CBT strategies to reduce the hair-pulling urge
| Awareness training | Increases patient’s awareness of pulling |
| Stimulus control | Establishes an environment less conducive to pulling |
| Habit reversal/ response | Patient develops alternate activities that provide competing positive reinforcement comparable to that gained from pulling |
Habit reversal and competing response procedures provide pleasurable physical stimulation as an alternative to pulling. The most effective methods engage the same motions as used in hair pulling. Examples include sculpting with clay, hulling sunflower seeds, and playing with Koosh® balls—small rubbery balls filled with a jellylike plasma and covered with hundreds of soft “tentacles.”
‘CALMER, HAPPIER’
We explain habit reversal to Jane and instruct her to use the Koosh ball a few times a day. She enjoys pulling its rubber strands, an action that uses the same muscles as hair pulling. Because she will need Koosh balls during all identified high-risk situations, we instruct her to buy one for her book bag and to leave one near the couch where she watches TV.
Over time, Jane reports a gradual decrease of hair pulling with the use of awareness training and stimulus control techniques. Using the Koosh ball (habit reversal) helps her improve. By the 10th week, Jane and her parents report a 70% decrease in hair pulling, based on the pulling calendar entries and other objective evidence of treatment response. All report feeling “calmer and happier.”
CONCLUSION
Cognitive and behavioral strategies are useful and safe for treating pediatric TTM. Enlisting the parents and patient in identifying problem situations and applying creative solutions may increase the chances of success.
Follow-up is important for maintaining new cognitive and behavioral patterns. We recommend that you see patients monthly for at least 3 months, depending on how the patient feels about additional sessions. We encourage families to call and report on progress or relapses. Booster CBT sessions can help deal with setbacks.
Related resources
- Trichotillomania Learning Center, Inc.; devoted to improving TTM understanding and providing access to treatments and support groups. www.trich.org. Accessed Sept. 17, 2004.
- Golomb RG, Vavrichek SM. The hair pulling “habit” and you: how to solve the trichotillomania puzzle (rev ed). Silver Spring, MD: Writer’s Cooperative of Greater Washington; 2000. Book for children and teenagers.
Drug brand names
- Fluoxetine • Prozac
- Naltrexone • Depade, ReVia
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
Preparation of this article was supported in part by a grant from the National Institute of Mental Health (MH61457).
Trichotillomania (TTM) is distressing to pediatric patients who pull their hair and to their parents who feel helpless to stop the destructive behavior. Hair-pulling with psychiatric comorbidity requires comprehensive assessment and treatment, but we have found that cognitive-behavioral therapy (CBT) alone can help children and adolescents with uncomplicated TTM.
This article describes a typical patient with adolescent-onset mild-to-moderate TTM and the three-step CBT approach—awareness training, stimulus control, and habit reversal—that we find effective in reducing pediatric hair pulling.
Jane, age 12, was referred to our clinic by her primary doctor after an 8-week trial of fluoxetine, 80 mg/d, failed to stop her hair pulling. Jane, who is right-handed, has been pulling her hair for 2 years, mostly in the right front scalp. Her shame over the hair loss makes her reluctant to participate in social activities. A dermatologist found no medical cause for her behavior, such as alopecia or folliculitis.
Jane’s parents say she has no history of a major mood disorder or anxiety. Her hair pulling causes significant “tension and stress” for all family members.
WHY DO PATIENTS PULL HAIR?
Cognitive-behavioral theory suggests that chronic TTM originates as a normal response to stress that often escapes personal and social awareness but gradually increases in frequency and severity (Box).1-8 Thus, hair pulling becomes associated with internal and external cues through conditioning and is maintained primarily by positive reinforcement. Hair-pulling urges that are reinforced by pulling intensify the need to pull, perpetuating the behavioral cycle.
