Treating Trichotillomania

1 Theoretical and Research Basis for Treatment

Trichotillomania (TTM; or “hair-pulling disorder”) is the recurrent pulling of one’s own hair (American Psychiatric Association [APA], 2013). The hair-pulling associated with this disorder can occur at any site on the body, with the scalp being the most common target. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) classifies this disorder as a form of obsessive compulsive disorder, as it involves recurrent thoughts about, urges, and impulses to engage in pulling (the “obsession”), followed by recurrent and uncontrollable episodes of the hair-pulling behavior itself (the “compulsion”). TTM can be associated with significant distress arising from shame, embarrassment, and frustration over not only the hair loss itself, but also the perceived lack of control with regard to pulling. In addition, impairment in functioning can be caused by reluctance to participate in activities that might reveal problems related to hair loss or social withdrawal in general due to embarrassment.

Given that TTM can cause significant distress and dysfunction, identification of effective treatments for this disorder is important. Division 12 of the American Psychological Association provides a list of empirically validated treatments for various disorders, but TTM is not addressed specifically on that list. Nevertheless, the literature does indicate that a variety of treatment models have been successfully applied to this condition, including habit reversal training (HRT; Morris, Zickgraf, Dingfelder, & Franklin, 2013), the Comprehensive Behavioral Model for TTM (ComB; Mansueto, Sternberger, Thomas, & Golomb, 1997), and Dialectical Behavior Therapy (DBT). Although DBT was originally developed for borderline personality disorder, Keuthen et al. (2010) as well as Keuthen and Sprich (2012) reported that DBT strategies can enhance standard behavioral therapies and improve treatment outcomes for TTM. Although HRT and ComB can be considered forms of behavior therapy specifically, DBT is considered to be a form of cognitive-behavioral therapy (CBT; meaning that underlying thought processes are addressed in addition to behavior change). Indeed, the literature indicates that the cognitive-behavioral approach is effective for TTM in general (e.g., Franklin & Tolin, 2007; Keuthen et al., 2015; Toledo, De Togni Muniz, Cobrita Brito, de Abreu, & Tavares, 2015). In addition to studies of CBT effectiveness in general for TTM, others have demonstrated that CBT can be tailored to specific client needs to improve outcomes. For example, Pellisier and O’Connor (2004) conducted a case study in which they successfully adapted CBT to focus on perfectionistic thoughts, as such thoughts were a trigger for hair-pulling in that case. It should be emphasized that the manualized treatment implemented in the case study described here (Keuthen, Stein, & Christenson, 2001) is indeed a CBT approach, but also provides helpful information on symptoms of TTM, etiology, assessment, and other available resources for clients.

Because Keuthen et al. (2001) emphasize HRT heavily in the behavioral component of their treatment, we elaborate on this strategy more fully here. Initially introduced as a method for “eliminating nervous habits and tics” (Azrin & Nunn, 1973), HRT encourages clients to develop awareness of when the problem behavior (i.e., hair-pulling) occurs, then use alternative or “competing” responses as a way to prevent that behavior from occurring. There are four steps involved in implementation of HRT: (a) awareness training, (b) competing response (CR) practice, (c) habit control motivation, and (d) generalization training. Because TTM consists of an obviously habitual behavior, it is no surprise that HRT has been applied to the treatment of this disorder. In fact, several published reports suggest that HRT alone is an effective behavioral treatment for individuals with TTM (e.g., Bloch et al., 2007; Michael, 2004; Morris et al., 2013; Twohig & Woods, 2004). In addition to these studies cited here, a recent meta-analysis by McGuire et al. (2014) showed a “large effect” of therapies using HRT on the reduction of hair-pulling across several studies.

Because of widespread evidence for their efficacy, standard behavior therapies (such as HRT) present obvious appeal for the treatment of TTM. However, the “cognitive revolution” of the 1950s and 1960s generated widespread interest in the role that thought processes play in human functioning, and the realm of psychotherapy was no exception to the impact of this movement. Accordingly, many modern treatments for TTM also overtly address the role that cognitive variables might play in this disorder. Developing an awareness of the thoughts that underlie hair-pulling, recognizing cognitive distortions, and restructuring one’s thoughts are specific examples of techniques that have been advocated in this literature and found to be effective.

Therefore, for the present case study, we outline the specific and successful application of a manualized CBT (based on Keuthen et al., 2001) to the case of a young woman with a longstanding history of TTM.

2 Case Introduction

Teri (a pseudonym) was a 21-year-old Caucasian college junior when she entered the treatment described here. She lived on a campus with a roommate, although her boyfriend and family lived only a short drive away from campus. She was referred to the clinic by one of her professors on campus, as well as by her mother. Teri presented as an intelligent, insightful, and socially skilled young woman who was eager to begin therapy. The setting in which she sought treatment was a training clinic staffed by doctoral students in clinical psychology (and supervised by licensed, doctoral-level clinical faculty) at a large public university.

