Amanda Jill Endler DiBart

Abnormal Psychology

Vassar College

May 9, 2002

The DSM-IV (American Psychiatric Association [APA], 1994) identifies trichotillomania as an impulse-control disorder not elsewhere classified. The diagnostic criteria include recurrent pulling out of one's hair resulting in noticeable hair loss, an increasing sense of tension immediately before the behavior or when attempting to resist the urge and a sense of pleasure or relief when engaging in the behavior (APA 1994). The lifetime prevalence is between 1 and 2% (Lerner, Franklin, Meadows, Hembree & Foa, 1998) by conservative estimates and as high as 3.4% by other estimates (Mansueto, Stemberger, Thomas & Golomb, 1997). The majority of those seeking treatment are women (Mansueto et al., 1997). One possible explanation for why more women present with trichotillomania is men can more easily explain hair loss with male pattern baldness. The impacts of the behavior on the life of the patient are far-reaching. Patients may lose large amounts of time engaging in the behavior and then concealing the resulting bald spots (Lerner et al., 1998). They may experience guilt, shame and low self-esteem (Lerner et al., 1998). Patients may avoid activities in which the hair loss might become noticeable, such as swimming, and activities which may lead to direct physical contact, which in extreme cases may lead to social isolation (Lerner et al., 1998). Medical complications include skin irritation, infections and, in cases in which the patient engages in trichophagia, gastrointestinal problems (Lerner et al., 1998).

Although the term hair pulling indicates one behavior, the disorder is characterized by a series of behaviors that vary by person (Mansueto et al., 1997). The sites of the pulling include scalp, eyebrows, eyelashes, pubic hair, body hair and facial hair. While some patients pull exclusively from one area, others pull from a combination. Some people pull with only their right hands, some only with their left and others with both. Selecting the hair to pull usually involves a process. Some people pull a single hair at a time; others pull a whole clump. A pulling cycle might be pulling only a single hair or it might mean pulling hundreds. It might last a few seconds or several hours. Disposing of the hair also varies by person. Some people simply discard the hair, others rub the root along their lips and others eat part of the hair or the entire hair.

The current measure for symptom severity is the NIMH Trichotillomania Questionnaire, developed by Swedo (cited in Lerner et al., 1998). The questionnaire is derived from the Yale-Brown Obsessive-Compulsive Scale and the Leyton Obsessional Inventory (Lerner et al., 1998). It is a semi-structured interview comprised of two clinician-rated scales, the NIMH Trichotillomania Impairment Scale (NIMH-TIS), for which scores range from 1 - 10 and the NIMH Trichotillomania Severity Scale (NIMH-TSS), for which scores range from 0 - 25 (Lerner et al., 1998). The NIMH-TSS consists of five questions related to average time spent pulling, time spent the previous day, resistance to urges, resulting distress and daily interference (Lerner et al., 1998). On both scales a higher score indicates greater severity.

Some controversy exists around the classification of trichotillomania in the DSM-IV as an impulse control disorder. The controversy stems from the absence in many presenting cases of the increased tension before pulling or when attempting to resist pulling and an absence of the pleasure, gratification or relief after pulling (Mansueto et al., 1997). As a result, some researchers contend that trichotillomania would be better classified on the obsessive-compulsive spectrum (Lerner et al., 1998). Indeed, trichotillomania has the same repetitive behaviors that characterize obsessive compulsive disorder (OCD) but without the accompanying obsessions. The similarity to OCD impacts theories about the etiology of trichotillomania and the approach to treatment thereof.

The psychodynamic theory of trichotillomania is that it occurs due to disrupted psychosexual development resulting from passive fathers and cold, domineering, provocative mothers (Friman, Finney & Christophersen, 1984). The hair-pulling behavior symbolizes self-hatred, self-castration or replacement of a love object (Friman et al., 1984). No research exists to confirm these theories. According to the biological view, some patients report an itchlike sensation or a tingling on the site of the pulling, which is eased by the behavior and which patients report as driving the motor-pulling response (DiBart, 2001). The experience is similar to Tourette's disorder, in which somatosensory urges seem to drive motor tics; furthermore certain neurological similarities have been observed between these conditions (DiBart, 2001). Furthermore, in experiments with rats, increased grooming occurred in response to heating of the limbic structures, especially the hypothalamus and the septum and as an aftereffect of stimulation of the hypothalamus and the brainstem (Dunn, Green & Isaacson, 1979).

