The Greek words thrix (hair) and tillein (to pull) name an impulse disorder in which people feel mounting tension that can be relieved only by pulling out their hair. Many people with trichotillomania (TTM) also bite nails, suck their thumb, chew their tongue, pick scabs, cut themselves, or bang their head. People with TTM can have obsessive-compulsive disorder or have relatives with OCD. Both conditions may be related to problems with the neurotransmitter serotonin. Although stress can aggravate or cause the first onset of hair pulling, TTM is most likely a biochemical, inherited disorder.
The following questionnaire supplies information needed prior to starting treatment for this problem.
HAIR PULLING QUESTIONNAIRE
What “risky” activities are likely to lead to hair pulling:
What behaviors or feelings come just before you start to pull your hair:
What behaviors would make hair pulling more difficult or impossible:
What rewards can you give yourself for days or hours when you resist urges to pull?
Behavior therapy can be very effective in eliminating hair pulling. Antidepressant medications that increase serotonin levels may first be needed if depression, panic disorder, or OCD accompanies TTM. This helps people gain the motivation and focus needed for behavior treatment. Beware of tranquilizers and sedatives that can prevent practicing or learning the following urge-reducing strategies:
1: Awareness training:
2: Relaxation training. Practice each of the following and decide which is most useful:
Competing response (imagery) training: Choose a behavior
from #4 on the Hair Pulling Questionnaire to substitute for hair
pulling. Imagine being in a situation in which hair pulling occurs
and see yourself practicing a competing behavior.
Exposure training to high-risk situations: Practice substituting a
competing response (#4 on questionnaire) through imagery
and then expose yourself to the actual situation. Give yourself
a reward if you are able to resist any urges to pull. Continue to
practice deliberate exposure in various situations until urges to
pull are absent or reduced. Use relapses to clarify high-risk
situations and practice exposure.
When hair pulling starts before the age of 4, it is often outgrown. Parents need only use simple interventions such as rewards for not pulling and distractions (competing responses) described above and on the questionnaire. TTM that starts at 13 or older may need intense intervention as described above. When young children are still pulling hair by age 6, they may have the later-onset type of TTM that requires behavior treatment.
Ideas for the questionnaire and the treatment program are adapted from Trichotillomania: A Behavioral Approach Video and Manual by Carol Novak (Pioneer Clinic, 1995) and Trichotillomania: A Guide by Anders and Jefferson (Dean Foundation, 1994).