Domestic Violence and Trichotillmania: A New Look At Treatment

It is well-established that survivors of domestic violence (DV) often struggle with mental health issues following their abusive experience. They can experience depression, anxiety, post-traumatic disorder and problems with emotional regulation. It is not uncommon for survivors to develop multiple mental health issues including trichotillomania (TTM). However, identifying and treating co-occurring disorders isn’t always a clear path. There are established treatment modalities, such as Dialectical Behavior Therapy (DBT), that are effectively used to treat certain aspects of post-DV trauma and the resulting emotional dysregulation. New research suggests that some of the same treatment modalities used to treat survivors of domestic abuse may in fact, be helpful in addressing those survivors who experience TTM as well. 

Understanding Domestic Violence

The prevalence of DV is thought to be under-reported. It is hard to identify, and survivors are often reluctant to report it. Co-occurring disorders can complicate the clinical picture. Domestic violence affects nearly 10 million people annually, in the United States alone. Internationally, numbers vary but the World Health Organization estimates the prevalence of domestic violence to be about 20-33%, depending on region. Women are overwhelmingly more likely to be the target than the perpetrator.

To understand TTM in the context of DV, it’s important to understand the dynamics of DV. Domestic violence is not a single type of violence. Rather, it is a broad term used to describe a type of violence that occurs in the context of relationships or families. It is most often associated with intimate partner violence. The dynamic underlying DV is the gaining of power over another person. DV can include physical violence, emotional or psychological abuse, or sexual abuse. It can include actions like physical or sexual assault, stalking, or psychological aggression or coercion.  

The DV and Trichotillomania Connection

The experience of DV over time can result in emotional dysregulation. Viewing DV through an emotional dysregulation model, over time, the experience of DV leads to the invalidation of the person’s thoughts and feelings. Over time, this cycle of invalidation by the perpetrator leads to guilt and shame that results in the person’s self-invalidation. Constant invalidation from the perpetrator and from within the self increases emotional sensitivity and heightened arousal. It becomes harder and harder for the person to return to emotional stability.

TTM can similarly be viewed through an emotional regulation model. Research supports that people with TTM tend to struggle with emotional regulation and distress tolerance moreso that those who do not have TTM. Hair pulling is thought to be an attempt to avoid or alleviate emotional distress. The act of pulling brings relief from painful thoughts and feelings, thus attempting to regulate emotions.

So, what does all this mean? Both DV and TTM can be viewed through the lens of emotional regulation. As such, researchers are looking at whether they can be treated concurrently using approaches that address the underlying emotional dysregulation.

Enhanced Treatments

Dialectical Behavior Therapy (DBT) was initially developed to address chronic suicidality in persons diagnosed with Borderline Personality Disorder. Over the years, DBT has been expanded in use with other populations including survivors of intimate partner violence (IPV). More recently, enhanced approaches that combine DBT with other more traditional treatments such as Habit Reversal Training (HRT) have been found to be helpful for people living with TTM.  

HRT is a behavioral therapy for tics and habitual behaviors. It can include awareness training, competing response training, and social support or contingency management and often, stimulus control strategies. Enhancing HRT with DBT techniques addresses the internal experience of TTM such as urges, negative emotions, and emotional dysregulation.  

Concurrent Treatment – What the Study Found

The 2021 study explored the possibility of concurrent treatment of an IPV survivor who was also diagnosed with a hair pulling disorder. A thorough assessment was completed with attention to the participant’s cultural and early childhood experiences. The researchers designed a dual session structure. Sessions were structured into two separate components, each with its own therapist to work with the person. Issues related to the IPV were addressed in a DBT-based IPV-skills group. Hair pulling was addressed in individual sessions using a DBT-enhanced HRT technique.

Group sessions were conducted over a 10-week period and individual sessions over a 9-week period. The focus of sessions were similar and complementary. The DBT for IPV focused on emotion regulation skills in a broad way. The DBT-enhanced HRT approached the hair pulling as an emotional regulation issue, encouraging both reduction in hair pulling and the development of improved emotional regulation skills.

Within 6 sessions, significant treatment gains were reported both in the participant’s insight and self-empowerment. A clinically significant reduction in hair pulling behavior was reported by 9 weeks. This reduction in pulling is quicker than what has been reported in previous studies. The researchers speculate that because DBT targets systemic emotional dysregulation and HRT seeks to replace problematic self-soothing behaviors, such as BFRBs, the combination of protocols helped to target both the actual behavior (in this case, hair pulling) and the underlying distress and emotional dysregulation.

This study also highlights the importance of client-oriented outcomes. When clients share their cultural information, clinicians can use that information to design culturally relevant treatment plans. The researchers suggest that the results of this this case study lends support to the implementation of DBT and DBT-enhanced HRT with cultural minorities, as both treatments were found to be acceptable by the participant.

While this study is a small, case-based study, the findings are intriguing and worthy of further exploration. Survivors of IPV and other traumas frequently present with symptoms of multiple diagnoses. It isn’t always clear which to treat “first”. This study suggests that some issues may be able to be addressed concurrently using compatible, enhanced treatment protocols. They might quite possibly treated more effectively in this way. While more research is needed, the results are promising for people living with BFRBs.

References

1.   Casas, J. B., Szoke, D. R., & Benuto, L. T. (2021). Concurrent Treatment of Intimate Partner Violence and Trichotillomania From an Emotion Regulation Framework: A Case Study. Clinical Case Studies, 20(2), 115–128. https://doi.org/10.1177/1534650120964581

2. World Health Organization: https://www.who.int/news-room/fact-sheets/detail/violence-against-women

3. Iverson, K. M., Shenk, C., & Fruzzetti, A. E. (2009). Dialectical behavior therapy for women victims of domestic abuse: A pilot study. Professional Psychology: Research and Practice, 40(3), 242-248. doi:10.1037/a0013476

4. Arabatzoudis, T., Rehm, I. C., Nedeljkovic, M., & Moulding, R. (2017). Emotion regulation in individuals with and without trichotillomania. Journal of Obsessive-Compulsive and Related Disorders, 12, 87-94. doi:10.1016/j.jocrd.2017.01.003

5. Snorrason, I., Berlin, G., & Lee, H. (2015). Optimizing psychological interventions for trichotillomania (hair-pulling disorder): An update on current empirical status. Psychology Research and Behavior Management, 105. doi:10.2147/prbm.s53977

6. Keuthen, N. J., Rothbaum, B. O., Fama, J., Altenburger, E., Falkenstein, M. J., Sprich, S. E., Kearns, M.,Meunier, S., Jenike, M. A., & Welch, S. S. (2012). DBT-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial. Journal of Behavioral Addictions, 1(3), 106–114. https://doi.org/10.1556/jba.1.2012.003