3 Presenting Complaints

During her screening and initial therapy appointments, Teri explained that she was troubled by recurrent and significant episodes of hair-pulling behavior. At that time, she indicated that she “fiddled” with her hair daily and estimated that she engaged in hair-pulling episodes four to five times per week, especially at night. She stated that she experienced significant tension when the urge to pull was present, much like “an itch that has to be scratched.” When touching or playing with her hair, it was common for Teri to feel around for “unusual” hairs (ones that were a little shorter, coarser, or more gelled) and then obsess about pulling them until giving into the urge. Her episodes often consisted of pulling many hairs, but led to a pleasurable sense of relief that was “almost like a high” once the pulling had occurred. This pulling occurred exclusively at the top and back part of her scalp (see Figure 1).

OPEN IN VIEWER

Figure 1.

Photographic documentation of progress over course of treatment, reproduced here with explicit written consent of client.

Teri reported significant distress and some impairment due to this aspect of her appearance. Indeed, as Figure 1 shows, Teri had developed a noticeable “problem area” on that part of her scalp. Although not completely bald in that spot, her hair was noticeably thinner and scarcer in that location due to the history of pulling. She described embarrassment about this spot and frustration about the need to spend more time than she would like styling her hair so that others would not notice it. She also expressed that her hair styling options were quite limited due to the need to cover this area, and a reluctance to consult with a stylist due to embarrassment. Moreover, Teri declined to participate in certain activities that she enjoyed (such as swimming) because of the potential for this problem to be revealed. She expressed feeling that her hair-pulling “is weird,” and that she was significantly frustrated by her lack of ability to understand or control this problematic behavior. Therefore, she sought therapy to “learn strategies” that would help her manage stress and reduce or eliminate her hair-pulling behavior.

4 History

Hair-pulling often begins in adolescence (Keuthen et al., 2001), and Teri indicated that she was “13 or 14” and in middle school when this problem started for her. During this time, she also reportedly experienced minor problems with anxiety and depressive symptoms that she saw as connected to her hair-pulling (i.e., more likely to engage in that behavior when experiencing these negative emotions). Emotional triggers for hair-pulling are not uncommon; according to Diefenbach, Mouton-Odum, and Stanley (2002) and Diefenbach, Tolin, Meunier, and Worhunsky (2008), emotional states such as stress, frustration, and boredom often serve as triggers for this behavior. To elaborate, pulling one’s hair can serve as way to reduce stress or frustration (i.e., as a coping mechanism), or to end boredom. When the problem first started in eighth grade, Teri had a short “boyish” haircut and would “fiddle” with it in the back (particularly when feeling anxious or bored) until finding an unusual hair, as described earlier. Her hair-pulling continued into high school and college, despite her participation in psychological treatment. Teri’s first therapy experience occurred “early in high school” with a therapist in her community, but was not sought to address hair-pulling specifically. Instead, Teri stated that she had been referred by her parents for concerns about “moodiness and hanging out with the wrong crowd.” At that time, Teri was reportedly uncomfortable addressing her hair-pulling and did not talk about it during sessions; as a result, she did not see any change in her pulling due to this treatment. Her second attempt at treatment involved working with a nurse practitioner at a local hospital. Here, Teri did address her hair-pulling specifically, but was told that “she would probably never be able to stop doing that.” She was treated with medication (Effexor) with the goal of indirectly reducing hair-pulling by treating anxiety. This also was not successful in reducing Teri’s hair-pulling, although she did continue taking Effexor because it reportedly helped with managing stress.

Frustrated by her lack of success with previous therapy and troubled by the increasingly prominent problem area on her scalp, Teri ultimately presented for the treatment which is the focus of this report during college. When she came to the training clinic, she had become particularly frustrated by her inability to understand or control her hair-pulling, as well as its effect on her physical appearance and social functioning.

5 Assessment

During her initial session, an informal semi-structured diagnostic interview revealed that Teri easily met the DSM criteria for TTM. She endorsed (a) recurrent episodes of hair-pulling that had resulted in noticeable hair loss (see Figure 1), (b) a prominent and unpleasant sense of tension before pulling her hair or when attempting to resist pulling, and (c) immense gratification upon actually pulling her hair. It was also determined that this behavior was not better attributable to another psychological or medical condition, and evidence for her distress and impairment was noted (see “Presenting Complaints” section).

Although she described earlier (and mild) problems with anxiety and depressive symptoms, she did not have any significant complaints about these symptoms at assessment and chose to focus our assessment (and her treatment) on TTM alone. Our semi-structured interview also revealed that Teri was a high functioning individual (i.e., full-time student with good grades, part-time employee, strong social support system) and did not exhibit any other symptoms indicative of psychopathology. Therefore, assessment was geared primarily at understanding the nature and severity of Teri’s hair-pulling behavior to inform the development of goals. Specifically, this involved (a) documenting photographically the problem area on her scalp, (b) extensive self-monitoring of hair-pulling frequency and severity (with therapist creating a graph for assessment over time), and (c) completion of the Milwaukee Inventory for Styles of Trichotillomania–Adult Report (MIST-A; Flessner, Woods, Franklin, Cashin, & Keuthen, 2007).

