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CBPRA-00405; No of Pages 11: 4C
Available online at www.sciencedirect.com
Cognitive and Behavioral Practice xx (2012) xxx-xxx
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Contains Video
1
DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania:
An Adolescent Case Study
Stacy Shaw Welch and Junny Kim, Anxiety and Stress Reduction Center of Seattle (Evidence Based Treatment Centers of
Seattle), University of Washington
Results and a case study for a DBT-enhanced habit reversal treatment (HRT) for adult trichotillomania (TTM) (Keuthen & Sprich,
2012) is adapted for use with adolescents. Trichotillomania in adolescence is a very important but understudied problem. Onset often
occurs in adolescence, and yet very little treatment research exists. DBT-enhanced habit reversal has shown promise in adult samples
(Keuthen et al., 2008) and may prove useful as a model for further study in adolescents. Here, we provide a case study using DBTenhanced HRT with an adolescent girl. The treatment emphasizes traditional CBT for TTM and also includes a focus on emotion
regulation, mindfulness, and distress tolerance to help manage both focused and automatic pulling.
R
ESULTS and a case study for a dialectical behavior
therapy (DBT)–enhanced CBT treatment for adult
trichotillomania (TTM) (Keuthen & Sprich, 2012) is
applied here to the treatment of adolescents. DBTenhanced CBT is aimed at improving outcomes and
maintenance of gains beyond those typically found to date
for TTM sufferers. In adult studies of CBT, complete
abstinence from hair pulling is rarely achieved and
relapse following treatment is a significant clinical
problem (Diefenbach, Tolin, Hannan, Maltby, & Crocetto,
2006; Lerner, Franklin, Meadows, Hembree, & Foa, 1998;
Mouton & Stanley, 1996). While the adult TTM literature is
certainly in need of more attention, the child and
adolescent treatment literature is almost nonexistent.
This gap in the treatment literature is quite concerning
given the potential importance of this developmental
period to the onset, maintenance, and chronicity of TTM.
Given the pressing need and lack of data, innovation is
sorely needed. The encouraging results from Keuthen et al.
(2010) inspired an adaptation of the protocol for use with
adolescents. This case study describes the protocol as used
to treat an adolescent presenting with TTM who was treated
by the first author.
1
Video patients/clients are portrayed by actors.
Keywords: trichotillomania; hair pulling; habit reversal; dialectical
behavior therapy; adolescent
1077-7229/11/xxx-xxx$1.00/0
© 2012 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
Trichotillomania in Adolescence
Adolescence is a time characterized by rapid developmental change and many psychiatric disorders have their
onset during this phase of life. This is true for TTM, which
usually develops in late childhood or adolescence. The
mean age of onset of cases reported in the literature is
8 years for males and 12 years for females; median age is 6
for males and 12 for females (Graber & Arndt, 1993). The
lifetime prevalence of the disorder in adolescents has been
estimated to be 1% (Hanna, 1997). The majority of studies
find a much higher percentage of females than males in
samples of children and adolescents (Hanna, 1997;
Mancini, Van Ameringen, Patterson, Simpson, & Truong,
2009). However, at least one epidemiological study found a
higher percentage of males. King, Scahill, et al. (1995)
conducted a study with a sample of 794 consecutive 17-yearold Jewish Israeli adolescents (369 male, 425 female). The
subjects were screened using a questionnaire and interview
for current and past hair-pulling and comorbid psychopathology. The study found that males slightly outnumbered
females in prevalence, by 5 to 3.
Adapting TTM Treatment for Adolescents: Can We
Adapt From Adult Models?
Given the almost total lack of data on treatment for
adolescents with TTM, clinicians are faced with a difficult
situation when teenagers and their families present for
help with this problem. Adapting a treatment that has
been researched with adults, as we have done here,
assumes that at least some basic elements of TTM in
adolescents are similar to those in adults. Though data are
Please cite this article as: Welch & Kim, DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case
Study, Cognitive and Behavioral Practice (2012), doi:10.1016/j.cbpra.2011.11.002
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Welch & Kim
limited, the available findings suggest that there are
significant similarities and overlap between adult and
adolescent TTM. There appear to be enough similarities
in how people pull and the function of their pulling to
justify an adaptation of the basic principles of adult
treatment models for evaluation of their effectiveness with
youth.