A genetic link? Familial research has associated TTM with increased rates of obsessive-compulsive disorder (OCD) or other excessive habits—such as nail biting or skin picking—among first-degree relatives.6,9,10 Neuroimaging of persons with TTM has shown hyperactivity in the left cerebellum and right superior parietal lobe11 as well as possible structural abnormalities in the left putamen,12 left inferior frontal gyrus, and right cluneal cortex.13
These findings do not necessarily indicate pre-existing brain pathology, however. Perhaps TTM leads to changes in brain structure or function, or both TTM and the brain abnormalities may be caused by another as-yet-unknown variable.
Decreased pain sensitivity. Patients with TTM often report that hair pulling is not painful,2 though we suspect that persons without TTM would disagree and derive no pleasure from it. Changes in pain sensitivity may influence the reinforcing quality of pulling behavior. One possible mechanism for such alterations is upregulation of the endogenous opioid system; some intriguing evidence suggests that opioid receptor antagonists such as naltrexone may reduce pulling.14
Trichotillomania (TTM) is an impulse control disorder characterized by repetitive hair pulling,1 which typically emerges during adolescence. In a large clinical sample of adult hair pullers, mean age of onset was 13.2 Very-early onset (before age 5) may be a more benign form of TTM that tends to abate spontaneously and requires little or no therapeutic intervention.3
Despite the absence of body hair in prepubertal children, their pulling patterns are consistent with those of adults. The scalp is the most common pulling site, followed by eyelashes and eyebrows.4
Psychiatric comorbidity. In two studies evaluating psychiatric comorbidity in pediatric clinical samples, 60% to 70% of children and teens with TTM had at least one comorbid axis I disorder.5,6 Disruptive behavior disorders were most common in one study,6 whereas overanxious disorder was most common in the other.5 In a large clinical sample of adults with TTM, 51% met criteria for comorbid depression.2
Early identification and treatment of TTM are recommended because of the disorder’s distressing nature and social stigma. Early interventions also may help prevent later adult psychiatric comorbidity and functional impairment, although no studies have been done to demonstrate this benefit.7,8
Pain tolerance at the preferred pulling site has not been studied, however. For patients who feel pain from hair pulling, the pain itself may reinforce the behavior by distracting the individual from negative emotional or physiologic states.15
CASE CONTINUED: COUNTING THE WAYS
Jane and her parents agree that she pulls her hair 5 to 8 times daily, one hair at a time with her right index finger and thumb while doing homework or watching TV. The trigger, she says, is “an itch” on her scalp; “sometimes pulling relieves the itch.” She fails to resist pulling her hair 9 out of 10 times.
Table 1
Defining hair pulling: What to ask the pediatric patient
| Response description | How many times do you pull your hair each day? |
| How many hairs do you pull each time? | |
| From what body areas do you pull hair? | |
| What are all the steps involved in pulling (Touching the head before pulling? Pulling one hair at a time with the thumb and index finger)? | |
| Response detection | Under what circumstances do you sense the urge to pull? |
| How strong is the urge on a scale of 1 to 10, with 10 being the greatest intensity you ever felt? | |
| How do you try to resist and overcome the urge to pull? | |
| Precursors | External cues (Do you pull when you look at yourself in a mirror?) |
| Internal cues (Do you pull when you are nervous?) | |
| High-risk situations | What are you usually doing when you get the urge to pull? (reading, talking on the telephone, watching TV, using a computer, etc.) |
| Consequences that reinforce the behavior | Do you pull to reduce physical sensations (such as itching) at the site of pulling? |
| Does pulling relieve sadness or worry about problems at home or in school? | |
| Do you pull to create a more even hairline? |
Psychiatric comorbidity is common—if not the norm—in adults with TTM. Although axis I comorbidity is also seen in children and adolescents, their hair pulling is frequently uncomplicated. Jane meets criteria for TTM, as determined by the Trichotillomania Diagnostic Interview,16 but her history does not support a comorbid disorder. After discussing the diagnosis with Jane and her parents, the psychiatrist begins treatment with CBT alone.
MEDICATION OR CBT?