As seen in Figure 1, Teri’s initial photograph revealed a significant problem area in the back of her scalp, due to pulling her hair with moderate frequency. In addition to her photograph, we placed an emphasis on self-monitoring as part our initial and ongoing assessment with Teri, as recommended by the Keuthen et al. (2001) manual guiding our treatment. The initial self-monitoring logs asked Teri to report (for each occurrence of pulling) the date/time/physical setting (as antecedents or “triggers”), how much time was spent pulling hair during the given episode, and the perceived consequences of pulling (e.g., sense of relief). Her first weekly log indicated that she spent 4 hr pulling in total; her second weekly log indicated approximately 2 hr over that week. However, after this second log, we revised her monitoring instructions to reflect how many hairs were pulled exactly during an episode instead of time spent pulling, for three reasons. First, Teri sometimes did not have easy access to a time-keeping device (as she did not always wear a watch or have her phone in reach), thus making it inconvenient to collect a recording. Second, and relatedly, counting an exact number of hairs pulled made for a more objective assessment of this behavior, as opposed to an “estimate” of time spent. Third, the exact number of hairs pulled in a given time frame (e.g., 2 min) would vary across episodes for Teri. If, for instance, Teri pulled many hairs in a short amount of time, a recording of time spent only may not have accurately reflected the “damage done” by pulling. Once Teri transitioned to counting the specific number of hairs pulled, she indicated that anywhere between 30 and 100 hairs were being pulled in the course of a week. Figure 2 depicts a graph of hairs pulled over time.

OPEN IN VIEWER

Figure 2.

Graph depicting number of hairs pulled over time via client self-monitoring logs.

In addition to the frequency and severity of pulling, Teri’s logs described the common antecedents (or “triggers”) for her. As is true of many clients with TTM, some of Teri’s triggers were emotional, whereas others were situational. The two most common emotional triggers for Teri included feeling anxious/stressed or feeling bored. Situationally, being alone (i.e., not in public), doing homework, or just having lied down for bed were common antecedents.

The MIST (Flessner et al., 2007) is a 15-item self-report survey that assesses the extent to which one’s hair-pulling is focused versus automatic. Focused refers to hair-pulling that is intentional and of which the client is aware; this pulling usually occurs in response to negative emotions as a coping mechanism. Automatic pulling, however, occurs outside the person’s awareness, typically during sedentary activities. Each item is rated 0 to 9; 0 means “this is never true of my hair-pulling,” whereas 9 means “this is always true of my hair-pulling.” The average item score is computed for each scale and thus can range from 0 to 9. This measure was chosen not only as a way to help Teri develop insight about her pattern of pulling (something she desired), but also because it could potentially inform the selection of techniques for therapy. Teri’s scores once again indicated a moderate level of severity (average = 4/9 for focused pulling; 6.1/9 for automatic) and also reflected that (more often than not) her hair-pulling occurred outside of her awareness. This was useful information, as it indicated that developing awareness of her urges and behaviors would likely be beneficial for Teri.

In summary, assessment revealed that Teri met the DSM criteria for TTM exclusively, with moderate severity. In addition, her episodes of hair-pulling occurred both within her awareness (at times, in response to stress), but even more frequently, outside of her awareness. Therefore, two treatment goals were developed collaboratively: (a) reduce the number of hairs pulled over time, and (b) increase the use of stress reduction techniques on a regular basis (given that anxiety and stress often served as triggers for pulling).

6 Case Conceptualization

Teri’s case of longstanding TTM was conceptualized using a cognitive-behavioral framework. Because her treatment began with behavioral strategies and then progressed to include cognitive elements, as recommended by the Keuthen et al. (2001) manual, we follow that same outline here and first address behavioral, then cognitive, factors.

Within a behavioral framework, Teri’s hair-pulling was conceptualized as a result of classical and operant conditioning over time. Mansueto et al. (1997) presented a comprehensive behavioral model of TTM (ComB) suggesting that classical conditioning plays an important role in understanding hair-pulling. In particular, ComB asserts that certain environmental settings and physical cues can serve as a trigger for urges to pull. Indeed, Teri’s hair-pulling (and in particular, her automatic episodes of such) were likely classically conditioned as this model suggests. Recall that automatic refers to pulling that is not purposeful and typically occurs outside the person’s awareness. This would explain why Teri’s behavior surfaced more readily in some situational contexts versus others. Classical conditioning occurs when a person responds to an initially neutral stimulus with a target response because the neutral stimulus has been paired with an unconditioned stimulus over time. This admittedly complex definition can be illustrated more easily using Teri’s case. Initially, the urge to pull hair is an unconditioned stimulus, and the pulling of her hair is an unconditioned response. This is a naturally occurring relationship for Teri that unfolded over years; she feels an urge (unconditioned stimulus), so she pulls hair (unconditioned response). Over time, however, Teri exhibited a pattern where her urges arose in some contexts more than others (for examples, when doing homework or lying in her bed at bedtime). The repeated pairing of her urges with being in those specific contexts served to make each of those contexts a potential trigger for pulling. The situation of lying down for bed provides a good example for elaboration. Like anyone else, on a nightly basis, Teri found herself in the situation of lying down in bed trying to fall asleep (the initially neutral stimulus). This experience was paired with the urge to pull (the unconditioned stimulus), which of course led to pulling (the unconditioned response). This repeated pairing of bedtime and urges causes bedtime itself to become a conditioned stimulus for pulling. Thus, bedtime becomes a “high-risk” situation, or potential trigger for the pulling behavior. In certain contexts, the urge to pull never arose; therefore, those specific contexts did not become potential triggers. One good example, to illustrate, would be the context of socializing with friends. The urge to pull did not surface in this context, likely because Teri was more engaged (i.e., not bored) with friends, and/or because of the embarrassment that would have been associated with pulling publicly. In essence, classical conditioning explains why the urge to pull was triggered by some environmental contexts, but not others.

