“They certainly give very strange names to diseases.” Plato 

One disorder I treat has this long name, “trichotillomania,” and thus is referred to as “trich” or “ttm” for brevity. I refer to those with this disorder of compulsive hair pulling as “trich sufferers.”

You may not have heard of this disorder, and if you have it, you may be relieved to know that it has a name, and therefore, you are not alone with it! It is actually much more common than previously thought: 1 in 50 suffer from trich. 

I am a professional member of a wonderful organization, the Trichotillomania Learning Center (TLC), which gave me intensive training, and which holds retreats and conferences. If you have trich, I strongly recommend that you check out TLC’s website and services:http://www.trich.org

What is Trichotillomania?

The definition of trich in the Diagnostic and Statistical Manual IV-TR (DSM IV-TR) is in itself controversial: The criteria according to the DSM IV-TR are:

A. Recurrent pulling out of one’s own hair that results in noticeable hair loss 
B. An increasing sense of tension immediately before or when attempting to resist the behavior 
C. Pleasure, gratification, or relief when pulling 
D. Not better accounted for by another mental disorder and not due to a general medical condition 
E. Causing clinically significant distress or impairment in social, occupational, or other important areas of functioning

The controversy: All those who pull compulsively do not have tension prior to pulling or pleasure, gratification, or relief when pulling. Many experts in trichotillomania believe the definition is overly restrictive and should include those who suffer from compulsive hair pulling regardless of whether or not they meet the “B” and “C” criteria. 

Trich ‘s Partners

Trichotillomania rarely comes or travels alone in a person’s life. Over 50 percent of sufferers have or develop Major Depression, and 27 percent have Generalized Anxiety Disorder (chronic worrying). Many abuse alcohol (19.4%) or other substances (16.1%). Some develop phobias (18.8%) and 13.4 percent also suffer from Obsessive Compulsive Disorder (OCD), which is distinct from trich.

How Much Suffering?

In one survey of the economic impact of trich, (Wetterneck, et al, 2006), over 3 out of 4 participants in the on-line survey said that trich interfered with their job duties at least weekly. Almost half in the same survey admitted to missing at least one day of work in 3 months due to trich. Approximately two-thirds of those surveyed believed trich interfered with their performance in school.

Research also reveals, not surprisingly, that trich impacts the sufferer’s social life. The overwhelming majority say that they have refrained from close relationships at least some of the time and almost all (96%) have refrained from intimate relationships at least some of the time. Most surveyed are single (44.8%) or divorced (11.4%).

Additionally, as a study by Charles Mansuetto’s (1990) and Ruth Stemberger’s (2000) research revealed, those who suffer with chronic hair pulling most often also suffer with low self esteem (84%), diminished sense of attractiveness (82%), shame and embarrassment (80%), problems with tension or anxiety (68%), and depression or mood problems (66%).

Trich is Treatable

There have been recent cognitive and behavior strategies which make trich more treatable than previously thought. Treatment begins with educating the patient and often loved ones about the neurobiological basis for the illness, so that the person (and parents) realize no one chose trich, no one caused it, and no one is to blame! 

Groups for Trich

One way to ameliorate shame is to join a therapy group or a support group for trich. I facilitate one therapy group for trich for children and teens and am doing intakes for a group for adults with trich. 

Behavior Strategies

Unlike treatment for OCD, much of the initial treatment of trich, focuses on “applied behavior analysis”: a fancy way of saying we need to figure out when and where you pull, and under what conditions (external cues and internal cues). Does hair pulling relieve boredom or tension (negative reinforcement) or give a pleasant sensation (positive reinforcement)? Additionally, do you pull in your car, when you are alone, when you are bored or depressed? Do you pull in order to play with the hair, to put it into your mouth, or even to eat it (sounds yucky and it is dangerous, but not uncommon)? Do you pull certain hairs because of their color or texture? Without this information, we are shooting in the dark. Not a good idea!

Then we work on what is called “stimulus control”: adapting the environment so that it is less conducive to pulling. You can see that if you aren’t “ready” to give up pulling, you could easily undermine any efforts of the therapist or loved ones if you aren’t going to make some changes. We can talk about your readiness, but it really depends on how much trich is getting in your way (not being able to go swimming, embarrassment, avoiding dates, etc.) rather than on just how much hair you have lost. 

We work to develop “habit reversal,” too. That is, we develop competing activities. It sounds common sensical, but if both hands are busy, you can’t pull your hair! Also, if the sensory integration or sensory deprivation needs are taken care of by playing with yarn, alfalfa sprouts, etc., you may find that your compulsion to pull doesn’t overwhelm you. Habit reversal also takes into account using the same motions as pulling with something other than hair: for example, playing with clay, rug hooking, etc.

