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CBT for Trichotillomania (Hair Pulling, Skin Picking, Nail Biting)

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What is Trichotillomania (and Body Focused Impulse Control Disorders)?

Trichotillomania (TTM) is defined as recurrent pulling out of one’s hair, resulting in noticeable hair loss, which is not due to another medical condition. There is often, but not always, an increasing sense of tension–strong urges– immediately before pulling out the hair, or when attempting to resist the behavior, and pleasure, gratification or relief during and/or immediately after the act. While the diagnostic manual does not yet recognize it, recent researchers have proposed the phrase Body Focused Impulse Control Disorders (BFICD) to describe the full range of behaviors associated with trichotillomania. The most common examples are nail biting, cuticle biting and picking, skin picking, and other compulsive, excessive grooming behaviors. The treatment described here applies equally well to this full range of specific body-focused problems. Trichotillomania is often related to other emotional disorders, such as panic attacks, worry & rumination, OCD and depression.

How many people are affected?

The true prevalence of TTM and BFICD is unknown, since people are often ashamed of their behavior and are consequently reluctant to discuss it, even with their doctor. So it is difficult to get reliable statistics. Historically it was thought to be rare, but the condition is now better understood and more people are seeking help. More recent estimates range from 0.5 to 3.5% of the population, depending on the definition used, and the nature of the study.

What is TTM like?

Sufferers as a group pull hair from a wide range of body sites including the scalp, eyebrows, eyelashes, beard, pubic areas; and, less commonly, underarms, chest, ears, nose and general body hair. The sites pulled by particular people vary widely, and may be restricted to one or two sites.

Associated behaviors include searching for hairs that stand out in some way; repetitive drawing of hair through the fingers, or over the lips, before or after pulling; picking of associated skin; careful examination of the hair or roots; compulsively playing with, or splitting the hair; biting off the roots, or the hair itself into segments.

The behaviors are also specific to the particular person; some just pull eyebrows with tweezers, for example, and others just pull from their scalp. Some pull intensively from particular sites; others try to manage their appearance by pulling less intensively, but from a wider range of sites. Some people eat the roots or the whole hair. Since hair is not digested, but remains in the stomach, this condition is potentially dangerous and medical examination should be sought.

What are the causes, and when does it start?

There is no known single or obvious cause, and there may be several contributing factors, such as genetic predisposition and stress. It is now commonly regarded as a medical illness, and it may be caused by a disruption in the system for communication between cells in the brain. People frequently start compulsive pulling at 12 to 13 years of age, although commonly at a much younger or older age. The onset may be associated with hormonal changes at puberty, although many people recall a significantly stressful event associated with the onset.

Why does pulling comfort me?

During hair pulling episodes, the sufferer frequently pulls from zones of heightened sensitivity. It is generally not painful to pull from these areas, or the pain is mild and the pulling causes great relief, or even comfort. The pulling can quickly become compulsive, causing relief and comfort on the one hand, but anxiety and distress at the increasing hair loss on the other. Sufferers can quickly become greatly distressed at an apparent inability to control their own behavior, and the continual increase in damage to both their hair and self-esteem.

Are there associated illnesses or conditions?

There are apparent similarities with the symptoms of Obsessive Compulsive Disorder (OCD), but only a low minority of Trichotillomania sufferers have OCD as well; 15% in one study. Depression has been reported to occur in a majority of people. However it is not known if this is due to a direct biological link between the two conditions, or whether the depression is a consequence of the severe loss of morale and self-esteem brought on by the hair pulling. Other behaviors believed to be common include nail biting and skin picking. Procrastination has been reported as a symptom. This behavior of putting off tasks is very frustrating to family and friends, and may be disruptive of personal relationships.

How is TTM treated?

While many approaches claim to help (example, hypnosis), only Cognitive-Behavior Therapy (CBT) is associated with supportive evidence from scientific studies. CBT involves identifying and modifying the patterns that lead to hair pulling. Through careful practice and professional coaching, the urges to pull may be effectively resisted and gradually subside. The treatment may also involve group therapy, and/or training in life skills such as assertiveness, anger/anxiety and stress management, goal setting, problem solving and relaxation. Programs are usually tailored to the needs of the individual and, where practical, involve the family and supportive others.

