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Behavioral and Pharmacological Treatment
of Trichotillomania
Ruth M. T. Stemberger, PhD
Dan J. Stein, MD, PhD
Charles S. Mansueto, PhD
Hair pulling, known as trichotillomania (TTM), has become increasingly recognized as an
often chronic problem for a large number of individuals, most of whom are women. This
paper discusses current conceptualizations of TTM with particular focus on the medical
and behavioral approaches. The relationship of TTM to other disorders is discussed and
issues in pharmacotherapy that are unique to TTM are reviewed. A comprehensive
behavioral model (ComB) that explains the environmental, motoric, sensory, cognitive,
and affective patterns involved in hair pulling is presented. This model is used to describe
how a clinician can develop treatment plans tailored to individual patients, including
specific strategies for hair pulling reduction. Potential pitfalls and complications that may
occur during treatment are also discussed. [Brief Treatment and Crisis Intervention
3:339–352 (2003)]
KEY WORDS: trichotillomania, hair pulling, obsessive-compulsive spectrum, cognitive
behavior therapy.
What Is Trichotillomania?
The ﬁrst medical report on chronic pulling was
written in 1889 (Hallopeau), but ancient texts
suggest that it has occurred for at least several thousand years (Christenson & Mansueto,
1999). It was not until relatively recently, however, that trichotillomania (TTM) gained suﬃcient attention and became better understood
by clinicians, researchers, and the “pullers”
themselves. Essentially, TTM is diagnosed when
an individual repeatedly pulls his or her hair
and suﬀers the physical, emotional, and social
consequences associated with this often chronic
condition (American Psychiatric Association,
2000). Hair is usually pulled from the scalp, but
the eyebrows, eyelashes, and pubic area are
other common sites. Less frequent sites include
beard, legs, mustache, sideburns, arms, and
underarms (Thomas, Stemberger, MacGlashon,
Witte, & Mansueto, 1999). Hair loss can range
from minimal, with little noticeable hair loss, to
severe, where most, if not all, hair at the pulling
site is gone. Pulling occurs across the age range,
from infants and young children, to adolescents
and adults. While hair pulling in very young
339
STEMBERGER, STEIN, AND MANSUETO
children is often temporary, it is usually a
chronic condition when present in later years.
Seemingly bizarre to those unfamiliar with the
syndrome, it is estimated that TTM actually occurs in approximately 2% of the population,
with females constituting 90% of adult suﬀerers
(Christenson, Pyle, & Mitchell, 1991; Rothbaum, Shaw, Morris, & Ninan, 1991).
Although hair pulling only poses health risks
in rare circumstances—when the individual either swallows large quantities of hair, damages
the skin to the point of infection, or avoids necessary contact with medical caregivers because
of shame and embarrassment—the emotional
and social consequences of pulling can be severe. “Pullers” report that the depression, anxiety, shame, embarrassment, feelings of unattractiveness, and low-self esteem associated with
pulling can be signiﬁcant. In addition, marked
avoidance of social activities is characteristic of
TTM suﬀerers who wish to maintain secrecy
and avoid embarrassment. Commonly avoided
activities include hair cuts, physical activities
such as sports and dancing, being in the outdoors or in public, and sexual intimacy (Stemberger, Thomas, Mansueto, & Carter, 1999).
Although pulling is not considered to be a sign
of a more severe disorder, the comorbidity of
TTM with other disorders—such as anxiety, aﬀective, and personality disorders—is signiﬁcant
and ranges from 20 to 50% of clinical samples
(Christenson, Mackensie, & Mitchell, 1991;
Christenson, Chernoﬀ-Clementz, & Clementz,
1992; Schlosser, Black, Blum, & Rise, 1994). It is
From the Behavior Therapy Center of Greater Washington,
Silver Spring, Maryland (Stemberger); University of Stellenbosch, Cape Town, and University of Florida, Gainesville
(Stein); Behavior Therapy Center of Greater Washington,
Silver Spring, Maryland, and Bowie State University, Bowie,
Maryland (Mansueto).
Contact author: Ruth M. T. Stemberger, PhD, The Behavior Therapy Center, 11227 Lockwood Drive, Silver Spring,
MD 20901. E-mail: rmtstemberger@aol.com.
© 2003 Oxford University Press
340
important to understand that while TTM is a
separate condition, the comorbid disorders can
complicate the nature and severity of the pulling
and the impact it has on an individual’s life.
Furthermore, it is important that to understand hair pulling is to understand what it is
“not.” Despite the fact that to onlookers it seems
like a form of self-injurious behavior, no evidence suggests that it is related to parasuicidal
behaviors such as cutting. This ﬁnding is consistent with the fact that the majority of those
who pull do not report that the goal of pulling is
to hurt or even numb themselves, as is the case
with cutting (Thomas et al., 1999). It is also important to note that no research has produced
evidence to support a causative relationship between childhood sexual or physical abuse and
hair pulling (although the two can certainly cooccur). Another condition to which hair pulling
has been compared is obsessive-compulsive disorder—that is, because individuals with TTM
feel compelled to pull. However, studies comparing the two conditions point to the conclusion that they are distinct syndromes requiring
diﬀerent treatment approaches (Stanley, Swann,
Bowers, Davis, & Taylor, 1992; Stanley, Borden,
Mouton, & Breckenridge, 1995). In fact, TTM is
classiﬁed in the DSM-IV-TR as an impulse control disorder, along with intermittent explosive disorder, pathological gambling, pyromania,
and kleptomania. The extent to which TTM
shares features with these disorders has yet to be
determined; but because these disorders do not
tend to co-occur with TTM as frequently as do
other conditions, such as depression or OCD, the
likelihood that they are closely related to TTM is
low. Moreover, the diagnostic grouping of these
disorders with TTM has been criticized (Christenson & Mansueto, 1999).