SSRIs. Literature on TTM pharmacotherapy is very limited and equivocal. Medications that have helped adults with TTM have been described,17 but the lack of a single, randomized, controlled trial in pediatric TTM severely limits treatment recommendations for children.
Selective serotonin reuptake inhibitors (SSRIs) have shown efficacy for treating anger and other impulse control problems but not for TTM. Some practitioners use SSRIs for TTM because of the belief that TTM is a variant of OCD. However, TTM may be maintained by positive reinforcement rather than compulsive tendencies and thus may not respond to SSRIs.
CBT. Evidence on CBT justifies cautious recommendations for pediatric TTM. In randomized trials, CBT reduced hair pulling in adults and was more effective than SSRIs or placebo.18,19
REDUCING THE URGE
Obtain detailed information about a child or adolescent’s hair-pulling episodes (Table 1), as recognizing triggers and reactions is vital to effective CBT. Explain to the patient that:
- the pleasure or satisfaction she derives from pulling reinforces the urge to pull
- she can reduce the urge by learning and using awareness training, stimulus control, and habit reversal (Table 2).
Awareness training involves patient self-monitoring to gain awareness of urges to pull and of pulling behavior. The child must become alert to every hair pulled and to response precursors, such as placing her hand on her head. For a patient such as Jane, a useful technique is to post reminders on the TV and school notebook and in the bedroom and bathroom—wherever pulling typically occurs.
A “PULLING CALENDAR”
Jane begins a daily “pulling calendar” in which she records each time she pulls a hair while watching TV or doing homework. She is asked to include the total number of hairs pulled and the intensity of the “itch to pull” on a scale of 1 to 10.
Stimulus control. Most patients can identify high-risk situations, such as time in the bathroom, talking on the phone, watching TV, driving, reading, or while falling asleep. Boredom, frustration, anxiety, and sadness may serve as pulling cues.
With stimulus control, the patient tries to reduce her ability to freely engage in pulling behavior in high-risk situations. For instance, you might encourage a child who pulls hairs while doing homework to stick Band-Aid®-type adhesive strips on her thumb and index finger tips before she starts studying as an impediment to gripping hairs. Such “speed bumps” may allow her to delay pulling and reach for tools that assist in habit reversal.
TREATMENT THAT APPEALS
Jane agrees to apply adhesive strips to her fingers and understands why. Because she is a fan of Peter Pan, we place Peter Pan stickers on her books and notebooks and on the TV remote control as reminders not to pull.
Table 2
CBT strategies to reduce the hair-pulling urge
| Awareness training | Increases patient’s awareness of pulling |
| Stimulus control | Establishes an environment less conducive to pulling |
| Habit reversal/ response | Patient develops alternate activities that provide competing positive reinforcement comparable to that gained from pulling |
Habit reversal and competing response procedures provide pleasurable physical stimulation as an alternative to pulling. The most effective methods engage the same motions as used in hair pulling. Examples include sculpting with clay, hulling sunflower seeds, and playing with Koosh® balls—small rubbery balls filled with a jellylike plasma and covered with hundreds of soft “tentacles.”
‘CALMER, HAPPIER’
We explain habit reversal to Jane and instruct her to use the Koosh ball a few times a day. She enjoys pulling its rubber strands, an action that uses the same muscles as hair pulling. Because she will need Koosh balls during all identified high-risk situations, we instruct her to buy one for her book bag and to leave one near the couch where she watches TV.
Over time, Jane reports a gradual decrease of hair pulling with the use of awareness training and stimulus control techniques. Using the Koosh ball (habit reversal) helps her improve. By the 10th week, Jane and her parents report a 70% decrease in hair pulling, based on the pulling calendar entries and other objective evidence of treatment response. All report feeling “calmer and happier.”
CONCLUSION
Cognitive and behavioral strategies are useful and safe for treating pediatric TTM. Enlisting the parents and patient in identifying problem situations and applying creative solutions may increase the chances of success.
Follow-up is important for maintaining new cognitive and behavioral patterns. We recommend that you see patients monthly for at least 3 months, depending on how the patient feels about additional sessions. We encourage families to call and report on progress or relapses. Booster CBT sessions can help deal with setbacks.