Using an operant conditioning lens, Teri’s behavior resulted from a longstanding history of negative and positive reinforcement. Negative reinforcement occurs when a target behavior (i.e., hair-pulling) is followed by the removal of something unpleasant (thus strengthening that behavior); positive reinforcement occurs when a target behavior results in a pleasurable consequence (thus also strengthening the behavior). Although initially triggered by boredom, anxiety, or fascination with unusual hairs, Teri’s episodes quickly escalated to a point of overwhelming urges and impulses. These urges would become quite strong, felt nearly impossible to refuse, and were associated with significant tension and anxiety. Once hair-pulling began, this sense of tension abated quickly and significantly, thus negatively reinforcing her pulling behavior. Moreover, she described feeling a pleasurable relief akin to a “high” after pulling, a desirable feeling that served to positively reinforce her behavior. This combined influence of dissipating tension and immense pleasure/relief, especially over the course of many years, undoubtedly served to strengthen Teri’s hair-pulling over time.

As outlined, behavioral processes have clearly played a role in the development of Teri’s hair-pulling. Thus, the Keuthen et al. (2001) emphasis on behavioral strategies for TTM makes for a good fit with this conceptualization. Drawing from the perspective of classical conditioning, HRT was chosen as a strategy; as described earlier, HRT involves not only awareness training, but also identification of CRs for use in situations involving the problem behavior. In an operant sense, also as recommended by Keuthen et al. (2001), it was decided that implementing a punishment contingency could be useful to counter the reinforcing effects of pulling.

The behavioral factors noted above are important in understanding Teri’s pulling. Nevertheless, those factors do not address the potential cognitive elements of the problem, as would be suggested by a CBT framework. Indeed, Teri openly addressed how she would sometimes “obsess” over whether or not to pull during her urges. More specifically, she described ambivalence during these episodes, simultaneously weighing the value of pulling (to obtain relief) with the value of refraining from pulling (to maintain her appearance). This insight from Teri suggested that her thought processes likely played an important role in her pulling. It is possible that Teri was entertaining thoughts that allowed for, or perhaps rationalized, her behavior in these instances. Therefore, cognitive therapy techniques (in particular, thought monitoring and restructuring) were also incorporated into treatment. To help Teri develop mastery over time, we started with behavioral techniques alone (as recommended by Keuthen et al., 2001), and eventually added in the cognitive elements. As described in the next section, the cognitive elements in particular proved to be invaluable additions in helping Teri to overcome TTM.

7 Course of Treatment and Assessment of Progress

The behavioral components of therapy were started very early on (i.e., by Session 2). We began with general strategies for anxiety reduction, given that (a) this is suggested by the Keuthen et al. (2001) manual and (b) Teri’s goals incorporated anxiety and stress reduction (as they served as triggers for pulling). More specifically, Teri was instructed on and practiced deep breathing, as well as the standard procedure for Jacobsonian Progressive Muscle Relaxation (PMR; see Ameli, 2014). Teri understood and implemented these techniques very well; therefore, we use the remainder of this section to discuss her primary goal of decreasing hair-pulling.

The standard four steps in HRT were implemented initially for Teri’s hair-pulling. First, she was instructed on and engaged in awareness training. For approximately 1 month, Teri carefully monitored occurrences of hair-pulling and logged the details of those episodes. These logs expanded over time, but initially included the date and time, antecedents to pulling (what was happening internally or externally right before the pulling), specific details of the motor sequence involved in pulling from start to finish, and immediate consequences of pulling. As stated previously, Teri initially reported on the amount of time an episode lasted, but later shifted to exact number of hairs pulled. A significant component of this training and monitoring was the piece related to her motor sequence of pulling, as this is emphasized heavily in the Keuthen et al. (2001) manual. As noted in their approach, hair-pulling is a complex sequence of motor behavior that can be broken down into component parts. This is consistent with initial conceptualizations of HRT proposed by Azrin and Nunn (1973), suggesting that problematic habits develop as response chains (or behaviors that occur in a predictable sequence with one another). Because the MIST revealed that Teri’s pulling was more often automatic, a focus on understanding her specific sequence of behaviors was essential. Teri did a very nice job of describing, in detail, what comprised her motor sequences. For example, Teri reported that one of her sequences progressed as follows (personal communication):

I was working on review questions for homework. As the time got to be close to 8:30, I kept glancing at the clock and getting slower with my work. As I was getting bored with the questions, my right hand pushed some loose hairs behind my right ear. Then I had a strong urge to put my hand up to my head again. It was almost like I could imagine feeling my hair. I checked my phone, but then my left elbow went on my desk and my left hand supported my head. My thumb and index finger began feeling around my scalp and “looking” for the short ones. I found a few, pulled them out, and then felt like I couldn’t stop doing it. I kept doing it with both hands. After 42 hairs, I felt “worn out” and stopped.

