Question 1

I am working with a teen who is struggling with anxiety and depression. Pulling out their hair and picking their nails seem to be used as coping mechanisms, but it makes sense that they are part of an OCD. What treatments have you had most success with in this age group?

David Tolin · Accepted Answer

Hair pulling and skin picking can be related to anxiety and depression, but generally require a focused, specialized treatment. The most well-validated treatment for these problems is called Habit Reversal, which includes building awareness of the behavior, training a competing behavioral response (for example, squeezing a fist or playing with a fidget toy), and using cues and barriers in the person’s environment to discourage pulling and picking.

For further reference see https://www.amazon.com/Treating-Trichotillomania-Cognitive-Behavioral-Hairpulling-Disorders/dp/1441924256

Question 2

Hi, I’m currently working with a 28 year old female with this disorder since she was 11. No medication, lots of CBT but nothing To prevent the severity. Wears a wig due to lack of hair left. She recognizes this as a form of OCD. Is there medication that has been successful in treating this?

David Tolin · Accepted Answer

Unfortunately, there are very few well-controlled studies of medications for trichotillomania, and some studies (for example, a trial of fluoxetine) showed minimal impact.  There is some preliminary evidence that clomipramine, olanzapine, and N-acetylcysteine might be effective for trichotillomania, but this comes largely from smaller studies.

Question 3

Hello David, for a transwoman client with trichotillomania which seems related to frustration around impeded transition (hair is seen as a major expression of femininity), do you have experience or advice?

David Tolin · Accepted Answer

Sounds like a very tricky case. Here, the hair pulling seems to be less of a true trichotillomania, and more related to gender identity.  Before starting in on the hair pulling, it might be helpful to work with this client to process their feelings about gender and the transition.

Question 4

Can hair pulling be related to ADD (a fidget type of behavior)?

David Tolin · Accepted Answer

Yes, there are high rates of ADHD in people with trichotillomania.  As a side note, sometimes, the medications that we prescribe for ADHD can actually make hair pulling get worse.

Question 5

Which parts of CBT are most effective in treating trichotillomania?

David Tolin · Accepted Answer

The name of the game in CBT, at least right now, is Habit Reversal.  This includes: (1) building up the client’s awareness of the behavior so it’s not done on “autopilot;” (2) teaching the client to use a competing response such as playing with a fidget toy or squeezing a fist when they have an urge to pull, and (3) stimulus control, which involves using cues (e.g., signs in high-risk locations) and barriers (e.g., wearing band-aids on the fingertips) to help the client get better control over the behavior.

Question 6

Why was trichotillomania reclassified in the DSM 5 from an impulse-control disorder to OCD?

David Tolin · Accepted Answer

You’ve got me there. I think it’s an impulse control disorder.  But there was a long debate about this issue, and some scholars have suggested that trich and OCD have common heritability and shared abnormalities in brain function.

Question 7

Why do you think that age of onset of hair-pulling in childhood is consistently 10-13 years?

David Tolin · Accepted Answer

No one really knows why hair-pulling begins around that age range.  But some research suggests that trichotillomania can start in response to stressors that often occur in childhood, such as alienation from friends, entrance into a new school, academic difficulties, onset of menarche, parental divorce, and the birth of a sibling.

Question 8

What is your theory on why boredom is a triggering state for some people for hair pulling? What treatment strategies would you recommend for this scenario?

David Tolin · Accepted Answer

Many people with trichotillomania pull when they’re bored, although some pull when they are overstimulated.  It’s thought that hair pulling serves an emotion regulation function, by relieving boredom or by helping the person to feel soothed.  In either case, however, it’s good to know what the trigger is so you can attack trich early.  For example, when boredom is the trigger, then we’d want to teach the person to start using their strategies whenever they notice themselves feeling bored, before the urges even come on.

Question 9

What is a typical natural course of this disorder if people don't get treatment?

David Tolin · Accepted Answer

Early childhood-onset trichotillomania can sometimes go away on its own or with a simple intervention.  However, in many cases, and especially with adults, the disorder tends to be chronic, with fluctuations in severity often related to environmental stressors.

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