What may provide a useful avenue for understanding TTM is the categorization of TTM
within a cluster of presumably related disorders
termed “obsessive-compulsive spectrum disorders” (OCSDs). In this view it is hypothesized
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Treatment of Trichotillomania
that a spectrum of disorders exists on a continuum that ranges from impulsive disorders
at one extreme to compulsive disorders at the
other (Stein et al., 1995). In this organizational
scheme, at one end are the relationships among
and within the obsessional syndromes, such as
OCD, hypochondriasis (in which the individual
obsessively fears having a disease), and body
dysmorphic disorder (in which the individual
obsessively fears that some aspect of their appearance is repulsive). At the other end are the
seemingly “impulsive” tic disorders, such as
Tourette’s syndrome (in which multiple motor
and vocal tics occur). TTM can be conceptualized as belonging somewhere in the middle of
this continuum (Ninan, Mansueto, Rothbaum,
O’Sullivan & Nemeroﬀ, 1998). In some respects
it is like a tic, in that it is rarely triggered by obsessional thoughts and can occur without conscious awareness. In other respects, it is like a
compulsion, in that it often involves a more
complex set of behaviors and is often associated
with some sense of relief from consciously experienced discomfort.
Treatment of Trichotillomania
A variety of approaches have been used to help
those who suﬀer from TTM, including psychotherapy, hypnosis, pharmacotherapy, and behavior therapy. Among these, the two most
promising, from limited clinical trials, are pharmacotherapy and behavior therapy. Thus, these
two approaches and their current applications
will be described in more detail.
Pharmacotherapy of
Trichotillomania
Earlier views of TTM as a possible OCD subtype
led to the ﬁrst controlled examination of the
eﬀectiveness of medication for alleviating hair
pulling. Given that OCD patients respond more
robustly to serotonin reuptake inhibitors (SRIs)
like clomipramine than to noradrenaline reuptake inhibitors such as desipramine, the eﬃciency of clomipramine was compared with that
of desiprimine. In that study, clomipramine was
found to be signiﬁcantly more eﬀective than desipramine for patients with hair pulling (Swedo
et al., 1989), which not only oﬀered a new treatment possibility for patients with this disorder,
but it also provided some evidence for the hypothesis that trichotillomania lies on a spectrum
of OCD-related disorders.
A newer family of antidepressant medications, the selective serotonin reuptake inhibitors
(SSRIs), have proven to be better tolerated than
clomipramine, and each of these agents has now
been shown to be more eﬀective than placebo
for the treatment of OCD. Nevertheless, the data
for the eﬃcacy of these agents in TTM is less
convincing. Thus, the use of medication in the
treatment of TTM deserves a more detailed examination than might be necessary if it were
more similar to the treatment of OCD.
Uncontrolled studies have suggested that SSRIs such as ﬂuoxetine, ﬂuvoxamine, and citalopram are useful in the treatment of TTM; in addition, controlled studies have shown eﬃcacy
for ﬂuoxetine (Piggott, L’Heueux, & Grady,
1992) and venlafaxine, a serotonin and noradrenaline reuptake inhibitor (Ninan et al.,
1998). However, a number of placebo-controlled
trials of SSRIs have been negative (O’Sullivan,
Christenson, & Stein, 1999). Furthermore, studies examining the maintenance of gains in patients receiving SSRIs have found relapse of
symptoms even in patients receiving maintenance pharmacotherapy (Pollard et al., 1991; Benaroche, 1991).
Disappointing results with SSRI treatment for
TTM have led to attempts to use other kinds of
medication, either as monotherapy or as a way
to augment serotonin reuptake inhibitors.
Dopamine blockers are known to be useful in
Tourette’s disorder and are used as augmenting
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STEMBERGER, STEIN, AND MANSUETO
agents in treatment refractory OCD. Indeed,
some data suggest that these agents have a role
in the pharmacotherapy of TTM (Stein & Hollander, 1992; Van Ameringen & Mancici, 1996).
New generation antipsychotics, such as risperidone and ziprasidone, have a better tolerability
and safety proﬁle than do older ones, such as
haloperidol. Nevertheless caution is warranted,
as these agents can have important adverse
events, and placebo-controlled trials showing
eﬃcacy in TTM have not been done.
A number of other agents have also been
examined as potential pharmacotherapentic
agents for TTM: naltrexone, an opioid antagonist; lithium, a mood stabilizer; and inositol, a
carbohydrate. However, certainty about the beneﬁts of these agents is limited because of
methodological shortcomings, such as small
sample size and inadequate controls. Therefore,
these agents cannot be recommended for routine
clinical use at the present time. Indeed, given
that behavior therapy is often eﬀective for the
treatment of TTM, it can be considered as the
ﬁrst-line intervention.
Despite these limitations, pharmacotherapy
can play an important role for some hair pullers,
especially when comorbid mood and anxiety
disorders are present. Given that such comorbidity is so common and that many mood and
anxiety disorders respond to SSRIs, the use of
these agents seems reasonable for the treatment
of patients who present with such features.
Guidelines for dosing and duration have often
drawn on work with OCD (i.e., relatively high
dose over long treatment intervals), although
some patients are likely to respond at lower SRI
doses than is expected for patients with OCD
(O’Sullivan et al., 1999). Other agents may be
useful for patients with diﬀerent patterns of
comorbidity.