Making treatment of trichotillomania more difficult is that comorbidity of trichotillomania with affective and anxiety disorders appears to be the rule rather than the exception (DiBart, 2001). Due to the similarities between trichotillomania and OCD, the most common pharmaceutical treatments for trichotillomania are those also used to treat OCD. Case studies of patients usually find some success with unusual drug treatments or unusual combinations of drugs (DiBart, 2001). The few clinical trial and controlled, double-blind experiments that have been conducted usually target fluoxetine and for the most part fail to find significant improvement in hair pulling (DiBart, 2001). Furthermore, pharmaceutical treatments might not be the ideal option because of possible side effects and the likelihood of relapse once the medication is discontinued.

The behavioral perspective notes that many patients feel an impulse or urge before engaging in the pulling and that certain conditions make the pulling more likely (Mansueto et al., 1997). The cycle of pulling is therefore assumed to result from an association that has developed between the cue and the impulse through classical conditioning (Mansueto et al., 1997). Such cues can be external, which fall into two categories: settings and implements (Mansueto et al., 1997). Settings can be in the home, such as the bedroom, or outside the home, such as the classroom. The thoughts, feelings and activities associated with each place play a role in developing an association between place and pulling. Implements, such as tweezers and mirrors, probably initially served to facilitate pulling but over time developed into cues for the behavior (Mansueto et al., 1997). Internal cues divide into three types. Emotions, either positive or negative, such as stress or happiness, can serve as cue (Mansueto et al., 1997). Visual, tactile and physical sensations can also serve as triggers for pulling (Mansueto et al., 1997). For example the sight of a gray hair, the feeling of a coarse hair or the sensation of tingling, like that described above, can all serve as cues. For the minority of patients, thoughts or a sequence of thought can cue the urge to pull (Mansueto et al., 1997).

Other stimuli come to facilitate or inhibit pulling through operant conditioning (Mansueto et al., 1997). Likewise, these stimuli can be internal or external. The presence of implements used in the behavior can be an external facilitator. External inhibitors can include the presence of others or the absence of an implement. Three types of internal facilitators are urges or impulses, posture and cognition (Mansueto et al., 1997). The urges or impulses are discriminative stimuli for pulling. Postures in which one hand is near the site of pulling and activities that leave a hand free are facilitators of pulling. In individuals who are aware of the urge to pull, thoughts such as "I will just pull one" can act as disinhibitors. The sensation following the pulling of the hair usually serves as a reinforcing consequence (Mansueto et al., 1997). Various factors, such as someone entering the room or lack of additional appropriate hairs, can lead to the end of a pulling cycle (Mansueto et al., 1997).

In experiments focusing on Cognitive Behavioral Treatments (CBT), clinicians usually teach the different aspects of treatment at each session. Treatment effectiveness increases as the involvement of the therapist increases (Friman et al., 1984). For example, collecting hairs for the therapist is more effective than simply counting the number of hairs pulled. Another explanation for the increased effectiveness is that collecting hairs is more tangible than counting them.

Therapy usually includes a type of self-monitoring such as recording circumstances surrounding the urges and the pulling episodes and collecting the hair pulled (Lerner et al., 1998; Vitulano, King, Scahill & Cohen, 1992). The purpose of the self-monitoring is twofold. The recording and collecting creates a baseline measure by which we can track progress throughout the treatment. The self-monitoring is also part of the treatment because tracking the urges and the pulling makes the patient more aware and may act as an inhibitor as may the collection of the hairs because it is aversive to the patient. Because the self-monitoring is not only a measure of pulling severity but also part of the treatment, it cannot be the only measure of pulling severity in an experiment. Furthermore, the information regarding when and where the patient pulls is important for tailoring the therapy to suit the patient's needs. This tailoring occurs in the habit reversal training session of the therapy.

