Trichotillomania

1. Trichotillomania Barbara Bisch Holy Family University

2. Diagnostic criteria for 312.39 Trichotillomania A. Recurrent pulling out of one’s hair resulting in noticeable hair loss. B. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior. C. Pleasure, gratification, or relief when pulling out the hair D. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g. dermatological condition) E. The disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 2000)

3. General Information: (continued) • Body Focused Repetitive Behaviors (BFRB) • Trichotillomania, Skin-Picking • Repetitive self-grooming behaviors in which pulling, picking, biting or scraping of the hair, skin or nails result in damage to the body • (TLC, 2011)

4. General Information: • Also know as “Hair Pulling Disorder” • Experts prefer this terms • term “mania” • Can be abbreviated • TTM • Trich • Until 20 years ago there was little focus or research on this disorder • Hair is pulled from eyebrows, eyelashes, scalp, or other areas of the body (Trichotillomania Learning Center (TLC), 2011)

5. Types of Hair Pulling Focused Pulling Automatic Pulling (Flessner et al., 2009) • Pulling with a compulsive quality • May be in response to negative emotional state • Stress, anxiety, anger, etc • Fluctuation due to psychological stress associated with different ages Pulling without awareness No change from adolescence to adulthood

6. Who does this disorder affect? • 2-5% general public suffer from Trichotillomania • 9 million Americans (TLC, 2011) • All ages, genders, ethnicities, nationalities, and SES backgrounds are included (TLC, 2011) • Predominately seen in females (Stein et al., 2010) • Usually begins in adolescence (Stein et al., 2010)

7. Developmental Differences • Changes in pulling sites • Developmental Maturation • Stigma • Women become more aware of stigma associated with disorder with increased age • Rotating sites • Anxiety • Increases with age • Physical anxiety most common (Flessner et al., 2009)

8. Living with Trichotillomania **The therapist must address these issues and develop skills in these areas to prevent relapse.** (TLC, 2011) Social Impairment Interpersonal Impairment Shame Isolation Low-self esteem Problems with school Lack of vocational interest

9. Other Mental Health Disorders TTM and Alopecia TTM and OCD • Can be mistaken for each other • Typical way to differentiate: • Hair is broken at different levels • Damage to hair follicle (Radmanesh, Shafiei, & Naderi, 2006) Share similar characteristics Respond to different treatments More similar to anxiety or impulse control disorder (Malhorta et al., 2008)

10. Treatment • Cognitive Behavioral Therapy • Provides core techniques for treating this disorder (Tolin et al., 2007) • Habit Reversal Training: • Awareness Training • Competing Response Training • Social Support • Other CBT techniques: • Assessment/Self-monitoring • Behavioral Techniques • Addressing the Environment, Feelings, Thoughts, and Behaviors

11. Other Effective Treatments • Acceptance and Commitment Therapy (ACT) • One does not “have to” respond to an urge or emotion • Dialectic Behavior Therapy (DBT) • Focus on living in the moment through: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance • When paired with traditional CBT techniques treatment has been enhanced (Keuthen et al., 2010)

12. Case Study: Jennifer, age 29 months Background Information: Jennifer, age 29 months Treatment Used: Behavioral Treamtent (Rahman, Toufexis, Murphy, & Storch, 2009) • Fascination with hair as infant • Pulls out hair 100 times per day • Ingests hair after • Antecedents: • Boredom, frustration, or being restrained • Hides behaviors from parents • Other than TTM no behavioral issues are present • 14 daily behavioral sessions • Identified patterns • Rewards • Responded after 3 days of treatment • At conclusion of the treatment • Reduction of hair pulling – 30 min/day or 1-10 hairs per day

13. Resources: • http://www.youtube.com/v/oO5qAuja5_8&fs=1&source=uds&autoplay=1 • http://www.trich.org • Stoppulling.com • Stoppicking.com

14. References: • American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author • Flessner, C., Woods, D., Franklin, M., Keuthen, N., & Piacentini, J. (2009). Cross-sectional study of women with trichotillomania: a preliminary examination of pulling styles, severity, phenomenology, and functional impact. Child Psychiatry And Human Development, 40, 153-167. • Keuthen, N., Rothbaum, B., Welch, S., Taylor, C., Falkenstein, M., Heekin, M., & ... Jenike, M. (2010). Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania. Depression and Anxiety, 27, 953-959. • Malhotra, S., Grover, S., Baweja, R., & Bhateja, G. (2008). Trichotillomania in children. Indian Pediatrics, 45, 403-405. • Rahman, O., Toufexis, M., Murphy, T., & Storch, E. (2009). Behavioral treatment of trichotillomania and trichophagia in a 29- month-old girl. Clinical Pediatrics, 48, 951-953. • Stein, D. J., Grants, J. E., Franklin, M.E., Keuthen, N., Lochner, C., Singer, H.S., & Woods, D.W. (2010). Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: toward DSM- V. Depression and Anxiety, 27, 611-626. doi:10.1002/da.20700 • Tolin, D., Franklin, M., Diefenbach, G., Anderson, E., & Meunier, S. (2007). Pediatric trichotillomania: descriptive psychopathology and an open trial of cognitive behavioral therapy. Cognitive Behaviour Therapy, 36, 129-144. • Trichotillomania Learning Center. (2011). Treatment guidelines for trichotillomania, skin picking and other body focused repetitive behaviors. Santa Cruz, CA: Author