By Hannah Sommer Garza, Ph.D.

Welcome back to the second part of our two-part series on myths and misconceptions about trichotillomania from a trichotillomania treatment provider. If you missed Part 1, check out our previous post (https://psychologyhoustonpc.com/2017/08/03/common-myths-and-misconceptions-about-trichotillomania-part-1-what-is-it-who-gets-it-and-why/ ) on myths about what trichotillomania is, who experiences it, and why. Today’s post will focus on misconceptions about reasons for pulling behaviors and how trichotillomania is treated. The hope with this two-part series is to dispel some common myths and misconceptions about trichotillomania, to pass along up-to-date information, and to reduce stigma associated with the lack of awareness about trichotillomania and trichotillomania treatment.

As a reminder of some of the basics, trichotillomania is also known as hair-pulling disorder, TTM, or “trich.” It involves the recurrent pulling out of one’s own hair despite attempts to stop pulling. It is considered a Body-Focused Repetitive Behavior (BFRB), similar to other behaviors like skin-picking and nail-biting. Now let’s keep dispelling some of these pesky myths.

Myth: People with Trichotillomania are Pulling to Get Attention

This couldn’t be further from the truth. Often due to feelings of shame and embarrassment, many individuals with trichotillomania go to great lengths to hide their trich from others. In reality, the majority of people with trichotillomania attempt to REDUCE attention they receive related to their trich, not get more of it. Furthermore, research has shown that pulling can occur outside the individual’s awareness (also known as “automatic” pulling). It is not being used as some sort of manipulative strategy to get attention from others.

Myth: Trichotillomania is a form of self-harm

The big take-home here is that it’s all about function. For individuals with trichotillomania, the intention of the pulling is NOT to hurt oneself. In contrast, that is the intention for self-harm. The injuries or damage caused by hair-pulling are merely a result of pulling and not the goal of pulling. Furthermore, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) distinctly categorizes self-harm as separate from trichotillomania, using language like “the behavior is not better explained by another mental disorder or medical condition (e.g. trichotillomania).” Trichotillomania is specifically mentioned in the DSM-5 as a rule-out for self-harm, implying that they are distinct from each other.

Functions of trichotillomania pulling are usually sensory related (e.g. seeing a hair out of place, or feeling discomfort with a coarse hair), emotionally related (e.g. pulling more when feeling nervous, bored, or stressed), and/or cognitively related (e.g. “I will just pull one more” or “pulling this eyebrow hair will ‘fix’ my brows”). The function of NSSI pulling is to harm oneself.

Myth: People with Trichotillomania can “Just Stop”

This myth always reminds me of a comedy sketch with Bob Newhart called “Stop It” (https://www.youtube.com/watch?v=Ow0lr63y4Mw). It’s a parody of a therapy session, where the provider’s treatment for the patient’s concern (not trich-related) is to “just stop it.” As you can imagine, it’s over the top, not very therapeutic, and has no impact on helping the patient to “stop” her unwanted concern. All silliness aside, I imagine that this is what many people with trichotillomania experience when people tell them to “just stop” pulling. It’s just not helpful.

Many factors can influence pulling to make it a difficult behavior to change. Researchers suspect a genetic component, as many BFRBs cluster together within families. Overriding genetics is no easy task without evidence-based techniques for doing so. Additionally, people with trichotillomania often describe an enjoyable/soothing/calming sensation that occurs during pulling. I often think of it as similar to eating chips and queso (my great diet weakness). I may be very consciously aware that I am breaking my diet as I continue to reach for chip after chip after chip after chip…but boy do they taste good in the moment! The long-term effects of pulling are very difficult to keep in mind when the body is experiencing immediate “rewards” while pulling. Trichotillomania treatment involves the patient and therapist working together to identify targeted ways to prevent and manage urges for pulling. It takes a lot of work to change a behavior like pulling, and saying that the person can “just stop” is extremely invalidating.

Myth: Once with Trich, Always with Trich

Trichotillomania is a Body-Focused Repetitive Behavior (BFRB; http://bfrb.org/ ). Other common BFRBs include skin-picking (excoriation), nail-biting (onychophagia), and knuckle-cracking. Evidence suggests that it is not uncommon for individuals to change target BFRBs throughout development or to engage in multiple BFRBs simultaneously. For instance, someone may start pulling eyebrows as a child, then focus more on chronic skin-picking during adolescence and early adulthood, and may even shift back to trichotillomania during adulthood. Researchers are actively attempting to unveil reasons for these shifts.