The clinician explains the rationale for habit reversal (Lerner et al., 1998), it is intended to interrupt pulling, prevent additional pulling and cultivate an opposing behavior incompatible with hair pulling (Vitulano et al., 1992). Patients are taught to engage in the opposing behavior at the first urge to pull or when they first notice themselves pulling and to practice the opposing behavior a certain number of times a day, whether they feel the urge to pull or not (Vitulano et al., 1992). The most common opposing behavior is making fists and holding them for several minutes (Lerner et al., 1998; Vitulano et al., 1992). However, this behavior does not seem to be an equivalent behavior to that of hair pulling. Clenching one's fists does not seem like a realistic replacement for the tactile and physical stimulation that pulling provides and the reinforcing sensation following pulling. While perhaps no other behavior can recreate the sensation following pulling, the opposing behavior should try to engage the same senses that pulling does.

In addition to habit reversal training patients are sometimes taught stimulus control and overcorrection. In stimulus control, patients decrease opportunities to pull by wearing gloves or bandages in high-risk situations, prohibiting behaviors that serve as a stimulus, such as looking into a well-lit mirror, and placing meaningful notes in locations that serve as cues, such as the bedroom (Lerner et al., 1998). Wearing gloves or bandages in a high-risk situation is a difficult task for the patient. If high-risk situations are in public, the patient might be fearful of the attention gloves or bandages might bring. Furthermore, the patient might not have the urge to pull when entering the high-risk situation and think, "This time I will not pull" and not put on the gloves or bandages. Once the pulling begins, the patient might find putting on the gloves or bandages too difficult. In overcorrection, the patient is taught to practice brushing or combing hair properly on a daily basis and after each episode if possible (Vitulano et al., 1992). However, this practice only makes sense for those who pull from their heads and for whom hair brushing is a stimulus for pulling.

At least one session is usually devoted to relaxation training. This training is designed to reduce stress and, based on the assumed association between stress and pulling, indirectly reduce pulling (Lerner et al., 1998). However, if the patient is already feeling overwhelmed due to stress, simply learning and practicing relaxation techniques is not sufficient to reduce stress. Another aspect of treatment is cognitive restructuring with guided self-dialogue in which the clinician helps the patient identify irrational and negative self-dialogues and replace it with adaptive and task-enhancing responses (Lerner et al., 1998). The new adaptive responses may not be effective unless they are valid and salient for the patient. Other therapies do not include this session and instead use an annoyance review in which the clinician and the patient list the reasons why the patient wants to stop the pulling behaviors (Vitulano et al., 1992). While definitely salient for the patients, the list alone does not lead to stopping the behavior and as such could decrease a feeling of self-efficacy.

Relapse prevention takes place towards the end of treatment. In this session the patient imagines encountering stressful situations and coping effectively (Lerner et al., 1998). The clinician and the patient also discuss the difference between a lapse and a relapse and what tools the patient now has to keep a lapse from developing into a relapse (Lerner et al., 1998). One technique for doing this is to ask the patient to recall how he or she effectively handled a lapse during active treatment (Lerner et al., 1998). If the patient cannot remember an example, this technique loses its power.

Most research on CBT for trichotillomania has been limited to uncontrolled case reports and small case studies. While recent research has included manualized CBT programs, assessment of symptoms by independent evaluators and long term follow-up, the methodology still prohibits drawing strong conclusions about the effectiveness of treatment. Current studies lack random assignment. The no-treatment control group is comprised of treatment refusers (Lerner et al., 1998) or a control group is lacking entirely (Vitulano et al., 1992). Studies also do not exclude candidates who are on medication, even if that medication is intended for the treatment of trichotillomania. They also do not prohibit participants from starting medication while in the study. Formal assessments of treatment integrity are not conducted.