Because of the accumulating evidence that
both behavior therapy and pharmacotherapy
are beneﬁcial for treatment of TTM, many clinicians are disposed to recommending combined
342
therapy in which both treatments are provided.
Furthermore, some evidence suggests that in
naturalistic settings, patients with TTM derive
beneﬁts from combined treatments that incorporate pharmacotherapy as well as other behavioral and cognitive behavioral modalities
(Keuthen et al., 1998). Further work is needed,
however, to speciﬁcally conﬁrm the eﬀectiveness of pharmacotherapy in naturalistic settings
where comorbidity of TTM may be common.
Research on the optimal sequencing and combination of psychotherapy and pharmacotherapy is another area where additional work is
required.
The Case of Susan
Susan is a 34-year-old accountant who is happily
married and has two children. She presents as an
energetic, outgoing woman with appropriate social skills and demeanor. The only complaint for
which she is seeking treatment is what she describes as a “stress-related condition.” Since the
age of 12, she has pulled her scalp hair, eyebrows, and eyelashes. She has done so to the
point where she often has bald spots on her
scalp—up to two inches in diameter—and few,
if any, lashes or brows. She denies any other signiﬁcant psychiatric symptoms, besides the depressed mood, shame, and low self-esteem that
she believes are a result of her chronic pulling.
Although her pulling has waxed and waned
over the years, she has never gone more than one
month without pulling and has at times spent
one to two hours a day pulling. When she was a
teenager, her parents sent her to a dermatologist
and to “talk therapy,” but her hair pulling continued. Susan has recently heard that her condition has a name, trichotillomania, and that some
eﬀective treatments are available, so she is seeking help again
Susan had never received pharmatherapy for
her hair pulling and, like many patients, was
wary of the possible side eﬀects. Upon her ini-
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Treatment of Trichotillomania
tial evaluation, her options for medication were
fully explained, and the potential beneﬁts of
combining medication and behavior therapy
were discussed. Given that Susan had never attempted treatment before and had no comorbid symptoms that might beneﬁt from medication, she decided to try behavior therapy without pharmacotherapy, with the knowledge that
she could add medication in the future if she
desired.
Behavioral Treatment of
Trichotillomania
The ﬁrst published attempt to systematically
describe and treat TTM from a behavioral perspective was conducted by Azrin and Nunn
(1973), who developed the habit reversal
method. In their view, TTM was primarily a motor habit maintained by excessive practice and
chaining of behaviors. An essential element of
this treatment employed a motor response that
was incompatible with hair pulling (i.e., holding the arms straight down and clenching the
ﬁsts). Subsequent variants added features such
as self-monitoring, social support, awareness
training, and relaxation training (Mouton &
Stanley, 1996; Rapp, Miltenberger, Long, Elliott,
& Lumley, 1998; Rapp, Miltenberger, & Long,
1998; Rogers & Darnley, 1997). Although initial
reports were promising, it became apparent that
the eﬀectiveness of this approach was mixed
and that relapse was a signiﬁcant problem (Azrin, Nunn, & Franz, 1980; Lerner, Franklin,
Meadows, Hembree, & Foa, 1998).
Subsequently, further work was conducted to
address other aspects of TTM to enhance treatment eﬀectiveness. Cognitive aspects of TTM
were identiﬁed (Gluhoski, 1995; Thomas et al.,
1999) and thus argued to be signiﬁcant factors
for some hair pullers. These included (a) the low
level of awareness before and during pulling often reported by hair pullers, and (b) rigidly held
ideas about hair and pulling that can contribute
to the problem in some individuals (e.g., that
gray hairs are not acceptable or that hair lines
should be straight and symmetrical). Suggested
ways to boost treatment eﬀectiveness included
therapeutic tactics to increase awareness, such
as record keeping or self-monitoring, as well as
cognitive therapy to moderate the rigid beliefs
about hair (Gluhoski, 1995).
In addition, the behavioral theory of classical
conditioning has been applied to TTM. This theory posits that environmental cues trigger an
urge to pull, which has led therapists to the use
of environmental strategies such as stimulus
control—for example, avoiding or removing
stimuli that trigger pulling, such as being alone,
looking in a mirror in the bathroom, or seeing
tweezers available (Rothbaum, 1992). In cases
where sensory cues trigger pulling—such as
itching at the pulling site or the sight of gray
or uneven hairs—systematic exposure to these
cues as well as practice at preventing the pulling
response have also been used as treatment components (Brondolo, 2000).
In Susan’s case, being in the bathroom, looking in the mirror, and applying makeup were
cues for her to pull. In addition, the sight of
curly or gray hair, or an out of place lash or brow
hair, triggered her urge to pull.
Ideas drawn from operant conditioning have
also been useful with pulling. First, it seems
clear that hair pulling can be facilitated or inhibited by environmental variables. Examples
of these include (a) whether the individual is
alone or with others, (b) whether they have a
free hand to pull with, and (c) whether their
posture makes it likely that their hand will be
near the pulling site (e.g., when driving a car).
Thus, strategies to minimize facilitating conditions and maximize inhibiting conditions have
been used. The second idea from operant conditioning, that pulling is somehow reinforcing,
has also been useful in understanding its nature.
Thus, using reinforcers to increase the use of alternatives to pulling, such as habit reversal or
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STEMBERGER, STEIN, AND MANSUETO
relaxation strategies, has been useful—particularly with children and adolescents where a
third party is available to encourage the behavior and provide the reward, but also in selfreinforcement strategies for adults. In addition,
the recognition that pulling can be reinforcing
in a variety of ways—including the relief of
boredom, avoidance of frustrating situations,
or relief from itching or tingling at the site—
has provided the impetus to seek other means to
provide this reinforcement or tolerate these
aversive situations (Rapp et al., 2000).