The topography of TTM appears to be similar in
adolescents and adults. Although studies of children tend
to show less endorsement of the pattern of “rising
tension/relief” associated with hair pulling, older children/
teens endorse this symptom more similarly to adults
(Hanna, 1997; King, Zohar, et al., 1995; Reeve, Bernstein,
& Christenson, 1992). Pulling sites are also similar between
adolescents and adults (see Franklin & Tolin, 2007, for a
review of studies). Adolescents tend to pull primarily from
the scalp, followed by eyelashes and eyebrows, and then hair
from other areas of the body (e.g., pubic hair). Many pull
from multiple areas (Hanna). Routines associated with the
hair once it is pulled are also common (eating it, stroking the
lip or mouth, inspecting it, lining it up, biting or popping the
root, etc.). Additionally, pulling severity appears similar
across age groups (Flessner, Woods, Franklin, Keuthen, &
Piacentini, 2009).
Psychiatric comorbidity tends to be high among adults
with TTM, especially mood and anxiety disorders
(Christenson, Ristvedt, & Mackenzie, 1993; Franklin et
al., 2008; Reeve et al., 1992). Though data are more
limited, the same appears to be true for adolescents, with
around half to two-thirds meeting criteria for a comorbid
psychiatric disorder, most typically anxiety and/or depression (Hanna, 1997; Lewin et al., 2009). The recent
Child and Adolescent Trichotillomania Impact Project
(CA-TIP), an Internet-based study, found high rates of
comorbidity with depression and anxiety in a sample of
113 youth with TTM ages 10–17. Adolescents reported
more of these symptoms than children (close to half of
the teens in the sample compared to 17% of children).
Depressive symptoms appeared to partly mediate the
relationship between TTM symptoms and functional
impairment (socially, academically, and interpersonally),
and this was not related to duration of illness. The authors
concluded that, “taken together, development of TTM
during adolescence, a common age of onset, appears to
be particularly devastating” (Lewin et al., p. 525).
Automatic and Focused Pulling in Adolescence
A major research finding in the TTM field in the early
1990s was that there may be two primary types of hair
pulling behavior with different cues and reinforcers:
automatic/habitual pulling and pulling that functions to
regulate emotions (Christenson & Mackenzie, 1994).
For instance, approximately 75% of adults with TTM
endorse “automatic” pulling (i.e., pulling out of aware-
ness), often accompanying sedentary, contemplative
activities (Christenson & Mackenzie, 1994). Others pull
in a more “focused” manner associated with a more
compulsive quality. Here, pulling is often cued by negative
emotions, intense thoughts or urges, or attempts to create
symmetry (Diefenbach, Mouton-Odum, & Stanley, 2002;
Flessner et al., 2009). Focused pulling appears to function
more as emotion regulation behavior. It appears that
many TTM sufferers have both patterns, though different
patterns may accompany different episodes. A recent
survey found this pattern in both adults and children/adolescents (Flessner et al., 2007) as have other smaller
studies (Hanna, 1997).
Of particular relevance to the treatment of adolescents
are the results of a recent large cross-sectional study of
1,471 females with TTM ages 10–69 (Flessner et al., 2008).
Results indicated a dramatic rise in the incidence of
focused pulling at age 13, corresponding to the age of the
beginning of puberty. This study also found increases in
focused pulling in women of perimenopausal age,
followed by a decrease postmenopause. Both developmental epochs are characterized by well-known exacerbations in mood and anxiety related to hormonal
changes. Additionally, the Flessner study documented
increases in functional impairment that increased over
time. Younger children showed mild to moderate social
and interpersonal impairment related to their TTM,
which steadily increased into late adulthood, when
impairment was moderate to severe. Less than 1% of
the variance was related to duration of illness. These
findings underscore the importance of developing
effective treatments for teenagers living with TTM.
Treatments for Adolescents With TTM
Tolin, Franklin, Diefenbach, Anderson, and Meunier
(2007) published an open trial for youth with TTM and
have recently completed the first randomized controlled
trial for TTM in youth (Franklin et al., 2007). Their open
trial included eight biweekly meetings after active
treatment concluded for the purpose of helping prevent
relapse. Data from the open trial indicated significant
reductions in hair pulling as rated by clinicians on the
CGI; 77% were classified as “treatment responders” and
32% as “excellent responders.” At 6-month follow-up
these ratings were 63% and 32%. Self-report of depression
and anxiety showed decreases during treatment as well.
Interestingly, none of the patients who achieved an
excellent response relapsed. If the strength of initial
treatment response/achievement of abstinence predicts
future maintenance of gains, this may be an important
finding and would be similar to findings in other
disorders, such as depression and OCD (Frank et al.,
1990; Hiss et al., 1994; Vittengl et al., 2009). The results
are an extremely important first step in developing
Please cite this article as: Welch & Kim, DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case
Study, Cognitive and Behavioral Practice (2012), doi:10.1016/j.cbpra.2011.11.002
DBT2Enhanced CBT for Adolescent TTM
treatments for youth with TTM. This treatment is
comprehensive, state-of-the-art CBT, a major step forward
in the field, and includes strategies to prevent relapse.