Overview of Design & Statement of Hypothesis: The proposed research will test a newly designed and manualized CBT for trichotillomania. Not only will it test whether patients experience symptom improvement with this new version of CBT, but it will also test whether the CBT is more effective than treatment-as-usual and wait-list control. Furthermore, it will determine whether CBT is more effective in the long term than treatment-as-usual and no treatment by conducting a follow-up measure. In the study participants diagnosed with trichotillomania will be randomly assigned to one of three groups: the CBT group, the treatment-as-usual group, and the wait-list control group. For the purposes of this study, the treatment-as-usual will consist of supportive talk therapy because no one therapy has proven itself to be overwhelmingly more effective than the others in the treatment of trichotillomania have. Similarly, because pharmaceutical treatments have not been proven to be effective, no drug treatments will be included in the study. Both the CBT and the talk therapy groups will attend the same number of sessions for the same amount of time. The only difference between the groups is that the CBT group will receive the treatment described below whereas the talk therapy group will simply be encouraged to talk about whatever they want without giving an emphasis to the diagnosis of trichotillomania. The purpose of this group is to determine whether simply interacting in a supportive environment has any effect on pulling. The control group will undergo the same measurements as the two therapy groups but not receive any treatment. The purpose of this group is to determine whether spontaneous improvement occurs with time.

The hypotheses being tested state that the participants in the CBT group will show symptom improvement and that patients in the CBT group will show significantly more improvement than either the talk therapy group or the wait-list control group both immediately following treatment and at follow-up. Given how resistant to treatment trichotillomania has been in the past it seems unlikely that hair pulling would decrease without treatment or with a therapy that does not directly address the pulling behavior.

Methods: The subjects in this study will be 90 adults, aged 18 or above. The criteria for inclusion in the study are a diagnosis of trichotillomania according to the DSM-IV and a sufficiently high score on the NIMH Trichotillomania Questionnaire. Candidates taking pharmaceuticals for trichotillomania or any other psychopathology will be excluded from the study, as will candidates currently undergoing psychological treatment. Potential participants will need to agree to be placed randomly in one of the three groups. Participants will also need to agree not to commence any drug or psychological treatment during the course of the study. Given the high prevalence of trichotillomania presenting comorbid with another disorder, excluding participant on the basis of a concurrent diagnosis is unrealistic. However any additional diagnoses will be noted and their effect measured during the statistical analysis.

The independent variable is treatment. 30 participants will be placed into each of the three groups, CBT, talk therapy and wait-list. The CBT procedure will be manualized. However, in order to be effective the therapy must be tailored in certain ways to each patient. Any major deviations from the treatment protocol will be duly noted. The following is a session-by-session summary of the CBT.

Sessions 1 and 2: Self-monitoring. In the first session the clinician will present the rationale and the method of self-monitoring. Self-monitoring will include collecting all the hair pulled each week and keeping a journal. The patient will present both to the clinician at the beginning of each session. In the journal the patient will record for each urge or pulling cycle: the time, where the patient was, what was going on, what the patient was doing, the patient's emotional state, a rating of the severity of the urge on a scale of 1 to 4 with 4 meaning "strong urge, I could not resist it," 3 - "medium urge, I could have resisted but did not," 2 - "medium urge, I did resist it but it was difficult," and 1 - "weak urge, I resisted without difficulty." The patient will also record for each pulling cycle which hands were used, whether implements were used and, after the behavior ceased, what caused it to stop. If the urge did not result in pulling, the patient will record why. The clinician will present the patient with a monitoring sheet designed to track all the data. The patient will practice filling it out to become familiar with it. At the second session the clinician will review the first week's self-monitoring in detail with the patient. The clinician will point out any themes or consistencies in the pulling behavior. The therapist will review each week's self-monitoring at the beginning of each session but never in as much detail as the second session.