For Susan, what facilitated her pulling was being alone, having her hand in her hair or on her
face (i.e., when applying makeup), and driving
with one hand on the wheel. She would be able
to resist the urge when others were present, but
if alone, with a free hand that was near her face
or hair, she found it very diﬃcult to resist.
A Comprehensive Behavioral Model
for Trichotillomania (ComB/TTM)
Clearly, the cognitive behavioral approaches
have oﬀered a wide variety of alternative treatment strategies for hair pulling that were not in
use 20 years ago. However, as treatment strategies and “packages” have been developed and
tested, a dilemma for “pullers,” clinicians, and
researchers remains. With what can seem like a
hodgepodge of strategies available from standard cognitive behavioral therapy, how can the
most eﬃcient and eﬀective treatment plan be
developed for any one individual? In fact,
Mansueto, Stemberger, Thomas, and Golomb
(1997) have described a comprehensive behavioral (ComB) model for understanding individual cases of hair pulling and for choosing the most
eﬀective treatment strategies for a particular
person. In addition to systematically organizing
the knowledge applied from existing cognitive
behavioral theory and methods, this model
introduces the variable of sensory function,
which seems to play an important role in many
344
cases of pulling but has yet to be included
in previous treatment approaches. Speciﬁcally,
ComB addresses the role that ﬁve variables or
modalities play in pulling: environment, motor
response, sensation, aﬀect, and cognition.
ComB assumes that although certain patterns
of pulling can be identiﬁed, a wide range of
variability exists with respect to the nature of
pulling and the factors that inﬂuence pulling
(see Mansueto, Stemberger, Thomas, & Golomb,
1997). Therefore, to eﬀectively treat any particular case, the therapist must identify a detailed
description of the individual’s pattern. Consistent with a “generic” behavioral model, a
critical ﬁrst step in this approach is to employ a “functional analysis” in which three categories of components play a role in each case of
pulling: antecedents, behaviors, and consequences.
First, antecedents to pulling are elements that
either trigger or facilitate pulling, and they can
be identiﬁed as such:
• Environmental—a place where pulling typically occurs, such as in front of a bathroom
mirror
• Motoric—simple motor habits, often without full awareness, that may predispose one
to pull, like twirling or stroking the hair
during sedentary activities
• Sensory—enjoying the sensations associated with the pulling of hair or with afterpull; self-stimulating activities like nibbling
on the hair root
• Aﬀective—being calmed by or, conversely,
energized by hair pulling
• Cognitive—“weeding out” unwanted hairs
that are believed to be ugly or otherwise
unacceptable
For some individuals only one or two types of
antecedents play a role; for others, the list of antecedents is lengthy. Table 1 presents the possible types of antecedents and their associated
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Treatment of Trichotillomania
Table 1. ComB Model: Possible Antecedents Listed by Their Associated Modalities
Modality
Type
Common examples
Environment
Social
Implements
Bedroom, car, living room, bathroom, work, kitchen
Motor
Setting
Being alone, presence of others
Tweezers, wall mirrors, hand
mirrors, magnifying mirrors
Behavior
Sensation
Site sensation
Tactile
Affect
Hair qualities including coarse,
rough, curly, short, knotted,
sharp, straight, dirty/gritty, fine,
oily, long
Hair qualities including gray or
white, knotted, dark, light
Affect
Cognition
Thoughts
Awareness
Full, partial, or no awareness
Visual
Studying/reading, watching TV, talking on phone, working,
on computer, driving, getting ready for bed, trying to
sleep, using toilet, resting/napping, riding in car, groom/
applying makeup
Sensitivity/tingling, irritation, discomfort, itching, burning/
glowing, pressure
Indecision, tension/anxiety, boredom, frustration, loneliness,
anger, guilt, tired/sluggish, happiness/excitement, sexual
arousal
I don’t want certain types of hairs; it is important for hair to
be even, symmetrical, uniform; skin will heal better if I pull;
I’ll just pull this one
Note. From Thomas et al. (1999).
Table 2. ComB Model: Possible Behavioral Components Listed by Their Associated Modalities
Modality
Type
Environment
Going to a setting
Securing implements
Choosing site: Head, pubic, brows, lashes, beard, legs, mustache, sideburns, arms;
20% pull from 1 site; 26%, 2 sites; 14%, 3 sites; 14%, 4 sites; 26%, 5+ sites
Handedness: right, left, or both
Dispose of hair quickly or save hair
Tactile search for hair
Visual search for hair
Manipulate hair (twirl, twist, play)
Traction (gentle, quick)
Examine hair or root after pulling
Stimulate skin or mouth after pulling
Swallow hair or root
Motor
Sensation
Note. From Mansueto et al. (1997) and Thomas et al. (1999).
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STEMBERGER, STEIN, AND MANSUETO
modalities, as well as examples of each type of
antecedent, listed from the most frequently reported to the least frequently reported (Thomas
et al., 1999). The antecedents typically oﬀer
good potential for change because if the antecedents can be modiﬁed, pulling can be stopped
before it starts.
As mentioned, Susan’s antecedents included
(a) environmental stimuli (the bathroom or mirror) and sensory stimuli (seeing gray or curly
hair, or “out of place” lashes or brows), (b) the
thought that she must get rid of the gray, curly,
or “out of place” hairs, and (c) facilitators, such
as having her hands free or being alone.
