A brief introduction to Trichotillomania & clinical responses

SHIP Peer Group Supervision12th February 2014

Trichotillomania, which I will henceforth refer to as TTM for brevity, refers to the repetitive pulling of one’s hair to the point of hair loss and functional impairment (Woods & Twohig 2008)

Research on TTM’s etiology, maintenance and treatment is limited. The latest edition of the APA’s Diagnostic & Statistical Manual (DSM 5) estimates prevalence of the disorder at 0.6%. However this may be misleading as the authors continue to insist on criterion for TTM that include an experience of tension in the client prior to hair-pulling & a subsequent releasing of this tension by the act.

Christenson et al (1991) have suggested that prevalence jumps to 3% when these DSM criteria are disregarded. Presentation is more common in female clients than males by a ratio of 6:1

When working with SHIP clients, we routinely encounter incidences of cutting, scalding, & self-poisoning. Such acts often lead to medical intervention and thus get flagged on referral forms to our service. The SHIP assessment may uncover more about the client’s history of DSH behaviour, but TTM often may not be disclosed at this point owing to two issues concerning its ‘visibility’:

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•the automatic or subconscious nature of the behaviour• a historic minimisation of its significance in the clinical picture

Regarding TTM as Self Harming Behaviour

This is some disagreement about this. The DSM classifies TTM as an Impulse Control Disorder. This places it in the same taxonomy as gambling, kleptomania & sexual addiction.

The DSM also suggest that the behaviour lies on the obsessive-compulsive spectrum

It may be that TTM has not traditionally been regarded as self-harming for the following reasons-It usually doesn’t cause physical pain or immediate injury

-- it can be an unconscious or non-deliberate act

-TTM is harmful & does have consequences

-Trichophagia is co-present with TTM in about 18% of cases (Mansuetto 1999), This involves ingesting the hair, leading to gastro-intestinal disturbances including possible formation of an bezoar (a potentially fatal intestinal blockage)

-Increased shame & lowered self-esteem if the behaviour leads to noticeable changes in appearance (alopecia, folliculitis, atypical regrowth)

-- Other medical complications such as carpal tunnel syndrome, enamel erosion & gum disease

-- functional impairment; the behaviour can develop to such an extreme that several hours per day are devoted to it

-An non-conscious act?

-Two distinct forms of TTM have been identified; focused and automatic.

- -Grant (2007) argues however that most clients will indicate both of these variants. Unsuprisingly, it is easier to work with the former aspect therapeutically

Mansueto (1997) reviewed the literature and identified some notable features of TTM presentation:

•Most common settings for hair pulling were client’s bedroom & bathrooms respectively•Pulling increased during sedentary activity especially reading and while watching TV. Habituated driving was also cited.

•Specific physical, visual & tactile stimuli frequently brought on pulling e.g. ‘target hairs’ of a certain colour/shape/texture•Pre-pulling behaviour is often present and usually takes the form of stroking or twisting the hair. More time may be devoted to this activity than actual pulling.

N.B. the latter symptom often ‘joins the conversation’ in a therapy setting!

Emotional states associated with hair-pulling

•Anxiety•Tension•Boredom•Lonliness•Fatigue•Guilt•Anger•Frustration•Excitement

Phenomenological studies on those with TTM suggest that pulling often results in a temporary reduction of unpleasant emotional states. Such experiential avoidance is self-reinforcing and can create additional psychological consequences to those of hair-pulling

Cognitive Factors Associated with Pulling

•A dissatisfaction with ‘atypical hairs’. Common explanations include “hair should be symmetrical”; “grey hairs should be removed”.•This dissatisfaction may form part of wider dysfuntional beliefs about appearance, fears of negative evaluation and greater depth of shame

Focused pulling versus Automatic pulling

Focused Pulling

-Preceded by a private, internal event such as an urge, negative emotional state or bothersome cognition

-The pulling behaviour is then used to reduce or escape the urge or negative emotion & cognition

Automatic Pulling

-Occurs outside the client’s awareness-More often than not during sedentary activities as described earlier

However most clients presenting with TTM will be aware (or will become aware during therapy) that they exhibit both types of hair-pulling

Therapeutic Intervention

In cases where medical professionals involved with the client become aware of the TTM behaviour, pharmacotherapy may often be the initial response.

However, Woods, Flessner at al 2006 reviewed the efficacy of this approach and found the evidence for it to be limited.

Woods et al also found that merely 6 RCT had been conducted to evaluate SSRI efficacy in cases of TTM.Two of these RCT compared SSRI efficacy to behaviour therapy and found the latter to be of significant greater benefit.