Discussion of Teri’s logs also corroborated the findings from assessment that automatic pulling was a particular problem for her. Teri noted that it was easy to complete her log after an episode that she directly observed. However, there would also be circumstances in which she did not even know that pulling had occurred, and thus had trouble logging the incident appropriately. This lent increased support to the importance of awareness training, and in particular, paying attention to triggers for hair-pulling (which became a focus).

It should also be noted that these self-monitoring logs also formed a substantial basis for ongoing assessment. By noting weekly how many hairs had been pulled, Teri and her therapist were able to document with clarity whether therapy was effective. The weekly results of her logs were graphed over time (see Figure 2).

Finally, awareness training is also the period during which we introduced a punishment contingency for pulling. Although not a standard component of HRT, the Keuthen et al. (2001) manual addresses the use of punishment strategies, and we felt this would be a creative way to counter the effects of negative and positive reinforcement after pulling. We first examined what Teri had been doing with her hair after an episode. She noted that, most commonly, she would absently drop the hairs on the floor as she pulled. Sometimes she would pick them up to throw away; at other times, they were left for later vacuuming. Therefore, Teri was instructed to collect, clump together, and count all hairs that were pulled during each episode after the episode ended. She was asked to look closely, for a few minutes, at the clump of hairs pulled and then count them, one by one, vividly imaging the growing size of her unappealing problem area. She then recorded this number on the log and considered how much “damage” had been done. Our hope was that the unpleasant experiences of confronting her hair loss more directly, counting single hairs individually, and imagining the growing size of her problem area might diminish (or even negate) the reinforcing effects of pulling.

Step 2 of HRT involved identifying and implementing CRs. In essence, a CR is one that is physically incompatible with (or “opposite to”) the problem behavior. According to Azrin and Nunn (1973), a CR should also be capable of being maintained for several minutes, involve tensing of muscles pertinent to the target behavior, and be socially inconspicuous. For example, when feeling the urge to pull while reading, Teri could hold tightly onto both sides of the book, as this meets all of those criteria. When sitting but not reading, Teri could grab onto both sides of the chair with her hands. Playing a hand-held video game and repeatedly squeezing/releasing stress balls in both hands were other options generated. Throughout this process, Teri was educated on a major rationale for CRs: that urges can diminish in intensity when they are delayed due to neuronal and biochemical changes in the brain. The longer the delay, and the more this is practiced, the weaker the urges become. This rationale helped Teri to practice her CRs in and outside of session; additionally, her self-monitoring log was expanded to include recording the use of these strategies in the face of her urges. Teri started using CRs for an easy, manageable amount of time (2 min at first), and then increased this amount of time (to 3 min, then 4, etc.) across sessions.

Step 3 of HRT concerns habit control motivation, or ensuring that the client is sufficiently motivated to use the skills learned. A few weeks after beginning the process of HRT, Teri experienced a slight setback. She discontinued her medication, Effexor, in consultation with her nurse practitioner. Thus, she experienced elevated levels of stress and a corresponding increase in hair-pulling. Although frustrating for her, this temporary relapse presented the perfect opportunity to introduce Step 3. One entire session was dedicated to a discussion of why Teri had initially sought treatment, as well as the various sources of distress and dysfunction associated with her pulling. The Keuthen et al. (2001) manual provides helpful guidelines for facilitating discussions of this nature. Teri engaged well and identified several keys reasons to continue working hard in therapy. Among others, these included significant embarrassment about her appearance and consequent unwillingness to see a stylist, inability to engage in fun activities like swimming or going to the lake, and her own strong desire to control a behavior that had plagued her for years. We typed this list, and Teri agreed to keep it in her purse and post a copy in her room for continued motivation.

Step 4 consisted of generalization practice for Teri. Our goal was to ensure that she would continue using the skills learned well after the termination of therapy. One significant element of this concerns stimulus control procedures. Stimulus control refers to identifying and altering stimuli in the environment that could have an effect on hair-pulling. For example, if seeing a mirror is a trigger for pulling, one might suggest removal of mirrors to the extent possible. In their manual, Keuthen et al. (2001) provide a helpful rationale for clients and suggest several useful methods of stimulus control. This was particularly helpful in addressing episodes of automatic pulling for Teri. One interesting method of stimulus control developed, drawing upon Step 2, was the creation of a “Competing Response Kit” for Teri. This kit contained a variety of CR-related materials (such as her hand-held video game and stress balls). Teri kept this kit with her at all times. In “high-risk” situations (i.e., studying alone, lying in bed at night), the kit was placed in an obvious and visible manner (for example, on the table right in front of her) as a reminder to use CRs. Teri had also reported that looking in mirrors for prolonged periods of time could lead to pulling; therefore, superfluous mirrors in her dorm room and parents’ home were removed. Those that stayed were modified with small sticky notes that contained motivational phrases or reminders of CRs.

Teri also developed creative ways to modify her hands in situations that presented a high risk of pulling. This included putting Band-Aids on her fingers or gloves on her hands, both of which made her more aware of what she was doing with her fingers and made pulling more difficult. She also sometimes put lotion on her hands in these situations; she was reluctant to make her hair “greasy” by touching it with lotion on, and lotion also presented a challenge to pulling effectively. All of these materials were kept in her Competing Response Kit.