Session 3: Habit reversal training and stimulus control. Clinicians will present the rationale of both habit reversal training and stimulus control to the patient. The clinician will present the patient with options for opposing behavior that stimulate as much as possible the same senses as pulling does. Options include dolls with brushable hair, troll dolls, Koosh® balls and textured fabrics such as faux fur or velvet. The patient can select as many options as desirable and together with the clinician devise a strategy to make sure a hand toy is always nearby and accessible. Patients are instructed to engage in habit reversal procedures with competing responses at the first sign of an urge. Patients are also taught to put on gloves or bandages before entering high-risk situations. The patient and the clinician will review the high-risk situations as identified in the previous session. Similarly, if self-monitoring reveals that the patient only pulls with one hand, the patient may want to wear a glove or bandages on that hand only. The clinician and the patient will practice putting on the gloves or bandages before entering a high-risk situation even if the patient does not feel the urge at the time. If a high-risk situation is in a public setting and the patient is concerned about unwanted attention, the clinician and the patient will discuss how pulling in public is just as, if not more, conspicuous. If the patient uses an implement to pull, the clinician and the patient will discuss the possibility of the patient disposing of that implement.

Session 4: Coping techniques. In this session the clinician will present the hypothesized association between stress and pulling behaviors. The clinician and the patient will discuss whether pulling is an effective coping strategy. The clinician will present two effective coping techniques, relaxation and time management. The patient will be taught a relaxation technique and instructed to practice it everyday. To prevent the patient from feeling overwhelmed and thus more stressed, the clinician will discuss time management techniques with the patient. Together they will devise a schedule for the coming week in which relaxation practice is included.

Session 5: Annoyance review. Together with the clinician, the patient will write a list of reasons for wanting to stop pulling. The patient will practice reciting them while engaging in the habit reversal procedure to distract the patient from the urge to pull. The patient will create notes that either state the reasons or, to be less conspicuous, make meaningful references to the reasons to not pull. The patient will place the notes in high-risk areas.

Session 6: Guided self-dialogue. The clinician and the patient will discuss the patient's negative self-talk and self-deprecating thoughts the patient has stated in previous sessions. They will discuss the validity of these thoughts and list reasons why the thoughts are not valid. The patient will practice countering negative self-talk with why it is invalid while engaging in habit reversal. They will review the annoyances listed in the previous session. They will list why the patient deserves to stop pulling and the tools the patient has in order to accomplish that. The patient will practice overcoming an urge to pull by listing the reasons not to pull and the tools to do that while engaging in habit reversal.

Session 6: Relapse prevention. The clinician and the patient will discuss the difference between a lapse and a relapse. They will list ways of avoiding a lapse; these methods will include tools the patient has learned in therapy. Together they will plan a strategy for preventing a lapse from becoming a relapse. They will review the patient's journal and focus on ways in which the patient has successfully resisted urges and ways in which the patient successfully cut a pulling cycle short. They will discuss whether the patient wants to continue keeping the journal after treatment has ended. They will list procedures the patient can use if a lapse seems to be becoming a relapse, including calling the clinician.

The dependent measure in this study is severity of hair pulling as measured by the score on the NIMH Trichotillomania Questionnaire and inclusion under the DSM-IV diagnosis of trichotillomania. Severity is assessed during the intake interview, immediately following treatment and again two months later. The measures are always administered by a clinician who is blind to treatment condition, and scored for interjudge reliability.

References

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (Fourth Edition). Washington DC: Author.

DiBart, A. J. E. (2001). Pharmaceutical treatment for trichotillomania: A literature review. Unpublished manuscript. Vassar College.

Dunn, A. J., Green, E. J., & Isaacson, R. L. (1979). Intracerebral adrenocorticotropic hormone mediates novelty-induced grooming in the rat. Science, 203, 281 - 282.

Friman, P. C., Finney, J. W., & Christophersen, E. R. (1984). Behavioral treatment of trichotillomania: An evaluative review. Behavior Therapy, 15, 249 - 265.

Lerner, J., Franklin, M. E., Meadows, E. A., Hembree, E., & Foa, E. B. (1998). Effectiveness of a cognitive behavioral treatment program for trichotillomania: An uncontrolled evaluation. Behavior Therapy, 29, 157 - 171.

Mansueto, C. S., Stemberger, R. M. T., Thomas, A. M., & Golomb, R. G. (1997). Trichotillomania: A comprehensive behavioral model. Clinical Psychology Review, 17, 567 - 577.

Vitulano, L. A., King, R. A., Scahill, L., & Cohen, D. J. (1992). Behavioral treatment of children and adolescents with trichotillomania. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 139 - 146.