Still, the results suggest that further innovation in how we
provide CBT would be welcome. These results are more
modest than hoped for in terms of helping more children
stop pulling, and many children who did not achieve
excellent results during the active treatment phase
relapsed. CBT appears to be a good treatment; but we
still need to do better for these youth.
Improving Treatment for TTM
DBT-enhanced CBT was developed in an attempt to
improve and build upon the current state of the art by
adding specific skills to more comprehensively address
specific styles/functions of pulling. Recently, many researchers have suggested that the treatment for TTM might
be improved if interventions were more specifically
matched to the various functions of hair pulling (see
Flessner et al., 2008). It has been hypothesized that
traditional CBT interventions have had modest outcomes
to date as they may be effective primarily with the
“automatic” rather than the “focused” style of pulling
(which appears more related to emotion regulation and is
related to hair pulling severity). This may be especially
important in adolescence, when focused pulling increases.
Another goal in developing DBT-enhanced CBT was to
increase the options available to help deal with negative
or dysregulated mood states, very relevant for youth.
Adolescence is a time of intensified emotion and a rich
developmental period of learning emotion regulation
skills generally. Youth who have the additional struggle of
TTM may have even greater emotional vulnerability due
to either the difficulty of coping with the disorder,
existing psychiatric vulnerability, or both. Whether
mood symptoms comprise a risk profile for the disorder
or occur as a result of the disorder is unclear. Either way, it
makes sense that adding a more specific focus on emotion
regulation may be helpful to achieve better results from
treatment and maintain them over time. This seems
especially important in light of other data suggesting that
unremitting, comorbid depressive symptoms negatively
mediate treatment outcome in TTM in adults (Keijsers et
al., 2006; Keuthen et al., 1998). While the specific
mechanisms between negative affective states and pulling
behavior remain unknown, it seems clear that adding an
emphasis on coping with and reducing negative emotion
states could have a major impact on treatment efficacy.
DBT-Enhanced CBT for TTM
As described by Keuthen and Sprich (2012), the treatment includes the core components of CBT for trichotillomania, including psychoeducation, self-monitoring, habit
reversal, stimulus control, and relapse prevention. It also
includes skills to improve mindfulness, emotion regulation,
and distress tolerance, with specific application to TTM. We
hoped that the addition of mindfulness training would
complement and improve the focus on increasing awareness
and decreasing impulsive pulling, which is essential for
patients with automatic pulling behaviors. We also hoped
that the additional emotion regulation and distress tolerance
skills would provide a context for patients to improve
emotion regulation generally, as well as tolerate difficult
urges to pull that do not go away immediately and are very
difficult to tolerate.
The initial data in adult pilot samples have so far been
encouraging. In an open pilot trial with 10 adults who met
DSM-IV-TR criteria for TTM, significant improvements
from baseline in both hair pulling severity and emotion
regulation were reported at all study time points, though
some worsening occurred on some measures during the
follow-up period. Significant correlations were reported
between hair pulling severity and emotion regulation
throughout follow-up (Keuthen et al., 2010). No data are
currently available for adolescents with TTM, although we
hope there may be opportunity for further study.
The protocol has been modified for use with
adolescents in three main ways. First, important issues
related to therapeutic style were considered. In our
experience working with teens with TTM, overly formal,
rigid, or clinical approaches are generally less effective.
We believe that communicating expertise about TTM
while coming across as an approachable person the teen
can relate to helps build a strong interpersonal
relationship. Without that, we have found it difficult to
progress in therapy with a disorder like TTM, where both
the disorder and treatments are hard, long, and
sometimes very disappointing in the lack of an easier
answer to manage pulling urges. Readers can observe
some of this style in the videos contained in this article
(see Video 1: Psychoeducation About Trichotillomania;
Video 2: Chain Analysis; Video 3: Mindfulness; Video 4:
Emotion Regulation; and Video 5: Distress Tolerance).
Essentially, a more casual/friendly tone was used. Care
was taken not to use professional jargon. Warm
engagement was emphasized and opportunities to
communicate experience with TTM and also to validate
the teen's experience were taken whenever they arose.
Much of the style—while not formalized in this
adaptation—was borrowed from elements of DBT used
to engage clients who have been burned out in some way
on the mental health system. For different reasons, this
may be relevant to teens with TTM, many of whom have
had less than optimal experiences with clinicians who
did not recognize or understand their hair pulling
behaviors.
