Combining Psychological Treatments for Trichotillomania

Tasneem Abrahams
Apr 25th, 2016

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Trichotillomania is generally described as a condition in which a person compulsively pulls their hair out of their scalp until bald patches appear on their head, or they are left without hair. According to a recently published research paper on trichotillomania, it is: 

"a disorder that involves persistent and excessive removal of hair from one's body (e.g., scalp, eyebrows, eyelashes), resulting in evident hair loss."

The research paper, undertaken by Veerpal Bambrah of the University of Toronto Scarborough, is titled "Developments in Combining Psychological Treatments for Trichotillomania: A Review and Future Directions". While trichotillomania, which can affect anyone at any age can appear at first to be relatively harmless, and an innocent activity, the research paper has linked it to deeper-seated issues such as "low self esteem, high distress and severe social and vocational impairment".

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Hair pulling is a repetitive, habitual activity that either automatically happens without much thought being given to it, or a focused, intentional activity that is done on purpose to deal with negative experiences. It can occur in childhood and adolescence, and can continue for many years, even decades. It is something that hair pullers feel they cannot control, although they are aware of the damage they are doing to their hair. This habit, which people usually engage in as a way to relieve stress or anxiety can become a source of embarrassment at times when their hair starts to thin or they start to go bald. Trichotillomania usually requires treatment in the form of psychological counselling intervention. Sometimes trichotillomania results in trichophagia, the condition in which hair pullers eat their own hair, hair extensions or other peoples' hair.


Why does hair pulling happen?

While research indicates that it is not widely understood precisely why some people feel the urge to pull out their hair, eyelashes and even eyebrows, it has been documented that some people pull out their hair because it feels good. Trichotillomania can be associated with an underlying psychological issue, such as anxiety, depression and low feelings of self worth, or another issue that has not been adequately addressed or treated. Research has linked the occurrence of trichotillomania to irregularities in how the brain regulates emotional responses, movement and impulse controls, and plays a role in habit formation.

Treating trichotillomania

Depending on the severity of hair pulling, trichotillomania can result in a very noticeable hair loss that people try to cover up with hats and other forms of headwear. Treating trichotillomania can be difficult due to a lack of awareness about the condition, and a "limited awareness about effective treatment options". Furthermore, trichotillomania is not always recognised for what it is - a serious condition that requires professional counselling and strategies for replacing the repetitive hair pulling with an activity that is not self harming. It is usually, initially seen as a harmless activity unless the hair loss is noticeable. Medical professionals who recognise trichotillomania for what it is have noted that while some people successfully stop pulling their own hair out, and some continue to pull their own hair out, it is generally viewed as a "chronic, relapsing and treatment-resistant disorder". The combination of habit reversal therapy, acceptance and commitment therapy (ACT) and dialectical behaviour therapy has been found to greatly reduce the incidence of trichotillomania. While a comprehensive behavioural method and pharmacotherapies have been indicated to assist in treating trichotillomania, there is still ongoing research in this area for more effective future treatment of the condition. Habit reversal therapy is a multicomponent behavioural treatment approach that looks at addressing a wide variety of repetitive behavioural disorders, including, in addition to trichotillomanina, skin picking, nail biting and thumb sucking. Habit reversal therapy in terms of treating trichotillomania relates to creating awareness of the condition. This form of treatment focuses on showing the person how to self monitor their actions and removes environmental tools associated with hair pulling such as tweezers that could encourage hair pulling and teaches the person how to stop pulling their hair out with their hands. Sometimes, it may require a supervision of a person's hair pulling activities, especially in the case of children, to reinforce healthier choices instead of hair pulling. Research has shown that when habit reversal therapy is done in combination with the abovementioned therapies, especially other forms of cognitive behavioural therapy, a reduction in trichotillomania is seen.The comprehensive behavioural method is when a therapist will monitor the person's behaviour, and help them to identify targets and to develop and implement strategies and skills to stop this behavior. The therapist evaluates the person's response and improvement in stopping the act of hair pulling over a period of time. The research showed that habit reversal therapy is most likely more effective for the motion of automatic hair pulling and cognitive and emotion based regulation therapies and interventions may work best for those who intentionally pull their hair out in focused pulling. Providing support to people with trichotillomania is a very important aspect of treating the condition as it helps to prevent a relapse of the condition. Support given to someone dealing with trichotillomania includes speaking to the person about their condition, helping them to understand it, equipping and empowering them with strategies to cope with it and change their response to pulling their hair out, and conducting follow up conversations on how they are doing.

Future research

Trichotillomania is a challenge to research as researchers realise it is more complex in nature than initially thought. It is not exactly

 known what causes it, or how to effectively to treat it as each person is different, and different factors could trigger it. It has however been shown that the comprehensive behavioural method shows promise in effectively addressing trichotillomania, and helps to address and appropriately treat underlying issues such as anxiety, depression and emotional responses. Research in treating trichotillomania more effectively is still ongoing, and is a growing field of interest for researchers to study.


Tasneem Abrahams


Tasneem is an Occupational Therapist, and a graduate of the TLC foundation for BFRBs professional training institute. Her experience in mental health includes working at Lentegeur Psychiatric hospital forensic unit (South Africa), Kingston Community Adult Learning Disability team (UK), Clinical Specialist for the Oasis Project Spelthorne Community Mental Health team (UK). Tasneem is a member of both the editorial team and the clinical staff on TrichStop, providing online therapy for people who suffer from Trichotillomania and other BFRBs.

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