The next phase of this approach addresses
the behaviors associated with the act of
pulling. Again it is assumed that understanding the speciﬁc behaviors involved for any one
individual is critical in developing an eﬀective treatment plan. The components include
preparatory behaviors, such bringing tweezers
and a magnifying mirror into the bathroom;
the pulling itself; and analyzing the disposition of the hair or root, such as pulling the root
oﬀ of the hair shaft and rubbing it between the
ﬁngers. Table 2 provides examples of these
behaviors and their associated modalities. As
with the antecedents, the individuals will vary
in the nature and importance of each of these
components.
Susan’s pulling almost always involved looking in the mirror and visually examining the
hair to be pulled; a quick pull to remove it; and
then a visual and tactile examination of the hair,
particularly if it was gray or curly. She would
pull scalp hairs between her ﬁngers to feel how
coarse it was and to check that she got one that
was truly gray or curly.
Finally, the consequences of pulling serve the
important function of maintaining the cycle of
pulling by aﬀecting the duration any individual
hair-pulling episode, as well as by inﬂuencing
the likelihood that future episodes will occur.
Thus, consequences are critical elements that
inﬂuence the chronic nature of pulling for suﬀers of TTM. It is important to note, however,
that pullers often suﬀer punishing consequences for pulling, which may serve to end an
episode of pulling and which also may have limited the severity of pulling over the course of the
individual’s history. Examples of these and their
associated modalities are listed in Table 3. These
components can also play an important role in
treatment.
The consequences of Susan’s pulling were
(a) a sense of satisfaction upon removing the
Table 3. ComB Model: Possible Consequences of Pulling, Listed by Their Associated Modalities
Modality
Type
Example
Environment
Reinforcer
Punishment
Punishment
Reinforcer
Attention (e.g., from parent)
Criticism/disapproval
Fatigue
Increase sensation at site (e.g., invigorating/energizing; pain that is pleasurable)
Decrease sensation at site (e.g., relief from itching/burning/glowing)
Increase tactile sensation on finger tips (i.e., interesting to touch)
Increase visual sensation (i.e., interesting to look at)
Pain or bleeding
Distraction from obligations, relief from stress/boredom/urge, pleasure
Upset/anxious/depressed due to pulling
Achieve goal
Regain self-control, “coming to senses”
Motor
Sensation
Affect
Cognition
Punishment
Reinforcer
Punishment
Reinforcer
Punishment
Note. From Mansueto et al. (1997).
346
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Treatment of Trichotillomania
unwanted hair, and (b) sensory satisfaction
upon feeling the coarse or curly hair. However,
pulling also seemed to increase the urge to pull
subsequent hairs; so, as is the case for many who
pull, she often found herself pulling many more
than she had originally intended. She also felt
acutely embarrassed and ashamed when she
feared that anyone saw her pulling.
Assessment of the antecedents, behaviors, and
consequences can be conducted through two
primary means: semistructured interview and
self-monitoring. A semistructured interview
can be drawn from the list of factors in Tables 1,
2, and 3. In addition, self-monitoring or record
keeping involve the individual’s noting episodes of pulling and relevant factors, such as
the setting, degree of awareness, aﬀect, sensations, associated cognitions, and the consequences of pulling. Both the interview and the
self-monitoring are often very enlightening for
individuals who pull by enhancing their understanding of the predictable patterns in their behavior. A template for the development of a selfmonitoring form can be found in Mansueto,
Golomb, Thomas, and Stemberger (1999).
Before discussing how this assessment is used
to identify the treatment strategies most likely
to be eﬀective, two additional factors are worthy
of discussion. The ﬁrst is the uniquely important role of the sensory modality in hair pulling.
Individuals who work with the developmentally disabled or with children are likely familiar
with individual diﬀerences in the desire for sensory stimulation. These diﬀerences seem to exist
in the general population, with people either
seeking out sensory stimulation, actively avoiding it, or (perhaps most common) displaying
each pattern at diﬀerent times. Clinical and research experience suggests that this variable often plays an important role in TTM (Golomb &
Vavrichek, 1999; Thomas et al., 1999). Speciﬁcally, hair pulling, and its associated preparatory and postpulling behaviors, provides tactile
stimulation on the ﬁngers, at the site of the
pulling, and in some cases, on the lips, mouth, or
skin after pulling. In addition, it often provides
visual stimulation or interest before and after
pulling, which is more likely to be true for those
who have greater degrees of awareness of their
hair pulling.
Another potential function of hair pulling has
been recently elaborated upon by Penzel (2002).
He suggests that individuals who pull have a
relatively narrow range of acceptable levels of
internal comfort or arousal, such that too much
or too little sensation, aﬀect, or cognitive activity is aversive. Thus, they are motivated to relieve the over- or underarousal. Pulling and the
stimulation it provides are uniquely suited to either soothe the individual when he or she is
overaroused or invigorate the individual when
he or she is underaroused. This scenario may in
fact account for the occurrence of pulling when,
possibly by accident, these individuals ﬁnd
pulling to be uniquely reinforcing and always
available. It is probably true that when this pattern is present in children, treatment is often a
more straightforward process—that is, ﬁnd and
encourage the use of other sensory methods to
achieve the goal of maintaining the comfort
level. However, when an individual has been
pulling into adulthood, the complexity of other
environmental, aﬀective, and cognitive variables that have become associated with the
pulling might complicate the picture signiﬁcantly and thus require a more complex treatment plan.