Related resources
- Trichotillomania Learning Center, Inc.; devoted to improving TTM understanding and providing access to treatments and support groups. www.trich.org. Accessed Sept. 17, 2004.
- Golomb RG, Vavrichek SM. The hair pulling “habit” and you: how to solve the trichotillomania puzzle (rev ed). Silver Spring, MD: Writer’s Cooperative of Greater Washington; 2000. Book for children and teenagers.
Drug brand names
- Fluoxetine • Prozac
- Naltrexone • Depade, ReVia
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
Preparation of this article was supported in part by a grant from the National Institute of Mental Health (MH61457).
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed., text rev. Washington, DC: American Psychiatric Association Press; 2000;674-7.
2. Christenson GA, Mackenzie TB, Mitchell JE. Characteristics of 60 adult chronic hairpullers. Am J Psychiatry 1991;148:365-70.
3. Swedo SE, Leonard HL. Trichotillomania: an obsessive compulsive spectrum disorder? Psychiatr Clin North Am 1992;15:777-90.
4. Reeve E. Hair pulling in children and adolescents. In: Stein DJ, Christenson GA, Hollander E, eds. Trichotillomania. Washington, DC: American Psychiatric Association Press, 1999;201-24.
5. Reeve EA, Bernstein GA, Christenson GA. Clinical characteristics and psychiatric comorbidity in children with trichotillomania. J Am Acad Child Adolesc Psychiatry 1992;31:132-8.
6. King RA, Scahill L, Vitulano LA, et al. Childhood trichotillomania: clinical phenomenology, comorbidity, and family genetics. J Am Acad Child Adolesc Psychiatry 1995;34:1451-9.
7. Franklin ME, Bux DA, Foa EB. Pediatric trichotillomania: conceptualization and treatment implications. In: Orvashel H, Faust J, Hersen M, eds. Handbook of conceptualization and treatment of child psychopathology. Oxford, UK: Elsevier Science; 2001;379-98.
8. Keuthen NJ, Franklin ME. Trichotillomania: psychopathology and treatment development [presentation]. Reno, NV: Association for the Advancement of Behavior Therapy annual meeting, 2002.
9. Bienvenu OJ, Samuels JF, Riddle MA, et al. The relationship of obsessive-compulsive disorder to possible spectrum disorders: results from a family study. Biol Psychiatry 2000;48:287-93.
10. Lenane MC, Swedo SE, Rapoport JL, et al. Rates of obsessive compulsive disorder in first degree relatives of patients with trichotillomania: a research note. J Child Psychol Psychiatry 1992;33:925-33.
11. Swedo SE, Rapoport JL, Leonard HL, et al. Regional cerebral glucose metabolism of women in trichotillomania. Arch Gen Psychiatry 1991;48:828-33.
12. O’Sullivan RL, Rauch SL, Breiter HC, et al. Reduced basal ganglia volumes in trichotillomania measured via morphometric magnetic resonance imaging. Biol Psychiatry 1997;42:39-45.
13. Grachev ID. MRI-based morphometric topographic parcellation of human neocortex in trichotillomania. Psychiatry Clin Neurosci 1997;51:315-21.
14. Carrion VG. Naltrexone for the treatment of trichotillomania: a case report. J Clin Psychopharmacol 1995;15:444-5.
15. Christenson GA, Mansueto CS. Trichotillomania: descriptive characteristics and phenomenology. In: Stein DJ, Christenson GA, Hollander E, eds. Trichotillomania. Washington, DC: American Psychiatric Press, 1999;1-41.
16. Rothbaum BO, Ninan PT. The assessment of trichotillomania. Behav Res Ther 1994;32(6):651-62.
17. Lundt LP. Trichotillomania: a heads-up on severe cases. Current Psychiatry 2004;3(5):89-105.
18. Ninan PT, Rothbaum BO, Marsteller FA, et al. A placebo-controlled trial of cognitive-behavioral therapy and clomipramine in trichotillomania. J Clin Psychiatry. 2000;61:47-50.