The second adaptation to the protocol was the
inclusion of parents. Parents are often confused, upset,
Please cite this article as: Welch & Kim, DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case
Study, Cognitive and Behavioral Practice (2012), doi:10.1016/j.cbpra.2011.11.002
3
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Welch & Kim
and frustrated by the ongoing pulling they observe. It is
very common for power struggles over the hair pulling to
ensue, and frustrations build up over why the teen can't
“just stop” and why the parent can't “just stop saying
anything about it.” Both struggles are challenging, and in
our opinion, must be met with compassion and attention.
The struggle of teens, who must live with sometimes
constant urges to pull and the frustration of a disorder
that impacts their physical appearance, is intense.
Additionally, many teens feel that no one understands
what they are going through, including their own parents
(at best) and are criticized and humiliated for something
they wish desperately they could control, but can't (at
worst). The struggle of parents is also tremendous; in
addition to the normal challenges of parenting a teen,
they must find ways to support their child and sometimes
accept ongoing hair pulling that is highly distressing to
them, especially when they see it happening right in front
of them. It can be difficult to understand and very hard to
move towards a stance of silent support, as the therapy
sometimes requires. We took a case-by-case approach to
determine what level would be the best to include parents.
The parents were always seen during the initial assessment
and it was then determined whether it made more sense
to include them in an ongoing way (at the beginning and
end of sessions, for instance) or to have private “check-in”
meetings where their efforts to support their teen could
be discussed. Sometimes, we thought parents needed a
private place where they could work through difficult
feelings and say things that would be better not said in
front of their child. Occasionally, this would require an
additional therapist just for the parents, if the teen was not
open to the therapist having parental contact or there
were more in-depth issues that needed work (i.e., a more
formal behavioral parent training approach if there were
other issues such as oppositional behavior).
The third major area of modification included going
through the worksheets, forms, and handouts to make
sure they were developmentally appropriate and would
appeal to teens. At times, the amount of worksheets,
forms, and formal homework was decreased, depending
on the age and developmental needs of the teen. Skills
presented were revised slightly to ensure that they were
developmentally appropriate (for instance, a list of
pleasant events in the emotion regulation module was
revised to include activities typical of adolescents). Care
was taken to use examples relevant to teens, and at times
forms were created in session with the teen, as opposed to
using a more standard worksheet. Otherwise, the protocol
was delivered as it has been implemented and studied
with adults. Here, we provide a case example of an
extension of these treatment principles to therapy with an
adolescent girl who presented for treatment of TTM. Key
details have been changed to protect her confidentiality.
Case Study
2
Molly was a 15-year-old typically developing female.
She presented to treatment following earlier successful
treatment for an anxiety disorder at around age 10 with
the same therapist. Molly and her parents reported that
she had at least one episode of pulling early in life, around
the age of 5, when she pulled out most of her eyelashes
one day while sitting down watching television. They were
unsure if she pulled hair following this episode. Following
this episode, Molly frequently pulled her eyelashes as they
grew back, usually when trying to go to sleep, during long
car rides, and during sedentary activities. They reported a
long pattern of other body-focused repetitive behaviors
throughout childhood, most notably twirling her hair,
stating that “her fingers are almost always in her hair” and
they remembered that almost always having been the
case. Throughout childhood, Molly would often bite her
nails, chew on the inside of her cheek, and pick at any
scabs or flaking skin that she found on her body, lips,
scalp, or face. This pattern is similar to that of many
children who report multiple body-focused repetitive
behaviors (BFRBs) in childhood, and then find that the
number of different BFRBs decreases into adolescence
and adulthood. Molly and her parents reported that at
some point in middle childhood, she stopped pulling her
eyelashes over the summer, although she continued to
exhibit many other BFRBs. At around the age of 13, Molly
began pulling more scalp hair and some eyebrow hair.
She was unaware of any particular event that prompted
her increase in pulling. She noted that she pulled both
when she was sitting and bored as well as when she felt
stressed and upset, such as when she had tests or was
nervous about an upcoming social interaction. She was
also bothered by the extent to which she picked at the skin
on her lips and fingers/cuticles, which would sometimes
bleed and cause her social embarrassment.
Molly was given the following assessment measures:
Trichotillomania Scale for Children (TSC), Screen for
Child Anxiety Related Disorders (SCARED), Difficulty in
Emotion Regulation Scale (DERS), and Moods and
Feelings Questionnaire (MFQ). The TSC measures the
severity, distress, and impairment associated with TTM
(Tolin et al., 2008). The total score ranges from 0 to 2 with
lower scores indicating less severity and impairment. The
SCARED measures symptom severity linked to anxiety
disorders (Muris et al., 2007). The total score ranges from
0 to 82 with scores equal to or greater than 25 indicating
the possible presence of an anxiety disorder and scores
equal to or greater than 30 indicating the likely presence
of an anxiety disorder. The DERS measures clinically
2
Details about the case have been modified to protect the identity
of the client.
