Psychological treatments for trichotillomania: Update and future directions

Trichotillomania (TTM) is an obsessive compulsive-related disorder that is characterised by repeated removal of hair, typically from the scalp, eyebrows and eyelashes, resulting in hair loss.^1,2 TTM is associated with low self-esteem, high distress, and significant social and vocational impairment.^2,3 It is a chronic, relapsing and treatment-resistant disorder. ⁴ The difficulty in treating TTM is, in part, a result of limited awareness of effective treatment options. In a survey of 501 US psychologists and physicians, 72% of respondents believed that pharmacotherapies are effective treatments for TTM. ⁵ By contrast, expert consensus and meta-analyses of randomised controlled trials (RCTs) indicate that cognitive behavioural therapy (CBT) is the most empirically validated treatment for TTM.^6–8 Dissemination of treatment advances is a critical challenge in improving outcomes for TTM. ⁹ This paper provides an overview of evidence-based psychological treatments for TTM while highlighting areas in need of further study.

Habit reversal therapy

The specific style of behaviour therapy utilised in CBT trials is habit reversal therapy (HRT).^7,8 When HRT was developed, TTM was conceptualised as a “nervous habit” occurring beyond the individual’s awareness. ¹⁰ Behavioural models of TTM posit that hairpulling is reinforced via conditioning processes, and HRT aims to inhibit or modify the factors that have become associated with hairpulling (Box 1).^11,12 Despite positive outcomes using standard HRT in uncontrolled trials and case studies, ⁴ only two RCTs have been completed. Azrin and colleagues reported that single-session HRT (n=18) reduced self-reported hairpulling episodes by 99% compared with a reduction of 58% following 1 day of self-directed negative practice (n=15). ¹⁰ At 22-month follow-up, participants who completed a single HRT session and received telephone support for up to 4 months post-treatment maintained an 87% reduction in hairpulling episodes. More recently, van Minnen and colleagues compared six sessions of standard HRT over 12 weeks with fluoxetine treatment (60mg/day) or a waiting list. ¹³ HRT resulted in a significantly greater reduction of self-reported TTM severity. However, at 2-year follow-up, only nine of 24 participants had maintained a 50% or more reduction in symptom severity, while two participants reported increased symptom severity from baseline. ¹⁴

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Box 1.

Core components of habit reversal therapy for TTM^9,12

1. Awareness training and self-monitoring: to improve awareness of the hairpulling, and its associated antecedent and maintaining factors

2. Stimulus control: to inhibit hairpulling by removing or reducing the impact of conditioned cues in the environment (e.g. impeding access to hairpulling instruments like tweezers)

3. Competing response practice: involves practising a motor response (e.g. fist-clenching) that is incompatible with hairpulling

TTM: trichotillomania

Developments in treatment augmentation

Although HRT is an important component of TTM treatment, relapse rates suggest it is insufficient. Phenomenological research over the past decade has demonstrated that TTM is not simply characterised by habitual, “automatic” hairpulling. A second, “focused” style of hairpulling is intentionally performed in TTM to regulate negative internal experiences (i.e. emotions, cognitions, sensations). ¹⁵ Although less than 0.01% of individuals with TTM pull hair exclusively in either an automatic or focused manner, the distinction has generated speculation that HRT may be most effective for automatic hairpulling while emotion regulation and cognitive interventions may be most effective for focused hairpulling. ¹⁵ As such, HRT is increasingly being augmented with emotion regulation and cognitive interventions to simultaneously target both automatic and focused hairpulling styles.

Dialectical behaviour therapy

There is growing evidence that emotion dysregulation is implicated in TTM. Hairpulling is consistently associated with decreases in negative emotions like boredom, sadness and anxiety, and associated with increases in calmness.^3,16 Furthermore, pre-treatment depression symptoms may moderate long-term TTM symptom outcomes. ¹⁴ This has led to the augmentation of HRT with dialectical behaviour therapy (DBT) ¹⁷ to improve the emotion regulation and distress tolerance skills of individuals with TTM. The DBT-enhanced HRT protocol developed by Keuthen and colleagues^18–20 consists of 11 weekly treatment sessions followed by four “booster” sessions held at 2, 4, 8 and 12 weeks post-treatment (see Box 2).

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Box 2.

