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Tara Peris Ph.D.
Tara Peris Ph.D.
Body-Focused Repetitive Behaviors

Enhancing Treatment for Trichotillomania

Two new approaches may improve results in BFRB treatment.

The following guest post was authored by Nancy Keuthen, Ph.D, Associate Professor of Psychology at Harvard Medical School and Director of the Trichotillomania Clinic and Research Unit at Massachusetts General Hospital

It is often the case that in treatment studies for trichotillomania (hair-pulling disorder; TTM) a significant proportion of hair pullers do not improve, those who do improve often don’t cease all hair pulling, and those who achieve hair pulling abstinence often don’t maintain their treatment gains over time. This suboptimal treatment response and symptom relapse over time raise the question of what is missing in our current treatment protocols for TTM.

Recognition of considerable differences across those with TTM in terms of demographics, symptom profile, and comorbidity has prompted several researchers to propose different disorder subtypes/styles and disorder factors to better characterize individuals. These have included classifying them according to age of onset2, styles of hair pulling, including “focused” vs “automatic” pulling1, the predominance of the pulling factors of behavioral intentionality and emotional triggers and the presence of co-occurring personality traits.5

Unfortunately, research exploring different sub-groups of TTM has been limited (as has research in general for all body-focused repetitive behaviors, or BFRBs). To date, research has not yielded agreement on disorder sub-categories. There is no specification of TTM sub-categories in our formal diagnostic classification system (as we have for other disorders, such as OCD with and without co-occurring tic disorders).

Historically cognitive-behavioral treatment for TTM consisted of habit reversal training and stimulus control. These interventions improve awareness of urges and related motor behavior and train the person to use competing motor responses that are incompatible with pulling when triggered, to employ barriers to pulling (e.g., hats, band-aids, gloves, etc.), and to occupy one’s hands with fiddle toys when sedentary.

The field of cognitive-behavioral treatment evolved over time to acknowledge the importance of inner experiences, including emotions and sensations, in the etiology and maintenance of disorders and led to the advent of what are labelled “third wave” treatment approaches (including Dialectical Behavior Therapy and Acceptance and Commitment Therapy). Along the way, it was hypothesized that the early TTM treatments would be more successful with the habitual style of TTM (with lowered awareness of behavior) than focused TTM (with accompanying emotional and/or sensory triggers). Accordingly, several researchers proposed treatment packages augmenting habit reversal and stimulus control with Acceptance and Commitment Therapy9 and Dialectical Behavior Therapy3,4.

Empirical investigation of these enhanced treatment protocols with randomized controlled trials suggested that experiential avoidance (the failure to accept uncomfortable internal processes) and emotion regulation capacity are correlated with hair pulling severity. Additional support for the importance of addressing internal processes in TTM comes from the meta-analysis conducted by McGuire, et al8. This latter study showed superior TTM treatment outcomes in those studies when techniques from Dialectical Behavior Therapy or Acceptance and Commitment Therapy were included along with traditional behavioral treatment versus traditional behavioral treatment alone.

In the larger field of healthcare, the notion of precision medicine has been gaining momentum. This concept is represented in the use of genetic profiles in oncology to identify the chemotherapy agent most likely to optimize outcomes. Thus, it refers to a personalized matching of treatments to the individual on the basis of specific disease markers. Given the generic treatment blueprint used for TTM in the past, it is not surprising that our success rates were historically underwhelming. Improved treatment outcomes in the future will require much more extensive investigation of the different cognitive, affective, behavioral and sensory profiles of pullers (and how they cluster together) as well as an enhanced understanding of relevant genetic variables and brain structure/process in TTM.

Along these lines, the Body Focused Precision Medicine Initiative (the “BPM”), a multi-site collaborative project funded by the TLC Foundation for BFRBs, was designed specifically to explore these variables in a large-sample study to identify subtypes of TTM and to inform treatment development. The BPM holds great promise to significantly advance our knowledge of TTM and, in so doing, to refine treatment protocols to provide much-needed symptomatic relief and improved quality of life for those individuals who grapple with this challenging disorder.

For a broad discussion of currently accepted treatments for BFRBs, see the previous guest post on this blog by my colleague Emily Ricketts.


1. Christenson, G.A., Mackenzie, T.B., & Mitchell, J.E. (1991). Characteristics of 60 adult chronic hair pullers. American Journal of Psychiatry, 148, 365-370

2. Flessner, C.A., Lochner, C., Stein, D.J., Woods, D.W., Franklin, M.E., & Keuthen, N.J. (2010). Age of onset of trichotillomania symptoms: investigating clinical correlates. Journal of Nervous and Mental Disease, 198(12), 896-900.

3. Keuthen, N.J., Rothbaum, B.O., Falkenstein, M.J., Meunier, S., Timpano, K.R., Jenike, M.A., & Welch, S.S. (2011). DBT-enhanced habit reversal treatment for trichotillomania: 3- and 6-month follow-up results. Depression and Anxiety, 28(4), 310-313.

4. 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). Journal of Behavioral Addictions, 1(3), 106-114.

5. Keuthen, N.J., Tung, E.S., Altenburger, E.D., Blais, M.A., Pauls, D.L., & Flessner, C.A. (2015). Trichotillomania and personality traits from the five-factor model. Revista Brasileira de Psiquiatria, 37(4), 317-324.

6. Keuthen, N.J., Tung, E.S., Woods, D.W., Franklin, M.E., Altenburger, E.M., Pauls, D.L., & Flessner, C.A. (2015). Replication study of the Milwaukee Inventory for Subtypes of Trichotillomania-adult version in a clinically characterized sample. Behavior Modification, 39(4), 580-599.

7. Lochner, C., Seedat, S. & Stein, D.J. (2010). Chronic hair-pulling: phenomenology-based subtypes. Journal of Anxiety Disorders, 24(2), 196-202.

8. McGuire, J.F., Ung, D., Selles, R.R., Rahman, O., Lewin, A.B., Murphy, T.K. & Storch, E.A. (2014). Treating trichotillomania: a meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors. Journal of Psychiatric Research, 58, 76-83.

9. Twohig, M.P. & Woods, D.W. (2004). A preliminary investigation of acceptance and commitment therapy and habit reversal as a treatment for trichotillomania. Behavior Therapy, 35(4), 803-820.

10. Woods, D.W., Wetterneck, C.T., & Flessner, C.A. (2006). A controlled evaluation of Acceptance and Commitment Therapy and habit reversal for trichotillomania. Behaviour Research and Therapy, 44(5), 639-656.

About the Author
Tara Peris Ph.D.

Tara Peris, Ph.D., is Associate Professor of Psychiatry and Biobehavioral Sciences at the UCLA Semel Institute.

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