In addition to stimulus control, Step 4 addressed reinforcement contingencies that could be provided outside of therapy. Although the therapist was attentive to reinforcing Teri for completing her logs and practicing CRs, our goal was to ensure that reinforcement would be provided in other settings to promote generalization. Teri’s mother and boyfriend agreed to monitor the use of her strategies on a regular basis and reinforce accordingly. For example, her mother attended one session and agreed to provide friendly reminders about CRs, as well as to take Teri shopping for a small gift when she demonstrated progress toward her goal.

The behavioral strategies described thus far worked well in decreasing Teri’s hair-pulling. As can be seen in Figure 2, her pulling decreased from an initial 42 hairs (Week 1) down to 13 hairs (Week 10), or a 72% decrease, across the course of behavior therapy. However, behavioral techniques are only a piece of the puzzle in CBT, and Teri remained committed to decreasing her pulling further or eliminating it altogether.

Therefore, as recommended in our treatment manual (Keuthen et al., 2001), we decided to introduce cognitive therapy strategies on top of the behavioral techniques that Teri had mastered. Teri was educated on cognitive therapy and, in particular, the concepts of thought monitoring and thought restructuring were emphasized. Thought monitoring refers to the process of paying attention to and recording one’s own thoughts (Wright & Beck, 1996). For example, during an urge to pull, Teri would be encouraged to consider her thoughts as they went through her mind, and then write them down. Clients are often instructed that thoughts can be verbal (i.e., words) or visual (i.e., pictures); they are also reminded that thought monitoring can be challenging and takes practice. Indeed, Teri’s self-monitoring logs were modified to include what specific thoughts were going through her mind during her urges and episodes of pulling. Our goal was to analyze whether any particular patterns would emerge over time, as this can pave the way for cognitive restructuring. Cognitive restructuring is the practice of responding to and/or changing the content of one’s thoughts (Wright & Beck, 1996). For example, if Teri had a verbal thought such as “I really want to pull my hair right now,” a restructured response to that thought could be “But that doesn’t mean that I have to, and I want to control this behavior.” Not surprisingly, the literature has suggested that certain patterns of problematic thoughts can be associated with hair-pulling. For example, Gluhoski (1995) suggested that hair pullers are susceptible to thoughts that emphasize the value of hair-pulling (e.g., “You will feel so relieved if you just give in”), that give permission to pull (e.g., “I’ll let myself do it this one time”), or that are related to negative emotions in stressful situations (e.g., “Pulling my hair would help me cope with this anxiety.”)

Not surprisingly, Teri and the therapist uncovered an important pattern after only 2 weeks of thought monitoring: Teri was consistently giving herself permission to pull in her thinking during urges. For example, she would have thoughts that “The urge is just too strong to handle this time; I guess I will give in,” or “I’ll let myself pull just one hair and then stop.” Teri expressed that she “had never considered what a strong role” her thinking would play and eagerly agreed to practice and document her cognitive restructuring. Therapy discussions included potential responses to her permission-giving beliefs, for example, “Even though this urge is strong, I can overcome it by delaying pulling,” or “Even pulling just one hair is counter to my goals . . . and I also likely won’t be able to stop after one.” Teri’s efforts to monitor and restructure her permission-giving thoughts were handsomely rewarded; as seen in Figure 2, she was able to completely eliminate her pulling between Week 10 (when cognitive therapy was introduced) and Week 16. After ensuring that this trend continued, the focus of therapy discussions turned to relapse prevention and termination.

8 Complicating Factors

Teri’s treatment was associated with minimal complicating factors. She lived on campus where the clinic was located and had insurance that helped to cover the cost. Although she had school breaks over holidays and summer, her home was within a short driving distance to campus and appointments could be maintained.

Nevertheless, we did experience one complication during therapy that caused a “setback” for Teri. As noted earlier, Teri had been taking Effexor (150 mg daily) when she began treatment. This had been prescribed by a nurse practitioner to lower her anxiety and lessen her hair-pulling, albeit with limited success for this latter goal. Indeed, transitioning from the use of medication management to therapeutic strategies was one self-reported reason for Teri seeking therapy. At the time she turned in her third log, however, Teri disclosed that she had stopped taking her Effexor. She had previously disclosed plans to taper off the medication, but had not discussed the specific timing of stopping altogether; thus, this was new information for the therapist. This discontinuation of meds reportedly led to a host of problems related to anxiety and increased hair-pulling. Teri reported that the prior week had been “one of her most stressful ever” and her logs indicated that she pulled nearly double the amount of hair than she had previously. As a good example, she recounted a specific episode in which her computer was working slowly, so she began feeling very frustrated, crying excessively, and “pulling out lots of hair.”

To her credit, Teri was able to reflect on this setback with admirable insight. She appeared to understand the significant role that Effexor had played in anxiety management but stated that, despite a rough week, she wanted to continue without medication and use therapy techniques as much as possible to overcome this hurdle. Thus, our discussions focused on increased recognition of triggers, importance of stimulus control and CRs, and a heavy emphasis on anxiety reduction strategies. This was also the time during which we focused on Step 3 of HRT (outlined earlier), which involved revisiting motivation for self-control. Teri responded well to all of this. It appeared that she worked very hard to re-establish control of her emotions and pulling behavior in the following weeks and did so successfully. As can be seen in Figure 2, her hair-pulling decreased again shortly after the occurrence of this setback. Much to her credit, Teri was able to stay off this medication in the long-term, in accordance with her goals.