Treatment structure of DBT-enhanced HRT for TTM (as outlined by Keuthen and colleagues)^18,20

Session 1: TTM psychoeducation, motivational interviewing, HRT (self-monitoring/awareness training)

Session 2: HRT (competing response training, stimulus control)

Sessions 3–5: Mindfulness

Sessions 6–8: Emotion regulation skills training

Sessions 9–10: Distress tolerance skills training

Session 11: Relapse prevention training

Sessions 12–15: “Booster” sessions focusing on treatment review and relapse prevention

DBT: dialectical behaviour therapy; HRT: habit reversal therapy; TTM: trichotillomania

Expanding on an earlier pilot treatment trial,^18,19 an RCT ²⁰ found the DBT/HRT intervention (n=20) resulted in significantly greater reductions to self- and clinician-rated TTM severity and impairment compared with a minimal attention control condition (n=18). There were significantly greater pre- to post-treatment improvements in emotion regulation for the DBT group. Five participants receiving the DBT intervention were completely abstinent from hairpulling at the end of treatment, compared with one in the control group, with improvements generally maintained at 6-month follow-up.

Acceptance and commitment therapy

Experiential avoidance is the avoidance of unpleasant internal experiences through engaging in maladaptive behaviours. ²¹ Highly experientially avoidant participants with TTM had more frequent and intense hairpulling urges, felt less ability to control those urges, and experienced greater hairpulling-related distress. ²² Although high versus low experiential avoidance did not differentiate between actual hairpulling, these findings led researchers to trial acceptance and commitment therapy (ACT) ²¹ as an augmentation to HRT. Mindfulness, values work, and “defusion” from the literal interpretation of thoughts are some of the core components of ACT-enhanced HRT for TTM (Box 3).^23–25

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Box 3.

Treatment structure of ACT-enhanced HRT for TTM (Woods and colleagues) ²⁴

Session 1: TTM psychoeducation, orientation to therapy

Session 2: Values identification

Session 3: Identification and challenging of attempts to control hairpulling urges and unpleasant internal experiences

Session 4: Introduction to the concept of acceptance

Sessions 5–6: Cognitive defusion

Session 7: Incorporation of HRT (hairpulling/urge simulation) to allow practice of acceptance strategies

Session 8: HRT (awareness training, competing response training) and incorporation of social support

Session 9: HRT (stimulus control)

Session 10: Treatment review and relapse prevention

ACT: acceptance and commitment therapy; HRT: habit reversal therapy; TTM: trichotillomania

ACT for TTM has been trialled in one RCT, which comprised 10 sessions over 12 weeks. ²⁴ Compared with a waitlist condition (n=13), the ACT intervention (n=12) produced significantly greater reductions in self- and clinician-rated TTM severity/impairment from pre- to post-treatment. There were also significantly greater pre- to post-treatment reductions in depression, anxiety and experiential avoidance among the ACT group. At 3-month follow-up, self-rated TTM severity had significantly increased from post-treatment; however, there were no significant changes in clinician-rated impairment or the average daily number of hairs pulled.

Critique and future research

Both DBT- and ACT-enhanced HRT reduce acute TTM symptoms, with preliminary support for maintenance of reductions at 3^19,20,24 and 6 months post-treatment.^19,20 Meta-analyses demonstrate that these “mood-enhanced” HRT trials result in a significantly larger treatment effect than standard HRT or CBT trials. ⁸ Correlations between TTM symptom reduction and changes in emotion dysregulation and experiential avoidance suggest that these processes are possible change mechanisms, although specific studies are needed. ²⁴

Lacking in research is an understanding of the effectiveness of traditional CBT for TTM. Two RCTs have trialled cognitive restructuring as part of CBT protocols, but have small sample sizes and lack follow-up data.^26,27 Investigations regarding the content and role of cognitions in TTM are limited. These issues, combined with behavioural models that underestimate the role of cognitions and beliefs in TTM without strong evidence ¹¹ have resulted in this potentially important element of TTM phenomenology being ignored. However, emerging research has identified several classes of cognitions that are important in TTM, including negative self-beliefs, perfectionism and desire for control, and a preference to avoid expressing negative emotion. ²⁸ When CBT has addressed maladaptive cognitions specific to TTM and repetitive behaviours (including perfectionism and self-critical statements), significant acute and long-term symptom reductions have been reported.^29,30 There is a strong need for this research to be replicated under controlled conditions and with larger sample sizes of TTM-only patients.