19. Azrin NH, Nunn RG, Frantz SE. Treatment of hairpulling (trichotillomania): a comparative study of habit reversal and negative practice training. J Behav Ther Exp Psychiatry 1980;11:13-20.
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed., text rev. Washington, DC: American Psychiatric Association Press; 2000;674-7.
2. Christenson GA, Mackenzie TB, Mitchell JE. Characteristics of 60 adult chronic hairpullers. Am J Psychiatry 1991;148:365-70.
3. Swedo SE, Leonard HL. Trichotillomania: an obsessive compulsive spectrum disorder? Psychiatr Clin North Am 1992;15:777-90.
4. Reeve E. Hair pulling in children and adolescents. In: Stein DJ, Christenson GA, Hollander E, eds. Trichotillomania. Washington, DC: American Psychiatric Association Press, 1999;201-24.
5. Reeve EA, Bernstein GA, Christenson GA. Clinical characteristics and psychiatric comorbidity in children with trichotillomania. J Am Acad Child Adolesc Psychiatry 1992;31:132-8.
6. King RA, Scahill L, Vitulano LA, et al. Childhood trichotillomania: clinical phenomenology, comorbidity, and family genetics. J Am Acad Child Adolesc Psychiatry 1995;34:1451-9.
7. Franklin ME, Bux DA, Foa EB. Pediatric trichotillomania: conceptualization and treatment implications. In: Orvashel H, Faust J, Hersen M, eds. Handbook of conceptualization and treatment of child psychopathology. Oxford, UK: Elsevier Science; 2001;379-98.
8. Keuthen NJ, Franklin ME. Trichotillomania: psychopathology and treatment development [presentation]. Reno, NV: Association for the Advancement of Behavior Therapy annual meeting, 2002.
9. Bienvenu OJ, Samuels JF, Riddle MA, et al. The relationship of obsessive-compulsive disorder to possible spectrum disorders: results from a family study. Biol Psychiatry 2000;48:287-93.
10. Lenane MC, Swedo SE, Rapoport JL, et al. Rates of obsessive compulsive disorder in first degree relatives of patients with trichotillomania: a research note. J Child Psychol Psychiatry 1992;33:925-33.
11. Swedo SE, Rapoport JL, Leonard HL, et al. Regional cerebral glucose metabolism of women in trichotillomania. Arch Gen Psychiatry 1991;48:828-33.
12. O’Sullivan RL, Rauch SL, Breiter HC, et al. Reduced basal ganglia volumes in trichotillomania measured via morphometric magnetic resonance imaging. Biol Psychiatry 1997;42:39-45.
13. Grachev ID. MRI-based morphometric topographic parcellation of human neocortex in trichotillomania. Psychiatry Clin Neurosci 1997;51:315-21.
14. Carrion VG. Naltrexone for the treatment of trichotillomania: a case report. J Clin Psychopharmacol 1995;15:444-5.
15. Christenson GA, Mansueto CS. Trichotillomania: descriptive characteristics and phenomenology. In: Stein DJ, Christenson GA, Hollander E, eds. Trichotillomania. Washington, DC: American Psychiatric Press, 1999;1-41.
16. Rothbaum BO, Ninan PT. The assessment of trichotillomania. Behav Res Ther 1994;32(6):651-62.
17. Lundt LP. Trichotillomania: a heads-up on severe cases. Current Psychiatry 2004;3(5):89-105.
18. Ninan PT, Rothbaum BO, Marsteller FA, et al. A placebo-controlled trial of cognitive-behavioral therapy and clomipramine in trichotillomania. J Clin Psychiatry. 2000;61:47-50.
19. Azrin NH, Nunn RG, Frantz SE. Treatment of hairpulling (trichotillomania): a comparative study of habit reversal and negative practice training. J Behav Ther Exp Psychiatry 1980;11:13-20.