Susan’s therapist developed a self-monitoring
form in which Susan noted times when she
pulled; where she was when she pulled; and
what she did and how she felt before, during,
and after pulling. She was instructed to take
particular note of whether she sought the sensory stimulation during pulling and whether
she was “under- or overaroused” prior to and after pulling. Through the method, she and her
therapist realized that she was more likely to
pull when she felt hurried and stressed (e.g.,
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STEMBERGER, STEIN, AND MANSUETO
Table 4. ComB Model Possible Treatment Strategies Associated with Each Modality
Modality
Treatment Strategy
Environmental
Stimulus control (avoiding settings and implements)
Seek out inhibitors, such as people
Contingency management (rewards for using strategies)
Competing response training, as in habit reversal (e.g., clenching fist, cross-stitch,
holding koosh ball)
Response prevention during risky behaviors (e.g., band-aids or gloves on fingers,
wet or oily hair, hats or hair pulled back)
Use other means to meet sensory needs (e.g., touch dental floss, wire, feathers
or doll hair; nibble sunflower seeds; brush hair)
Numb site sensations with cortisone cream or lacrilube/remove visual sensation
with dyed hair or pull hair back
Use other means to soothe or invigorate (e.g., baths, massages, facial masks,
“aromatherapy”)
Relaxation, controlled breathing
Emotive: assertiveness training, journal writing, exercise
Imagery: positive visualization, self-hypnosis
Medication to moderate affect
Cognitive restructuring
Coping self-statements (e.g., “I’ll feel much better if I resist”; “If I start, it will be
Motoric
Sensory
Affective
Cognition
harder to stop”)
Note. From Mansueto et al. (1998).
when she was getting ready to go somewhere)
and when she was daydreaming and relatively
still (e.g., when driving).
Choosing a Treatment Strategy
With regard to the ComB model, once the antecedents, behaviors, and consequences for an
individual have been identiﬁed and listed by
modality, the relative importance of each modality will be apparent. As discussed, for some
individuals, the sensory modality will be primary; for others, the motoric and environmental
modalities will be most important; and for others, the cognitive modality will play a central
role. Most individuals will display a mix of contributions from a number of modalities. The relative importance of each modality will determine the choice of treatment strategy selected
from the variety of treatment options available.
348
A sample of treatment options for each modality
is listed in Table 4.
Several principles regarding this approach to
treatment should be kept in mind. First, the
most critical aspect of treatment is the assessment of the antecedents, behaviors, and consequences; and their associated modalities. Unsatisfactory eﬀects of previous treatments were
possibly due in part to the fact that no one treatment is best for all hair pullers. Rather, it is best
to tailor the treatment based on the detailed assessment to each individual. Second, a guiding
principle in all behavioral therapies is that each
attempt at treatment represents a single case
study in which the outcome of a particular strategy must be evaluated and in which the strategy
should be modiﬁed, augmented, or discarded if
the eﬀect is less than satisfactory.
Together, Susan and her therapist selected
three primary methods for treatment. First, she
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Treatment of Trichotillomania
was instructed to use several strategies to reduce the visual and environmental cues associated with pulling: covering all mirrors whenever possible and strictly reducing the amount
of time she could spend in front of a mirror to
groom. Second, she chose to use the wire from a
kitchen scrubber to satisfy her desire for sensory stimulation, and she kept some of this in
her car so she could use it when driving. Finally,
she identiﬁed ways to plan ahead and feel less
pressured when getting ready to go somewhere.
Although there are a number of other possible
treatment strategies, these are the three that Susan and her therapist felt would be most likely
to achieve the most change. After a trial of several weeks—during which Susan will return for
weekly updates and support—her pulling will
be reevaluated, and the plan will be augmented
or modiﬁed if necessary.
Complications in Treatment
Although a logical and systematic plan can be
developed from ComB and the treatment strategies that have been developed over many years,
it is often true that treatment does not follow a
textbook story line. A number of complications
may be present that require adjustments to the
standard approach.
Two variables that will aﬀect treatment are the
patient’s level of motivation and the nature of
their goals. Individuals vary widely in their desire to change their pulling. Some are ready to
make pulling the number one priority in their
life; others are more interested in keeping their
pulling on the back burner, while using any
strategies that might not require extraordinary
eﬀect. Additionally, some have the rigid goal
of completely eliminating the pulling, whereas
others are willing to accept some pulling—for
example, if it results in only minimal cosmetic
damage or if other negative consequences are
experienced as tolerable. It seems to make little
sense for the clinician to push clients in either
direction. There is not anything inherently
wrong with hair pulling—that is, unless the
client is swallowing large amounts of hair, causing damage to the skin and risking infections, or
avoiding medical care altogether (in these cases,
they need to be seen by a physician in addition
to their therapist). Rather, the clinician needs to
be aware of the client’s goal in order to plan appropriate, eﬃcient treatment strategies. However, if a client has the unrealistic goal of eliminating hair pulling in an unreasonable amount
of time or with minimal amount of eﬀort, the clinician needs to provide the client with accurate
information regarding how unlikely it is that
such a goal will be achieved.
In Susan’s case, her level of motivation seemed
extremely high, but her expectations for stopping quickly seemed unrealistic given the long
standing nature of her pulling. As treatment
progressed more slowly than she had hoped, she
felt disheartened and needed signiﬁcant support to maintain her motivation. With this support and several minor modiﬁcations to her
treatment plan, Susan was able to reduce her
pulling to minimal levels.
A second diﬃculty can arise in treatment
when the client is so emotionally distraught or
ashamed about hair pulling and its eﬀects that
these issues seriously interfere with the client’s
taking action to reduce the pulling. In such
cases, the client may be unable to take the essential steps necessary for eﬀective treatment
and may not be able to absorb information
needed to use treatment strategies eﬀectively.