Approximately 23% of people with trichotillomania have a relapsing and remitting course of symptoms with at least one period of complete symptom remission, according to a retrospective report study (Meunier, Tolin, Diefenbach, & Brady, 2005).

Another way trichotillomania can change for a person is through trichotillomania treatment. Will a flip be switched and the urges disappear? Unlikely. This is why learning skills in treatment for how to prevent and manage pulling urges is a powerful way to change pulling behaviors.

Myth: All Treatments are Created Equal

The Trichotillomania Learning Center’s Scientific Advisory Board, a panel of expert clinicians and researchers, have identified specific behavioral treatments (http://bfrb.org/storage/documents/Expert_Consensus_Treatment_Guidelines_2016w.pdf ) that have evidence for treating trichotillomania. Specifically, Cognitive Behavioral Therapy (CBT) and its related therapies are recommended.

CBT is a type of therapy that involves an identification of problematic thoughts, feelings, and behaviors, and a focused training in how to make them more helpful. For more information on CBT, check out our former blog post (https://psychologyhoustonpc.com/2016/06/01/all-therapy-is-not-created-equal/ ). Several treatments fall within the umbrella of CBT treatments, including Habit Reversal Therapy (HRT), Comprehensive Behavioral Treatment (ComB), Dialectical Behavior Therapy (DBT), and Acceptance and Commitment Therapy (ACT).

If you or a loved one are seeking treatment for trichotillomania, be on the lookout for words like “cognitive behavioral therapy (CBT),” “behavior therapy,” “habit reversal,” “third wave treatments,” “dialectical behavior therapy (DBT),” or “acceptance and commitment therapy (ACT).” The provider should also be familiar with body-focused repetitive behaviors and the Trichotillomania Learning Center. If they’re not using some language like this, then they may not be best trained to provide trichotillomania treatment.

Although the main treatment for trichotillomania is CBT, medication can also be helpful. There is no one medication that works for everyone with trichotillomania, but some medications have been found to reduce symptoms for some people. Medications are often used to relieve emotional symptoms that may be related to pulling for some people. Selective Serotonin-Reuptake Inhibitors (SSRIs) are often used to address symptoms of anxiety and depression that may be associated with pulling. There is preliminary support for N-Acetylcysteine (NAC), an amino acid working on the glutamate system (http://jamanetwork.com/journals/jamapsychiatry/fullarticle/483113) to reduce trichotillomania symptoms. Over 50% of individuals in the cited trial found significant improvement in trichotillomania symptoms over the course of 12-week NAC treatment. However, to date, no medication has been approved by the Food and Drug Administration (FDA) for the treatment of trichotillomania or other BFRBs. Scientists are working to better understand trichotillomania and to enhance its treatments. Check out this website (https://www.bfrb.org/research-programs-news/bpm) if you’re interested in learning more about the research initiative.

Other treatments do not have enough research support to be currently recommended by trichotillomania experts as stand-alone treatments. This includes approaches such as hypnosis, diets, massage, acupuncture, and electric stimulation.

Conclusions

I’m hopeful that this two-part blog series on myths and misconceptions about trichotillomania has been helpful, and that you can help to spread the truth about trichotillomania and its treatment. The unfortunate truth is that there is still a lot that we don’t know about trichotillomania and its successful treatment. If you’re at all interested in learning more about the research initiative or even getting involved in a study near you, I encourage you to check out the website linked above. For more information about trichotillomania, you can also check out the Trichotillomania Learning Center (TLC) Foundation for BFRBs (http://bfrb.org/).

Resources

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th Ed.; DSM-5). Washington, DC.

Grant, J. E., Odlaug, B. L., & Won Kim, S. (2009). N-Acetylcysteine, a Glutamate Modulator, in the Treatment of Trichotillomania: A Double-blind, Placebo-Controlled Study. JAMA Psychiatry, 66(7), 756-763.

Grant, J. E., Stein, D. J., Woods, D. W., Keuthen, N. J. (2012). Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors. Washington, DC, London, England: American Psychiatric Publishing Inc.

Meunier, S. A., Tolin, D. F., Diefenbach, G. J., & Brady, R. E. (2005, November). Severity and course of hair pulling symptoms across the lifespan. Paper presented at the Annual Meeting of the Association for Behavioral and Cognitive Therapies, Washington, DC.

Woods, D. W. & Houghton, D. C. (2014). Diagnosis, Evaluation, and Management of Trichotillomania. Psychiatric Clinics of North America, 37(3), 301-317.