Please cite this article as: Welch & Kim, DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case
Study, Cognitive and Behavioral Practice (2012), doi:10.1016/j.cbpra.2011.11.002
DBT2Enhanced CBT for Adolescent TTM
5
TSC Measure Scores
2
1.8
1.6
1.4
Score
1.2
TSC-C
TSC-P
1
0.8
0.6
0.4
0.2
0
TSC-C
TSC-P
Baseline
Mid-treatment
2
1.71
1.57
1.2
Post-treatment
0.3
0.5
Followup
0.5
0.5
Timepoint
Figure 1. Hair pulling severity and impairment scores (TSC) at baseline, midtreatment, posttreatment, and follow-up.
relevant problems related to emotion dysregulation
(Gratz & Romer, 2004). The total score ranges from 36
to 180. Lower scores indicate fewer problems with
emotion regulation. The MFQ measures depressive
symptom severity (Costello & Angold, 1988). The total
score ranges from 0 to 26. Higher scores indicate more
severe depressive symptoms. Molly's scores on these
measures are presented in Figures 1, 2, and 3.
Course of Treatment
Session 1: Psychoeducation and Assessment
Video 1. Psychoeducation about Trichotillomania: Therapist provides
psychoeducation to the client about the model and treatment of
trichotillomania.
The first stage of treatment involved educating Molly
and her parents about hair pulling and skin picking. A
behavioral model was presented that emphasized TTM as
a biologically driven behavior with a strong learning
component. Care was taken to validate the difficulty of
stopping, as well as to instill hope that new skills could be
learned to help decrease pulling behaviors. Molly and her
parents reported feeling relieved by the model presented,
as both she and her family had worried that her hair
pulling might represent some form of self-mutilation or a
deep expression of psychological trauma. They all noted a
positive reaction to the idea that TTM is not anyone's
fault, and that Molly's inability to “just stop” was normal.
Another important part of the psychoeducation for the
family was the idea that their frequent, occasionally
frustrated reminders to her to stop pulling when they
observed the behavior were not helpful, and were actually
agitating Molly. Early on in treatment, we engaged in a
conversation about what would be the best way for Molly's
family to support her in treatment around this issue. She
asked them to simply say “looks like trich is bugging you,
anything you want my help with?” one time, and after that
to refrain from commenting. Molly's father expressed a
high degree of anxiety about this, and privately expressed
to the therapist that he didn't know if he could do this
because he had been collecting hairs under Molly's bed
for quite some time as a means of monitoring her pulling
behaviors. Motivational enhancement strategies were
used with Molly, as well as her parents, to help increase
their readiness to engage in the requirements of the
Please cite this article as: Welch & Kim, DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case
Study, Cognitive and Behavioral Practice (2012), doi:10.1016/j.cbpra.2011.11.002
Welch & Kim
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DERS, SCARED, and MFQ Measure Scores
90
80
70
Score
60
50
DERS
SCARED-C
MFQ
40
30
20
10
0
Baseline
Mid-treatment
Post-treatment
Followup
DERS
82
67
55
49
SCARED-C
50
40
32
27
MFQ
27
25
23
20
Timepoint
Figure 2. Emotion regulation (DERS), anxiety (SCARED), and depressive (MFQ) symptom severity scores at baseline, midtreatment,
posttreatment, and follow-up.
treatment. Molly agreed that if her parents would “back
off” to some degree, and follow the therapist's suggestions, she would be open to a weekly check-in with her
parents during the therapy sessions to discuss progress
and let them know more about how she was doing. This
arrangement worked well throughout the course of
treatment. Both Molly and her father reported that as
her father increased supportive and validating statements
Weekly Hair Pulling Frequency
200
180
160
Frequency
140
120
100
wkly hair pulling
80
60
40
20
0
wkly hair pulling
Baseline
Mid-treatment
180
65
Post-treatment
4
Followup
7
Timepoint
Figure 3. Weekly hair pulling scores at baseline, midtreatment, posttreatment, and follow-up.
Please cite this article as: Welch & Kim, DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case
Study, Cognitive and Behavioral Practice (2012), doi:10.1016/j.cbpra.2011.11.002
DBT2Enhanced CBT for Adolescent TTM
about the difficulty involved with changing pulling
behaviors, Molly became more open with him outside of
the therapy sessions.