9 Access and Barriers to Care

Teri’s treatment was relatively uncomplicated by barriers. As stated previously, she lived on campus where the clinic was located and was able to drive the short distance to campus when at home (e.g., over summer break). She also had insurance and was able to pay her portion of the cost with relative ease. Thus, in this particular case, treatment was provided with little interference from outside factors.

To be clear, it should be noted that access to care may not always come as easily. In other treatment settings, such as community mental health centers, there may be barriers to consider that were not present in Teri’s case. First, transportation can become an issue for clients who are not living in an environment (e.g., on campus) where their appointments take place. Inability to attend sessions can obviously hinder progress; therefore, we recommend that clinicians work to help ensure that clients plan accordingly for any logistical barriers that may affect attendance.

Further, Teri’s use of insurance was relatively uncomplicated, but managed health care can come with limitations, such as number of sessions that are covered, or even professionals from whom treatment may be sought (e.g., a licensed provider may be required rather than allowing for a graduate student therapist). We would suggest that in instances of using insurance or other managed health care, the specific number of sessions covered (as well as provider and other requirements) be identified at the start of treatment. In this way, to the extent that the client relies on such a financial arrangement, the various steps in therapy and termination can be planned accordingly.

Finally, attending a training clinic meant that Teri would be treated by a graduate student who is learning about best available practices (and drawing upon a supervisor’s knowledge). Although likely rare, in some non-academic treatment settings, there may be less emphasis on evidence-based treatments such as CBT. We would recommend that, for complex problems such as TTM, clients take an active role in seeking practitioners who have knowledge and experience with evidence-based therapies.

10 Follow-Up

Follow-up with Teri occurred on two levels. First, we decided to significantly taper her sessions working up to termination. More specifically, we met bi-weekly for two sessions, and then held three sessions on a monthly basis. At each of those tapered sessions, Teri reported on her continued use of behavioral strategies, whether any pulling had occurred (and how much), and her overall levels of anxiety. Teri voiced excellent progress; not only had her pulling discontinued completely over time (see Figures 1 and 2 for evidence), she also reported successful management of her anxiety overall. Notably, this occurred without medication management, which was consistent with her goals for therapy.

In addition to those five spaced sessions, Teri was also recently contacted for two reasons: (a) to seek her permission to publish this case study, and (b) given her consent, to assess whether therapy gains had been maintained in the long-term (over 5 years after termination). Teri enthusiastically reported that she had maintained impressive gains over the 5 years since termination. She indicated that there had been only one “rough patch” that resulted in pulling more than one hair. This period occurred after a stressful return to college following a summer break, but Teri reported that she was able to suppress the pulling almost immediately after it began by drawing on what she had learned in therapy. Other than this, she stated that “a single hair will occasionally brush across her face” or otherwise feel strange and be pulled; however, this rare occurrence involves a single hair and has not resulted in any obvious hair loss.

Given her impressive level of insight, Teri was asked to speculate as to why her therapy gains had been maintained so strongly. She first indicated that the continued use of therapy strategies was an obvious factor. More specifically, she has reportedly continued to use stimulus control and CRs in successful ways. Second, and importantly, Teri indicated that it is not necessary to use these strategies frequently because her urges seem to have abated almost completely. That is, she no longer feels compelled to pull her hair, even in situations that would have previously elicited that behavior (e.g., feeling anxious/bored, bedtime).

Teri indicated a high level of satisfaction with her treatment and reported that she is presently very happy with her hair and overall appearance. As a final element of our follow-up, because she presented as so insightful, Teri was asked to reflect on what she had found to be the most helpful elements of therapy. She made a point of discussing the awareness training that we had so significantly emphasized early on. She indicated that it would be hard to imagine overcoming her compulsions without gaining a solid understanding of when, where, and how her hair-pulling was exhibited, including the role of thought processes. This feedback, we feel, helps to substantiate the importance of awareness training in cases like this.

11 Treatment Implications of the Case

The successful treatment of Teri’s TTM leads to a number of possible implications. First, and foremost, this case study corroborates findings from other published studies that CBT can be an effective treatment for clients with TTM. In this particular case, the manual published by Keuthen et al. (2001) was an invaluable resource for implementing the various steps of CBT. More specifically, we found that an early focus on HRT was very useful. We would note that, in this particular case, a punishment contingency was also introduced during Step 1 of HRT to counteract the reinforcing effects of pulling, and this appears to have been effective as well. Therefore, as an initial treatment implication, behavior therapy alone (HRT with reinforcement and punishment contingencies) appears to be effective in decreasing hair-pulling behavior.

Second, and importantly, we also found the cognitive element of treatment to be especially valuable. By carefully examining the role of cognition, we discovered that permission-giving thoughts had an obvious influence on Teri’s pulling. By monitoring and restructuring these thoughts as they occurred, Teri was able to expand upon the gains from using behavioral strategies and eliminate her hair-pulling completely. Overall, it appears that CBT (especially as laid out in the manual by Keuthen et al., 2001) is a promising avenue for helping clients with TTM.

