Trichotillomania, or hair-pulling disorder, is an understudied problem in children and adolescents, although it has received increasing attention in the last decade. This column provides a brief overview of what is known about the condition and its treatment in youth.
What is Trichotillomania (TTM)?
Trichotillomania (TTM) is a disorder in which affected individuals pull hair from one or more areas on their bodies, resulting in hair loss or thinning. The hair pulling typically is accompanied by considerable distress and, in many cases, impaired functioning. Pulling can occur anywhere on the body where there is hair, including the scalp, eyelashes, eyebrows, limbs, trunk, and pubic area. As such, the clinical presentation of TTM can vary considerably across individuals. Pulling can occur out of awareness or be triggered by a sense of tension. In the latter case, pulling often is focused on a single site and associated with an immediate sense of gratification or relief. The pulled hairs can be discarded, played with or, in some cases, chewed on or swallowed.
Understanding of the causes and underlying biology of TTM is relatively limited, although current theories suggest a neurobiological predisposition to pull as a self-soothing strategy (e.g., to cope with stress, anxiety, negative emotions, boredom). TTM is more common than typically thought, occurring in 0.6% to 3.4% of adults (Franklin et al., 2008), and it affects more females than males (Christenson, Pyle, & Mitchell, 1991). Child onset is typical with a mean onset age of 9 to 10 years.
How is TTM classified?
Along with skin picking and nail biting, TTM is classified as body-focused repetitive behavior (BFRB). Although considered an impulse control disorder in earlier versions of the DSM, TTM is classified under OCD and Related Disorders in the DSM-5. Although compulsive in nature, TTM primarily differs from OCD in that it is triggered by tension not an obsessive thought.
Evidence-Based Intervention Approaches
The treatment literature for pediatric TTM is just beginning to emerge, with only a few clinical trials to date. Although the literature does not yet support the efficacy of medications for hair pulling in youth, a small randomized controlled trial of Habit Reversal Training (HRT) provides initial support for the use of behavioral techniques in this age range (Franklin, Edson, Ledley, & Cahill, 2011). Notably, Behavior Therapy has also had demonstrated acute efficacy for TTM in adults (Ninan et al., 2000; Van Minnen et al., 2003), and expert consensus recommends this form of treatment for both children and adults (Flessner, Penzel, & Keuthen, 2010).
Behavior Therapy approaches include several techniques. The most central of these is Functional Analysis, or identification of the antecedents (precipitating behaviors, events, emotions, sensory experiences), behaviors (when, where and how does pulling occur?), and consequences (what does the youth get out of pulling?) associated with pulling. Other behavioral techniques include Habit Reversal Training (HRT) which consists of developing an awareness of sensations preceding and during pulling behavior through self-monitoring and related techniques and the use of competing responses or compensatory behaviors that are incongruous to pulling. Stimulus Control which focuses on reducing environmental or other circumstances that trigger pulling is often included as well. Relaxation and other anxiety-management strategies, cognitive restructuring of thoughts related to pulling and self-soothing, and strategies to enhance motivation for treatment compliance may also be utilized as part of a behavioral approach.
Acceptance and Commitment Therapy (Fine et al., 2012; Woods & Twohig, 2008) and Dialectical Behavior Therapy (Welch & Kim, 2012) have both demonstrated preliminary, yet promising, support as augmentation strategies for the behavioral treatment of TTM in adolescents.
Resources for Clinicians and Families
The Trichotillomania Learning Center (TLC; www.trich.org) is a national non-profit organization providing support and resources to individuals and families with TTM. TLC also provides resources and training in evidence-based treatments to clinicians and holds an annual conference each spring for individuals, families, clinicians and researchers. The next TLC Annual Conference on Hair Pulling & Skin Picking Disorders is April 25-27 in Los Angeles.