Chain Analysis and Self-Monitoring
During an early session, Molly and the therapist
completed a chain analysis of her most recent pulling
episode. A behavioral chain analysis is a strategy used by
behavior therapists to obtain a moment-by-moment
sequence of events; this has been operationalized for
clinical use and termed “chain analysis” by Linehan in
DBT (Linehan, 1993). Molly's chain, which she thought
was typical of some of her pulling patterns, involved a
busy, stressful week at school, feeling anxious about how
much she had to get done academically, and social strain
with a peer. She recalled having strong urges to pull while
she was at drama practice, sitting in the theatre watching
others go through some scenes. She resisted the urges to
pull because she was too embarrassed to pull in front of
others. She began pulling while she was in the car going
home from practice. She then put on the hood of her
sweatshirt and tried not to pull her hair while at dinner
with her family because she knew that they would notice
and call attention to the pulling. She had to stay up late
writing a paper, and again worked hard not to pull her
hair, even taking a shower at one point because she knew
getting her hair wet would help. She had to stay up very
late working on her paper, however, and at one point
became highly frustrated and anxious about the work; at
that point she noted that she had thoughts about giving
up and mounting urges to pull and pulled her hair
intermittently while staring at her computer screen. She
recalled feeling terrible after pulling and then picked at
skin on her lip until it hurt/bled.
In addition to details about the environmental context
of hair pulling (the “what” and “when”), the chain anal-
Video 2. Chain Analysis: Therapist conducts a chain analysis with
client to figure out what led to a recent pulling episode.
ysis included details about the specific components of
Molly's hair-pulling patterns (the “how”). Like many hair
pullers, Molly would begin by fingering her hair and scalp,
looking for hairs that were slightly different in some way
(thicker, more wiry, or shorter). She would then isolate
the hair and tug it. Following the pull, she would examine
the hair and bite the bulb, or “root” of the hair. She would
often stroke her lips with the hair, and then release it. She
did not eat the hair. After conducting the chain analysis,
Molly was asked to monitor all hair pulling using forms
provided by the therapist. Through the chain analysis and
self-monitoring, she and the therapist identified high-risk
situations where she was likely to pull her hair: in the car,
studying by herself late at night, going to sleep, getting
ready for a date or important social interaction she was
nervous about, math class (which she found both boring
and anxiety-producing), watching TV, and when very
angry at her parents.
Session 2: Habit Reversal and Stimulus Control
Habit reversal is a technique to help patients use a
competing response to help tolerate urges to pull/control
the behavior. Substituting a “competing response,” or a
motor behavior that is incompatible with hair pulling,
helps the individual shift to a new habit. Ideally, the
competing response can be maintained for at least 90
seconds, be as inconspicuous as hair pulling, be easy to do,
and produce increased awareness of the behavior.
Sometimes, people find it useful to employ the same
muscles that would have been used to pull hair. Muscle
tension is produced and held, which may help “burn out”
the urge to pull. Molly was taught to make tight fists and
hold them for 90 seconds. She was taught to use this
strategy if she had an urge to pull or was in a high-risk
situation for pulling. She and the therapist also came up
with multiple other competing responses, including
squeezing a squishy/koosh ball, holding pens hard during
schoolwork, squeezing the mouse on her computer, and
holding her books or phone with both hands and
squeezing her fingers together. She and her father
worked out a system where they would buy a dozen
small items to use for competing responses at a time, and
then rotate them every few days. Molly reported that the
novelty seemed to help increase their use. She also found
it useful to pop bubble wrap, or bite the bubble wrap, blow
and bite bubbles with gum, and pick out alfalfa sprouts
out of a box and bite the “bulb” of the sprout. Other orally
stimulating activities were used such as pop rocks or hard
candy, gummy worms that she could play with, rub on her
lips, and bite, and popping bath beads between her
fingers/rubbing the oil from the beads on her hands to
moisturize them. This also helped her avoid skin picking
on her hands, as well as avoid hair pulling because she did
not want to get her hair oily.
Please cite this article as: Welch & Kim, DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case
Study, Cognitive and Behavioral Practice (2012), doi:10.1016/j.cbpra.2011.11.002
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Welch & Kim
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Stimulus control
Stimulus control techniques are strategies implemented by the client to decrease pulling by (a) providing cues
to maintain awareness, (b) reducing the stimulation
provided by pulling, or (c) interfering with or preventing
pulling. To apply these strategies, Molly and the therapist
discussed how she could apply specific strategies to help
her through high-risk situations for pulling. Molly
obtained permission to wear a hat at school during her
math class and she tried wearing bandages around her
fingers so that it would be difficult to isolate a hair and
pull it. At night when going to bed, she wore moisturizing
gloves (used with lotion) when falling sleep. While
studying, she tried wetting down her hair and applying
conditioner, which she left in her hair for hours. She also
kept her nails cut very short and her father agreed to
schedule some manicures for her as a reward for using
her strategies. She also put notes on her computer and
sent messages to herself on her cell phone during highrisk times to remind her to use her strategies.
began practicing mindful awareness during the day and
started reporting that she noticed more times when she
pulled. She also said that the mindfulness exercises
helped her notice when she was picking at the skin on
her lip, an activity that she did primarily out of awareness.