Although the outcome of this case lends support to the CBT model for TTM, we would also emphasize that there are limitations to case studies designed in this manner. Our particular design (the “AB” or “baseline/intervention” design) allowed us to demonstrate that Teri pulled significantly less hair over time. However, it is limited in that it cannot delineate that Teri’s progress was caused by our intervention alone. Other factors (such as the passage of time, or decreased environmental stressors) can account for treatment effects when this type of design is used, limiting inferences about specific causes and effects. Although this case study suggests promising effects of CBT for TTM, a truly experimental design (such as a randomized control trial with a large, diverse sample) would help to discern cause and effect related to treatment more stringently.

12 Recommendations to Clinicians and Students

The treatment implications noted above represent an obvious starting point for our recommendations; more specifically, we strongly encourage practitioners to consider CBT in the context of treating TTM. The procedures described here addressed a case of the disorder spanning over 5 years, with previous (and unsuccessful) attempts at both psychological treatment and medication management. Once a regimen of CBT was implemented, much to her satisfaction, the client was able to cease her hair-pulling completely.

Outside the obvious recommendation for CBT, we also offer other advice that may be pertinent to similar cases. First, during Teri’s follow-up, she noted that her high degree of rapport with her therapist was one factor that helped her to succeed. Although personal or relational variables have not traditionally been emphasized in behavior therapy, Teri stated that she found her rapport with her therapist to be a highly motivating factor. Therefore, although it may be tempting to overlook relational variables in a highly systematized procedure like HRT, it appears this would not be helpful.

Second, as done with Teri, we encourage practitioners to carefully assess the specific pattern of hair-pulling that occurs for a given client. Understanding whether hair-pulling is focused (i.e., purposeful, as a coping mechanism) or automatic (i.e., occurring outside the client’s awareness) with an instrument such as the MIST may be an essential component of effectively devising a treatment strategy. In Teri’s case, pulling was largely automatic; this suggested that awareness training was of the utmost importance. We suggest that awareness training is an important step regardless, but even more essential (and perhaps requiring more attention) with a pattern of automatic hair-pulling.

Third, we suggest that creativity is essential to effectively implementing CRs. The use of CRs is a central component of HRT. Indeed, it reflects the basic premise of exposure and response prevention: confronting one’s urges, but delaying (and ultimately refusing) the compulsive response. In the case of TTM, finding a competing (but inconspicuous) use of both hands during urges can be challenging, but hardly impossible. We suggest that client ideas, therapist ideas, and suggestions from established treatment manuals (such as Keuthen et al., 2001, or Franklin & Tolin, 2007) all form the basis of possible CRs. Ideas can be practiced and revised according to their utility, but ultimately finding CRs that a client is willing and able to use is an essential ingredient to success. Moreover, making the CRs visible and convenient (especially in the case of automatic pulling, as outlined for Teri) is likely to facilitate improvement. Finally, as done with Teri, we suggest facilitating mastery of CRs by gently increasing the demand for use over time. To review, Teri was initially instructed to use CRs for 2 min, then 3, then 4 (and so on), and this appeared useful as a way to improve her mastery of the skill.

Fourth, we recommend that clinicians allow for flexibility when dealing with the cognitive aspect of TTM treatment. There are indeed a number of themes that clients with this disorder manifest as far as thought processes are concerned. As described earlier, Gluhoski (1995) suggests that common themes include the value of hair-pulling, permission-giving beliefs, and automatic thoughts about a situation that causes negative emotions. For obvious reasons, accurate identification of one of these themes (such as permission-giving for Teri) is likely to facilitate success. However, we suggest that not all clients might demonstrate a classical case involving one of these themes. In such situations, it would be recommended to not abandon the cognitive approach, but instead to think flexibly about the nature of the underlying thoughts. Perhaps some clients demonstrate multiple themes, each of which needs to be targeted. Perhaps others demonstrate thoughts that fall outside these themes altogether. For example, it is entirely possible that a person might demonstrate cognitive distortions related to self-esteem (e.g., “I am not capable of overcoming this problem”) that equate to self-handicapping during treatment (see Yavuzer, 2015). We suggest that careful and consistent thought monitoring (using a log that is modified for this purpose), perhaps over an extended period of time, is the best way to discern the pattern or theme that will be the ultimate target of restructuring for a given client.

Fifth, and finally, we encourage practitioners to consider available additions to therapy above and beyond CBT. CBT appears to be effective for a wide range of disorders, including TTM; nevertheless, it may not work for every client seeking treatment. We recommend consideration of CBT in cases like this, but also acknowledge that other approaches exist. For instance, recent attention has been paid to the potential success of Acceptance and Commitment Therapy (ACT) in treating TTM (see Crosby, Dehlin, Mitchell, & Twohig, 2012). To the extent that a client’s values and preferences are consistent with the ACT model, this framework may also contribute to success, particularly if CBT does not fully meet the goals for treatment.

In summary, there is evidence (from this case study and other published reports) that CBT provides a first-line option for treating TTM. By adhering to the principles of HRT and cognitive restructuring, yet remaining creative and flexible in how the various steps are implemented, a combined cognitive and behavioral approach is likely to help clients who are seeking to decrease or eliminate their hair-pulling behavior.