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
Hair-pulling tends to begin early
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? |