Medications are reported to have limited long term effectiveness, but may be a useful adjunct to CBT. They may also be used to reduce the symptoms of associated depression.

A sense of community is a powerful force for healing with many people – to know that you are not alone; to discover after years, or even decades, that your condition is known to medicine; to share your thoughts and feelings; to feel understood and accepted; to see people, who share the same affliction, caring for one another.

Skin care has been shown to be important for control of the condition in some people. A variety of effective and readily available products have been identified to relieve intense itching or other associated problems, which are present with some people. Those who pull from eyebrows or lashes may benefit from avoiding furry pets and frequent washing of the hands and eye area with soap and water.

It is important to note that, regardless of the mode of intervention, improvement tends to be gradual and incremental rather than all-or-none. It is helpful to gauge improvement by all aspects of the person’s overall quality of life.

How can I meet other sufferers?

There are two broad ways to interact with fellow sufferers: via support groups in your own locality and via the various Internet networks. The Trichotillomania Learning Center (TLC; www.trich.org) attempts to maintain a comprehensive listing of support groups. For those who have an Internet connection, there are support groups using email, which are knowledgeable, helpful and provide a safe environment for interaction and learning.

What can I do for friends and family who struggle?

The best way to help sufferers with TTM is to care about them, to try to understand them, and to help them to learn more about their condition and how to manage it. Sufferers commonly express enormous relief to discover that they are not alone; to find that the condition has a name; and to be reassured that they are not weird or mad. It can be a profound experience for a sufferer to describe their behavior and associated feelings to others people, and for this to be accepted. Parents of sufferers have often sought guidance about what is a helpful approach toward their children and specific information and contacts are available for parents.

Habit Reversal Training (HRT)

HRT is a series of exercises intended to help you effectively channel your willpower and break the trichotillomania habit for good. The approach is simple but not easy. It takes consistency and patience. To improve your follow-through, your therapist will coach you along the way. The essential strategy is to replace hair pulling with other activities that occupy your hands, and to develop healthy coping skills for addressing the stressful mood states that often contribute to pulling. HRT involves the following steps:

Awareness Enhancement-Hair pulling tends to be an automatic behavior. The first step in treatment then is to carefully study your pattern by becoming aware of when you are pulling. This will help you determine the circumstances that contribute to pulling, such as mood (e.g., lonely, bored, angry), time of day (e.g., early morning, getting home from work), and activity (e.g., working at desk, watching TV). Understanding your pattern provides valuable information for developing a successful treatment program.

Stress Management through Abdominal Breathing and Progressive Muscle Relaxation (PMR) – These simple stress management exercises are practiced to reduce the stress and anxiety that often arise when one resists urges to pull. They should be practiced daily for the first three weeks (See “Natural Relaxation” handout) until they become familiar and automatic. This way they can be applied effectively during difficult periods.

Alternative Behaviors – These consist of almost any activity that is incompatible with pulling. Generally, that means actions that occupy your hands. Examples of activities that have been helpful to our patients are: playing with a paper clip, silly putty, knitting, tensing and releasing the muscles of the hands (as described above).

Stimulus Control – This involves managing your environment with the goal of limiting the triggers that lead to and allow pulling. For example, if you only pull while you’re alone, try to be around other people, leave the bathroom door open, etc, while you work on gaining confidence. If you use grooming tools to pick at your skin or cuticles, discard these tools.

Putting it All Together – The following sequence incorporates awareness, stress management, and habit reversal.

  1. Detect situations likely to lead to pulling or actual urges to pull (ideally, before or as soon as pulling starts).
  2. Immediately engage your alternative behavior.
  3. Repeat this sequence at least 6 times per day for practice, whether or not you are having urges to pull.
  4. Use this sequence every time you have an urge to pull. Repeat it as often as necessary.

A complete treatment plan usually involves several other coping strategies to occupy your hands and get your mind off urges to pull. Treatment for secondary low self-esteem and depression often associated with Trichotillomania and BFICD may also help to improve your self-confidence and get you back on track.

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