At that point, until pulling-reduction strategies can be implemented, appropriate treatment
would include working on acceptance of the
current situation, as well as implementing
eﬀorts for enhancing self-esteem, reducing depression, addressing relationship problems, and
so forth.
When rigidly held beliefs about hair and
pulling are present, treatment can also be complicated. For example, in some cases hair pulling
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
349
STEMBERGER, STEIN, AND MANSUETO
is associated with comorbid body dysmorphic
disorder (BDD), in which the individuals are obsessively preoccupied with thoughts that something is wrong with their hair; thus, they spend
several hours each day checking and ﬁxing their
hair, as well as pulling hair that is gray, crooked,
out of place, or somehow unacceptable. In such
cases, treatment of the BDD must be incorporated into the entire plan, thus making treatment more time consuming and diﬃcult. In less
severe cases, individuals who are perfectionistic
about their hair, eyebrows, or eyelashes, but do
not have BDD, will often need extra attention in
the area of reducing perfectionism and tolerating the discomfort associated with hair that is
“out of place” or not symmetrical.
Therapists need to be aware of another variety
of belief about the pulling that can interfere
with progress in therapy. Individuals who have
a long history of avoiding social interaction and
relationships as a result of their hair pulling may
believe that when they stop pulling, their lives
will change in ways for which they are not prepared. This belief can create a lot of pressure and
may interfere with the goal of pulling cessation.
Addressing these beliefs in the course of assessment and treatment will ease the negative impact they might have.
In some cases, a secondary pattern can develop, in which pulling becomes a means of
maintaining control and individuality in a relationship. In adolescent girls, for example, some
parents become so distraught over their daughter’s pulling that that they attempt to use extreme methods of control (e.g., punishment, invasion of privacy) to get her to stop pulling.
Children and adolescents who have a need for
greater self-control and privacy may become increasingly resistant of their parents eﬀorts and
may therefore become unwilling to work to stop
the pulling. Unfortunately, parents can not eliminate the pulling without the cooperation of the
girl herself. In such cases, a focus on family issues with the goal of supportively helping the
350
parents to relinquish control will allow the girl
to work toward management of her own hair
pulling.
Because pulling can co-occur with other disorders—including depression, the anxiety disorders (i.e., social phobia, panic, and agoraphobia), and OCD—it may be that another disorder must be treated before progress can be
made with the hair pulling. For example, even
mild depression can make it diﬃcult for an individual to employ the strategies necessary to reduce the hair pulling; therefore, the depression
may need to be the initial focus of treatment. A
comprehensive assessment of other possible comorbid disorders and a frank discussion of how
they might aﬀect treatment is always important.
In conclusion, much progress has been made
in the treatment of TTM over the past 30 years.
New strategies are promising, although much
room exists for improvement in initial eﬀectiveness and long-term gains. In addition, a great
need exists for outcome research that addresses
the question of which treatments are most eﬀective and eﬃcient for which individuals. Thus,
the speciﬁc strategies and approaches available
need to be examined in the context of individual patterns of pulling. However, for individuals seeking help for hair pulling, current approaches have much to oﬀer.
References
American Psychiatric Association (2000). Diagnostic
and statistical manual for mental disorders (4th
ed., text revision). Washington, DC: author.
Azrin, N.H., & Nunn, R. G. (1973). Habit reversal: A
method of eliminating nervous habits and tics.
Behaviour Research and Therapy, 11, 619–628.
Azrin, N.H., Nunn, R. G., & Franz, S. E. (1980).
Treatment of hair pulling (trichotillomania): A
comparative study of habit reversal and negative
practice training. Journal of Behavior Therapy
and Experimental Psychiatry, 1, 13–20.
Benarroche, C. L. (1991, May). Discontinuation
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
Treatment of Trichotillomania
of ﬂuoxetine in trichotillomania. New Research
and Abstracts of the 144th Annual Meeting of
the American Psychiatric Association, New
Orleans.
Brondolo, E. (2000). Using imaginal desensitization
as an adjunctive treatment for trichotillomania.
Behavior Therapist, 23, 169–172, 179.
Christenson, G. A., Chernoﬀ-Clementz, E., &
Clementz, B. A. (1992). Personality and clinical
characteristics in patients with trichotillomania.
Journal of Clinical Psychiatry, 53, 407–413.
Christenson, G. A., Mackensie, T. B., & Mitchell,
J. E. (1991). Characteristics of 60 adult chronic
hair pullers. American Journal of Psychiatry,
148, 365–370.
Christenson, G. A., & Mansueto, C. S. (1999).
Trichotillomania: Descriptive characteristics
and phenomenology. In D. Stein, G. A. Christenson, & E. Hollander (Eds.), Trichotillomania
(pp. 1–42). Washington, DC: American Psychiatric Press.
Christenson, G. A., Pyle, R. L., & Mitchell, J. E.
(1991). Estimated lifetime prevalence of trichotillomania in college students. Journal of Clinical
Psychiatry, 52, 415–417.
Gluhoski, V. L. (1995). A cognitive approach for
treating trichotillomania. Journal of Psychotherapy
Practice and Research, 4, 277–285.
Golomb, R. G., & Vavricheck, S. M. (1999). The hairpulling habit and you: How to solve the trichotillomania puzzle. Silver Spring, MD: Writer’s Cooperative of Greater Washington.
Hallopeau, M. (1889). Alopecie par grattage
(trichomanie ou trichoillomanie). Annales de
Dermatologie et de Syphiligraphie, 10, 440–441.