Using behaviourist interventions to TTM with SHIP clients

•The inclusion of the term ‘Programme’ in our title suggests to clients that a specific approach will be offered•Behavioural interventions lend themselves well to time-focused therapeutic processes•Reduction of Self-Harming behaviours is at the forefront of what we do

However we must always remain aware of co-existing psychological conditions

Adult onset TTM is often co-morbid with Tourette’s syndrome & OCD and thus may require closer exploration than a TTM presentation in an adolescent client or in TTM issue reported present since adolescence

Useful questions to pose of clients presenting with TTM

The Milwaukee Inventory for Styles of TTM is a useful tool (copy attached)

What are the environmental factors associated with hair-pulling? What settings or activities activate or amplify the behaviour?

What are the psychological factors? Identify mood states & thought patterns at times of pulling. Do thoughts, emotions and physical sensations change as a result of hair pulling? In what regard?Clients may need to journal this between sessions before an accurate picture emerges (sample attached)

It is also useful to obtain:

-A detailed history of the behaviour (onset, context of onset)

-any prior treatment attempts (may have implications for client’s engagement with the process)

-Reactions of significant others in the client’s life (how does the client thus relate to their symptoms?)

-Details of pre- and post-pulling behaviours, paying particular regard to that which reinforces the behaviour

-Client’s beliefs about hair-pulling in the wider context of their life functioning

Following the assessment…

Once assessment of the issue has been completed, a psycho-educative piece may be required. Many clients minimize or fail to comprehend the potential pitfalls and dangers of the behaviour. As in some other form of self-injury, they may ‘enjoy their symptom’.Is client seeking behavioural changes or are they after ‘bigger game’. Assess & define expectations

The twin planks of this behaviourist approach to TTM are Stimulus Control and Habit Reversal Therapy

Stimulus control•Aims to identify and use tools/techniques that make hair pulling more difficult. •These are usually quite simplistic; help skeptical clients understand that is in fact an advantage

•Stimulus Control techniques should be specifically tailored to the environment in which the hair-pulling occurs.

Generally the therapist should introduce examples and then encourage client to generate more.

Examples:

-Pulling can often occur when a client is engaged in legitimate contact with their face e.g. shaving or removing make-up. Suggest using lower watt lighting, standing further from the mirror etc

-Clients should be encouraged to consider surrendering immediate possession of their tweezers, compacts or handheld mirrors. When DSH involves cutting, we may suggest clients keep knives etc at a remove or in a location that delays or diminishes their accessibility

-Timing (and limiting) use of mirrors

For pulling that occurs when client is sedentary or pre-occupied e.g. watching TV, reading, using PC

- Postural readjustment should be recommended-Encourage sitting in the middle of the couch or on a seat with no armrests. This increases distance between clients hands and their hair

-Place a timer at a remote distance from their seat. This should be set to go off at 10 min intervals (interrupts reverie and/or pulling)

-Hold a furry object or stress ball in the hands (or a single hand if reading)

Habit Reversal Therapy

•This is a technique aimed at developing control over the act of pulling by increasing the client’s awareness and introducing competing responses•Encouraging clients to become more aware of their pulling may require a simulation to be held in session and/or a detailed describing of what pulling looks and feels like

•Awareness training also requires a client to become more cognizant of pre-pulling sensations and behaviours (warning signs). A typical example is the raising of a hand to the face, followed by stroking or playing with hair•Competing response training involves introducing a response that is (a) portable (b) incompatible with pulling (c) relatively inconspicuous.

Examples of HRT: Introducing Competeting Responses

-Client requested to place their arms down by their sides and gently clench fists for 1 minute following onset of an urge to pull or commencement of pre-pulling behaviour.

-Alternatively; to bend their arm at the elbow and to press the arm and hand firmly against their side at waist level.

-Attempt diaphragmatic breathing for 60 seconds

-Folding arms together-Putting hands in pocketsIt may be necessary to provide reassurance and affirmation to the client as they may find they need to repeat these techniques ad-nauseum at the outset

These treatment strategies need to be monitored for effectiveness on a session by session basis and modified as required.

Reviewing of the rationale and types of replacement or competing behaviors that may help decrease TTM symptoms should be performed collaboratively.

Client should be offered encouragement & affirmation; both in view of their current achievements and also the future benefits

References

• Christenson G, (1996). "The characterization and treatment of trichotillomania". The Journal of clinical psychiatry

•Woods DW, Wetterneck CT, Flessner CA (2006). "A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania". Behaviour research and therapy 44 (5): 639–56.

•Woods, D & Twohig (2008) Trichotillomania Oxford University Press