Does it Work ?


A psychotherapy approach called cognitive behavior therapy (CBT) is the treatment of choice for BFRBs.


What is CBT for Trichotillomania?

The Cognitive Behavioral Frame of Reference is a learning theory based in evidence that our thoughts, behaviors and emotions are invariably intertwined and therefore have a direct influence on each other. Cognitive Behavioural Therapy is a practical, problem-solving approach fundamentally rooted in an understanding of an individual’s cognitive behavioural sequence. The premise is that our thoughts and beliefs influence our interpretation of the events that we experience on a daily basis. These thoughts then create feelings, our feelings influence our behavior, and our behavior then either reinforces or refutes our thoughts and beliefs.

Figure 1: Cognitive Behavioral Sequence

When the behaviour we engage in, in response to negative thoughts and emotions, provides relief, it positively reinforces this behavioural response the next time we have a similar experience. For example people with trichotillomania often report feeling a sense of release from stress or anxiety while engaged in hair pulling. Hair pulling therefore becomes a learned response to events or situations that elicit stress or anxiety. This then sets in motion an undesirable cognitive behavioural cycle. The goal of CBT for trichotillomania is therefore to help you unlearn the reaction of hair pulling in response to certain stimuli, and to replace it with more acceptable alternatives.

Figure 2: Hair Pulling Cognitive Behavioral Cycle

In CBT, the therapist will help you identify the factors that trigger negative thoughts and emotions that lead to hair pulling. The therapist will encourage you to develop an increased awareness of the times of day, emotional states and thought patterns during times when hair pulling occurs. You will be guided in exploring and challenging “faulty” thoughts and interpretations, and the therapist will help you identify behavioural responses that interfere or compete with hair pulling. CBT is thus a very hands-on treatment, often involving assignments which you complete between sessions, e.g. keeping a hair pulling record, or learning to record your thoughts and looking at them more realistically.

Figure 3: Action Reflection Experiential Learning Cycle

CBT differs from other therapies in that it has a clear structure and is focussed on what you are experiencing in the present as opposed to exploring events of the past. You and your therapist will work as a team to identify goals and find practical solutions to achieving them. A large component of this is reflecting on your values and vision for your life and finding ways to engage in behaviour that are congruent with these.

Does CBT work for trichotillomania?

CBT is recognised among health professionals as the most effective method of treatment for Body-Focussed Repetitive Behaviors such as Trichotillomania. The compulsive hair pulling disorder involves two core behavioural processes: automatic and focused pulling. Habit Reversal Training (HRT) and Stimulus Control (SC) are two methods of CBT used to treat automatic pulling, while acceptance and commitment therapy (ACT) is employed to treat focussed pulling. One study looking at the effectiveness of ACT and HRT found that there was a significant reduction in hair pulling severity, impairment ratings, and hairs pulled, in the participants who received ACT/HRT compared to those who were in the control group. Another study examined the efficacy of CBT and the serotonin reuptake inhibitor, clomipramine, compared with placebo in the treatment of trichotillomania. The results indicated that CBT had a dramatic effect in reducing symptoms of trichotillomania and was significantly more effective than clomipramine or placebo.

Figure 4: Symptom reduction observed after 10 sessions of ACT/HRT treatment

Does online CBT work?

So we know that CBT for trichotillomania works, but the evidence refers to traditional face-to-face therapy. Can internet-based therapy ever really be as effective? In a technology-driven world, the internet has bridged the gap in access to support and information for individuals who either cannot afford professional help, do not have geographical access to experts in the field, or find face-to-face interaction too challenging.

"StopPulling" is an on-line, interactive self-help approach derived from evidence-based cognitive behavioral models of treatment for trichotillomania. Preliminary data from 265 users of the program during the first year of public availability suggested significant improvement in symptoms. Response rates were comparable to long-term follow-up after more intense cognitive behavioral treatment.

There is also evidence of the effectiveness of online CBT for other conditions such as OCD and anxiety disorders. One study that examined the relative efficacy of online versus clinic delivery of CBT in the treatment of anxiety disorders in adolescents, found that 78% of adolescents in the online group no longer met criteria for the principal anxiety diagnosis at 12-month follow-up compared with 80.6% in the clinic group.

Figure 5: Efficacy of online VS clinic delivery of CBT

CBT is also widely regarded as an effective treatment for obsessive compulsive disorder (OCD), but similar to trichotillomania, CBT therapists who specialize in this field are scarce. One study that evaluated internet-based CBT for OCD found that 61% of participants at post-treatment had a clinically significant improvement in OCD symptoms, and 43% no longer fulfilled the diagnostic criteria of OCD. The treatment also resulted in statistically significant improvements in self-rated OCD symptoms, general functioning and depression.

Figure 6: Evaluation of internet-based CBT for OCD

The available evidence indicates that CBT is effective in the treatment of trichotillomania and that internet-based CBT is as effective as traditional face-to-face therapy. With full support from an expert therapist to guide and support you through the program, the TrichStop online therapy program has the potential to provide an effective alternative to inaccessible traditional therapies for trichotillomania.