This dramatically reduced the amount that she picked the
skin in that area. She found the pulling on her scalp to be
more difficult to decrease. Molly initially reported that
mindfulness of her scalp pulling seemed to make it more
difficult to stop. She and the therapist worked on using
her mindfulness skills to help her focus on making
mindful choices about what strategy to use when she was
aware of urges. She noted that the mindfulness practice
helped her work on practicing different strategies to
decrease pulling, as opposed to relying on a single skill
all/most of the time. She reported this was helpful and
she noted that she was using many more strategies on a
regular basis than she had at first.
Sessions 6–8: Emotion Regulation
Molly was introduced to mindfulness and stated that
this was a new concept for her. Although she had done
yoga in her PE class and she noted that mindfulness
seemed somewhat similar to the breathing exercises she
had done there, she reported that she had not previously
thought about the idea of the practice of being aware of
the moment and nonjudgmental observation. She and
the therapist reviewed the DBT concepts of states of mind
(wise mind, emotion mind, reasonable mind) and
discussed where pulling fit into these. She and the
therapist discussed the concept of practicing increased
awareness, and began engaging in different mindfulness
practices during the beginning of each session, such as
awareness of the breath, or observation of thoughts. Molly
The emotion regulation module consists of a wide
range of skills that draw from an evidence base about (a)
regulating emotions more generally and (b) regulating
emotions in response to events that are emotionally
difficult. Upon review with clients, skills that seem
particularly relevant to pulling are selected to work on
with more focus. Molly's general emotion regulation
strategies were good; she exercised, had good social
relationships, and regularly used strategies she had
learned in her earlier course of CBT to help regulate
emotion (progressive muscle relaxation, cognitive restructuring). She and the therapist talked about her general
tendency to be doing something all the time as something
that made her more vulnerable to becoming dysregulated
and pulling. They worked on planning breaks so she
could relax, especially on nights when she had a lot of
Video 3. Mindfulness: Therapist teaches the client mindfulness,
practicing and demonstrating the skill in session.
Video 4. Emotion Regulation: Therapist teaches the client emotion
regulation skills.
Sessions 3–5: Mindfulness
Please cite this article as: Welch & Kim, DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case
Study, Cognitive and Behavioral Practice (2012), doi:10.1016/j.cbpra.2011.11.002
DBT2Enhanced CBT for Adolescent TTM
studying to do. She found that planning a few 10-minute
breaks as opposed to taking “pulling breaks” was
extremely helpful. Molly and the therapist also worked
on the skill of “opposite action” (exposure) to anxiety in
math class. This involved talking, answering questions, or
asking questions in class early on during the hour. She
found that if she did this toward the beginning of the class
she was less agitated and this seemed to help decrease
pulling.
Sessions 9–10: Distress Tolerance
Distress tolerance skills help patients find ways to
tolerate distress without pulling, including tolerating
strong and difficult urges to pull. Molly was already
making very strong efforts to avoid pulling, but mostly just
told herself not to do it. In this module of therapy, she and
the therapist worked on identifying other ways she could
get herself through a “crisis,” which in Molly's case was
simply the incredibly strong urge to pull her hair. She
developed a number of strategies, including self-soothing
(listening to her favorite music, eating chocolate,
shopping online, and snuggling with a childhood blanket
while watching TV). It took some work for Molly to realize
that these strategies were not designed to make her urges
go away, but to help her coexist with the urges without
resorting to pulling. She and the therapist also worked on
the skill of “radical acceptance”—specifically, accepting
that she had TTM and continued to experience urges to
pull, even though she had done very well in treatment.
This was very difficult for her and would sometimes make
her want to give up and pull. She worked hard on taking a
nonjudgmental stance toward her urges and pulling, and
this was useful to help her focus more frequently on
making mindful choices about what to do in response to
her urges.
Video 5. Distress Tolerance: Therapist teaches client distress tolerance
skills to help in situations where there are urges to pull.