Keuthen, N.J., O’Sullivan, R. L., Goodchild, P., Rodriguez, D., Jenike, M. A., & Baer, L. (1998). Behavior therapy and pharmacotherapy for trichotillomania: Choice of treatment, patient acceptance, and long-term outcome. CNS
Spectrums, 3, 72–78.
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. G., Golomb, R. G., Thomas, A. M., &
Stemberger, R. M. T. (1999). A comprehensive
model for treatment of trichotillomania. Cognitive
and Behavioral Practice, 6, 23–42.
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.
Mouton, S. G., & Stanley, M. A. (1996). Habit reversal training for trichotillomania: A group approach.
Cognitive and Behavioral Practice, 3, 159–182.
Ninan, P. T., Mansueto, C., Rothbaum, B. O., O’Sullivan, R. L., & Nemeroﬀ, C. B. (1998). Challenges
facing the treatment of trichotillomania. CNS
Spectrums, 3, 30–35.
O’Sullivan, R. L., Christenson, G. A., & Stein, D. J.
(1999). Pharmacotherapy of trichotillomania. In
D. Stein, G. A. Christenson, & E. Hollander (Eds.),
Trichotillomania (pp. 93–124). Washington, DC:
American Psychiatric Press.
Penzel, F. (2002). A stimulus regulation model of trichotillomania. In Touch, 3, 1, 12–14.
Pigott, T. A., L’Heueux, F., & Grady, T. A. (1992,
December). Controlled comparison of clomipramine
and ﬂuoxetine in trichotillomania. Abstracts of
Panels and Posters of the 31st Annual Meeting of
the American College of Nueropsychopharmacology, San Juan, Puerto Rico.
Pollard, C. A., Ibe, I. O., Kronjanker, D. N., Kitchen,
Bronson, & Flynn (1991). Clomipramine treatment
of trichotillomania: A follow-up report on four
cases. Journal of Clinical Psychiatry, 52, 128–130.
Rapp, J. T., Miltenberger, R. G., Ellingson, S. A.,
Stricker, J., Garlinghouse, M., & Long, E. S.
(2000). Treatment of hair pulling and hair manipulation maintained by digital-tactile stimulation.
Behavior Therapy, 31, 381–393.
Rapp, J. T., Miltenberger, R. G., & Long, E. S.
(1998). Augmenting simpliﬁed habit reversal with
an awareness enhancement device: Preliminary
ﬁndings. Journal of Applied Behavioral Analysis,
31, 665–668.
Rapp, J. T., Miltenberger, R. G., Long, E. S., Elliott,
A. J., & Lumley, V. A. (1998). Simpliﬁed habit reversal treatment for chronic hair pulling in three
adolescents: A clinical replication with direct observation. Journal of Applied Behavioral Analysis,
31, 299–302.
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
351
STEMBERGER, STEIN, AND MANSUETO
Rogers, P., & Darnley, S. (1997). Self-monitoring,
competing response and response cost in the
treatment of trichotillomania: A case report.
Behavioural and Cognitive Psychotherapy, 25,
281–290.
Rothbaum, B. O. (1992). The behavioral treatment of
trichotillomania. Behavioural Psychotherapy, 20,
85–90.
Rothbaum, B. O., Shaw, L., Morris, R., & Ninan,
P. T. (1991). Prevalence of trichotillomania in a
college freshman population. Journal of Clinical
Psychiatry, 54, 72.
Schlosser, B. A., Black, D. W., Blum, J., & Rise B.
(1994). The demography, phenomenology, and
family history of 22 persons with compulsive hair
pulling. Annals of Clinical Psychiatry, 6, 147–152.
Stanley, M. A., Borden, J. W., Mouton, S. G., &
Breckenridge, J. K. (1995). Nonclinical hairpulling: Aﬀective correlates and comparison with
clinical samples. Behaviour Research and Therapy,
33, 179–186.
Stanley, M. A., Swann, A. C., Bowers, T. C., Davis,
M. L., & Taylor, D. J. (1992). A comparison of
clinical features in trichotillomania and obsessivecompulsive disorder. Behaviour Research and
Therapy, 30, 39–44.
Stein, D. J., & Hollander, E. (1992). Low-dose pi-
352
mozide augmentation of serotonin reuptake
blockers in the treatment of trichotillomania.
Journal of Clinical Psychiatry, 53, 123–126.
Stein, D. J., Hollander, E., Trungold, S., Cohen, L.,
DeCaria, C. M., Mullen, L., et al. (1995). Compulsive and impulsive symptoms in trichotillomania.
Psychopathology, 28, 208–213.
Stemberger, R. M. T., Thomas, A. M., Mansueto,
C. S., & Carter, J. G. (1999). Personal toll of trichotillomania: Behavioral and interpersonal sequelae. Journal of Anxiety Disorders, 14,
97–104.
Swedo, S. E., Leonard, H. L., Rapoport, J. L.,
Lenane, M. C., Goldberger, E. L., & Cheslow,
D. L. (1989). A double-blind comparison of
clomipramine and desipramine in the treatment
of trichotillomania (hair pulling). New England
Journal of Medicine, 321, 497–501.
Thomas, A. M., Stemberger, R. M. T., MacGlashon,
S. G., Witte, T., & Mansueto, C. S. (1999). Behavioral components of trichotillomania: Empirical
veriﬁcation of the functional analytic approach. Unpublished manuscript.
Van Amerigen, M., & Mancini, C. (1996, March).
Treatment of trichotillomania with haloperidol. Paper presented at the Annual Meeting the Anxiety
Disorders Association of America, Orlando, Florida.
Brief Treatment and Crisis Intervention / 3:3 Fall 2003