Cognitive Strategies

We work together to figure out how you are thinking about your hair and this illness, not because your thinking caused it (it didn’t!) but in order to help you get your life back! This takes a lot of work (ugh, including homework…) on your part, as well as mine. We examine whatever dysfunctional thinking you might have about your hair: for example, that the curly hair or the dark hair has to go! We work to help you regain perspective and to reduce self-blaming, catastrophic and negative thinking. 

Medications

While I try to treat trich sufferers without medication if at all possible and I am not licensed to prescribe medication, I work along with psychiatrists who do prescribe. In one small study (we are still just getting research on trich!), results indicated that behavior therapy and medication together had better results than either one alone (Dougherty, 2006).

Medications frequently used for trich:

Clomipramine (Anafranil)

SSRI’s (Selective Serotonin Reuptake Inhibitors)

      Citalopram (Celexa)

      Fluoxatine (Prozac)

      Fluvoxamine (Luvox)

      Paxil (Paroxetine)

      Zoloft (Sertraline)

      Lithium

      Naltrexone

      Atypical Neuroleptics 

            Olanzapine

            Risperidone

      Topiramate (Topamax)

Some trich experts (Penzel, 2007) are also recommending the use of Inositol (one of the B-Vitamins).

Hypnosis in the Treatment of Trich

Finally, with your permission (and with your parents’ permission if you are a minor), I may use hypnosis as part of the comprehensive treatment for trich. Please note that this is after a thorough intake (lots of questions) and getting to know you and your trich. That is, trich is one weapon in an arsenal to fight trich, and is not the only weapon.

D. Corydon Hammond (1992) defined Hypnosis:

“Hypnosis is a state of inner absorption, concentration, and focused attention. This altered state of consciousness is like using a magnifying glass in the sun—when the rays of the sun are focused, they are more powerful. Similarly when our mind is concentrated and focused, we are able to use more of our potential and more of the power of our mind. In this sense, learning hypnosis is the ultimate in a self-control skill, rather than being out of control.”

You may have heard or even believed some of the myths of hypnosis:

• That a person will do things she/he wouldn’t do otherwise
• That only the very gullible or very suggestible will be hypnotized
• That the intelligent cannot benefit from hypnosis
• That there will be amnesia
• That there will be loss of control

Remember that these are myths (untrue)!

What happens with hypnosis? You are able to focus better. Time may go by very quickly. You may or may not have amnesia for the session. The trance can be deep, medium or light. You may notice a slower heart rate, slower breathing, and relaxed muscles.

Why do I use hypnosis for some trich sufferers? 

Several reasons:

• There is still a high relapse rate for trich, even after the use of the other strategies, including medication. I think this relapse rate should make us open minded about adding some new weapons for our arsenal! 

• Hypnosis can for many people alter physical sensations, such as pain and pleasure. That means that the trich patient who doesn’t feel pain when pulling might be able to “get” the pain and pulling will be more aversive. 

• There is plenty of research on the use of trich with other “habits,” including smoking and overeating. 

• Hypnosis has been used for other biologically based disorders.

• Hypnosis can be a good treatment for problems with focusing and staying alert, and 75% of hair pullers are  
  ”automatic pullers” (not aware when pulling) at least s some of the time.

• Hypnosis can help regulate internal levels of stimulation

• Hypnosis can help you imagine how you will look and feel and what you will be doing after you win your battles over trich. In other words, it can restore hope!

Again, I believe in only using hypnosis as a supplement or as one part of the comprehensive treatment for trich. It is not a magic pill, although I wish it were. If the hypnosis “works” for a while and it helps you to be aware of what is going on and to be more in charge, instead of trich running your life, good for you! If the trance suggestions wear off, then you will still have your behavior strategies in place! I have found that hypnosis often gives some relief and can increase your chances of success in battling this illness. In order for hypnosis to work, the trance needs to be tailored to your special circumstances and how trich operates in your life. Any hypnosis metaphors and stories also need to be ones that work for you.

So how much research is there on the use of trich for hypnosis? Not enough, but that is the state of much of the research for this disorder. Basically, there have been single case studies. Why haven’t there been more studies? Well, pharmaceutical companies do not fund research which will not help them profit, and the definition of trich has been so restrictive that until recently (2007) the National Institute of Mental Health and other researchers were not looking at trich as an illness which is actually common and devastating to many individuals and families. Because of the work of the Trich Learning Center in educating not only sufferers but academics about trich, we can expect more research in the near future! Again, I want to recommend that you check out the website for the Trich Learning Center: http://www.trich.org

Trichotillomania Therapy Group 

• Psychoeducation for compulsive hair pulling—much more common than previously thought!
• Reduction of shame
• Homework assignments & reviews
• Habit reversal training
• Cognitive therapy
• Motivation, support & hope
• Relaxation training