Parent Training
Molly's parents, her father in particular, were involved
throughout treatment. At the beginning and end of each
session, a brief check-in was done with her parents. Often,
Molly taught the skills she had learned in session to her
father, and then her father was coached in how he could
support Molly during the week. Often, he was coached
simply to withhold comments about pulling. Parental
involvement at this level is not always possible with
adolescents, who sometimes do not wish their parents to
be actively involved in their treatment, but in this case it
was useful and appeared to help make Molly's relationship to her parents closer. Molly's father agreed to
support her by not talking about the hair pulling/skin
picking and by buying all tools to help Molly when
requested. In addition, her father participated in several
sessions with the therapist to help support his efforts to
not say anything about the pulling and encourage the rest
of the family to do this as well, which was extremely
difficult for him. He responded well to praise by therapist
and also engaged in his own effort to stop a difficult
behavior (overeating) by using some of the strategies that
Molly was using in therapy. Both Molly and her father said
that the bond between them improved as a result. Other
behavioral parent training interventions were also taught
during sessions with her father, such as attending to
positive behavior, validation and encouragement, and
differential reinforcement of other behaviors.
Session 11–16: Relapse Prevention and Booster Sessions
Towards the end of therapy, Molly worked on a relapse
prevention plan with the therapist, identifying what had
worked in treatment and how she could keep working on
her hair pulling. She and the therapist also discussed the
“abstinence violation effect” and how she could avoid a
Video 6. Parent Training: Therapist provides education to client’s
father about trichotillomania and advises ways that father can be
helpful.
Please cite this article as: Welch & Kim, DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case
Study, Cognitive and Behavioral Practice (2012), doi:10.1016/j.cbpra.2011.11.002
9
Welch & Kim
10
full relapse when inevitable slips occurred. Booster
sessions were then spaced out every few weeks. Molly's
pulling decreased substantially over the course of
treatment (see Figure 1). It did increase slightly posttreatment (see Figure 1) but both Molly and her family
reported that the pulling was not contributing to
noticeable hair loss or significant distress. While Molly
said that she wished trich could go away completely, she
felt that she had control over hair pulling and that the
skills she had learned were helping her deal with other
stressful situations in her life.
Discussion
Adolescence is an important time in terms of the
development of TTM. As reviewed above, TTM often onsets
in adolescence. Important patterns of pulling often begin
during the teen years, such as the beginning of “focused”
pulling that may serve to regulate emotions (Christenson et
al., 1993). Adolescence may be a particularly important
time for treatment of TTM, and the possibility of preventing
the kind of chronic, difficult-to-treat disorder seen in adults
is an exciting propect. However, the child and adolescent
treatment data are even more sparse than the adult data,
with only one published open trial to date (see Tolin et al.,
2007), and no RCTs yet published (Bloch, 2009). The case
study described here details an adaptation of a new
treatment package for TTM, DBT-enhanced CBT
(Keuthen et al., 2010). The treatment is an attempt to
improve existing CBT treatments through the addition of
skills to target specific pulling styles and has been reviewed
elsewhere (Keuthen & Sprich, 2012) and has some
promising, if preliminary, data (Keuthen et al., 2010).
Given the importance of emotion regulation and the
emergence of focused pulling in adolescence, we hoped
that adapting the DBT-enhanced CBT protocol for use with
teens might prove useful and pave the way for more
rigorous study. Although the results of any case study must
be interpreted cautiously, we were encouraged by the
response of the teen described here. Our clinical impression was that the DBT skills did appear to enhance her
response to the typical CBT skills. We observed that the
mindfulness and distress tolerance skills, in particular,
seemed very useful. The mindfulness skills appeared to
help Molly increase her awareness generally of her pulling,
in a way that actually increased her use of the more
traditional CBT skills, such as habit reversal and stimulus
control. The distress tolerance skills also appeared to help
Molly live with the distressing, uncomfortable urge to pull
long enough to employ the CBT techniques. She also
seemed to be more engaged with using them even when
they did not result in an immediate reduction in her pulling
urges. The positive results from these clinical innovations
and this case study are encouraging and we hope that
further research will demonstrate the efficacy of this
approach in treating teens with TTM.
Supplementary materials related to this article can be
found online at doi:10.1016/j.cbpra.2011.11.002.
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Address correspondence to Junny Kim, University of Washington,
Anxiety and Stress Reduction Center of Seattle, 1200 5th Ave., Suite
800, Seattle, WA 98101; e-mail: jkim@ebtseattle.com.
Received: December 3, 2010
Accepted: November 5, 2011
Available online xxxx
Please cite this article as: Welch & Kim, DBT-Enhanced Cognitive Behavioral Therapy for Adolescent Trichotillomania: An Adolescent Case
Study, Cognitive and Behavioral Practice (2012), doi:10.1016/j.cbpra.2011.11.002
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