[View original article published in Psych Central here]
After school, Henry would sit down and watch TV, but one hour later, his mom would discover he had been pulling his eyelashes and eyebrows. It wasn’t that he didn’t want them, he just couldn’t stop plucking them.
When his friends called him to hang out, he found excuses not to be around them. He didn’t want to face unwanted questions or comments. The embarrassment and shame were causing isolation, and his confidence and self esteem were suffering.
Henry is challenged by trichotillomania (TTM). Individuals who experience this disorder have difficulties resisting the urge to pull out their hair. It is estimated to affect between two to four percent of the American population.
Many hair pullers are not even aware they are doing it until it’s too late. They may zone out when they are bored or may pull their hair as a self-soothing behavior. Other sufferers are aware of their behavior and purposely do it to release stress. The urge is irresistible.
TTM is a chronic illness but those being challenged by it can learn skills to manage it. Besides awareness of the action, individuals also need to become aware of their feelings, thoughts, and the situations that occur before and after pulling. Triggers are different for everyone.
Research thus far has shown that the most effective treatment for TTM and other body-focused repetitive behaviors such as tics, nail biting, and skin picking is behavioral therapy, including habit reversal training (HRT). This therapy was developed in the early 1970s by Drs. Nathan Azrin and Gregory Nunn.
There are four main components for habit reversal training:
- Self-awareness training. Individuals learn to become aware of their hair pulling and keep a detailed record of all the instances when they pull their hair. They also keep relevant details that will help them recognize patterns in their behavior.
- Self-relaxation training. Individuals practice progressive muscle relaxation exercises.
- Diaphragmatic breathing. Individuals add deep breathing to their relaxation skills.
- Competing response training. Individuals learn to practice a muscle tensing action which competes with the hair-pulling behavior. Usually it involves tensing the arm muscles.
Because TTM is a complex disorder, most clinicians have discovered that besides implementing HRT they need to add CBT (cognitive behavioral therapy), DBT (dialectical behavior therapy), and ACT (acceptance and commitment therapy) components for best treatment results. For instance, Dr. Penzel, executive director of Western Suffolk Psychological Services, has added a fifth component to HRT: stimulus control. Through his research and conversations with expert clinicians, he agrees that HRT alone is simply not enough. It is not just about blocking hair pulling. Sensory aspects, environmental cues, and daily routines need to be considered to optimize the treatment for TTM.
In Henry’s case, he was exhibiting cognitive distortions about himself, others, and the world. He felt ashamed. Depression andanxiety had ensued. He had developed some routines that were facilitating his hair pulling. Treating him with HRT alone would not be effective.
Dr. Charles Mansueto, director of the Behavior Therapy Center of Greater Washington, and his colleagues have been doing extensive research for TTM treatment. They have written scientific papers and have presented their findings to various entities including the Trichotillomania Learning Center. They agree that HRT has been proven effective, but not reliable. A treatment that covers the behavioral, affective, and cognitive variables had been absent. For this reason, Dr. Mansueto and his colleagues developed the Comprehensive Behavioral (ComB) model to cover those missing areas.
This treatment uses several techniques that can help modify the deep-seated behaviors, thoughts and feelings that are associated with TTM. It is an individualized plan that covers five essential areas in individuals’ everyday life that affect their hair-pulling behavior. Dr. Mansueto and colleagues created the acronym SCAMP to facilitate remembering the five modalities:
- Sensory: Visual, tactile, and physical urges. Can involve all five senses before and after the behavior.
- Cognitive: Thoughts and beliefs about hair before, during, and after the behavior.
- Affective: Emotions before, during and after. They may be positive or negative.
- Motor Habits/Awareness: Ways that the individual’s body makes it easier to pull hair. It may be automatic or focused, or both.
- Place: It may include the environment, location, activity, social environment, time of day, and various tools that trigger hair pulling.
As clinicians use the ComB model, they conduct a thorough assessment and functional analysis to identify the triggers in each of the areas listed above. Sufferers begin self-monitoring so that they can identify potential target components and select the intervention strategies for each SCAMP modality.
Individuals are able to choose at least two skills they will work on during the week. They then report how the skills worked for them. Adjustments are made and additional skills in another area are added. When individuals report a particular skill has not been effective, the clinician along with the individual will choose other alternatives from those modalities.
Dr. Mansueto and colleagues continue to do clinical trials and research. However, clinicians working with individuals suffering TTM and other body-focused repetitive behaviors believe the ComB model is a better option than HRT alone. It is a unique but effective alternative to what is being used in treating the disorder. It is a comprehensive approach and addresses the diverse elements of TTM. It also organizes information according to the individuals’ experiences and provides the opportunity to use a variety of therapeutic interventions.
Treating individuals with psychological conditions is not a “one size fits all” situation. Trichotillomania is a great example of how a therapist cannot just simply focus on changing the hair-pulling behavior. There are other elements affecting the behaviors, thoughts, and feelings. Habit reversal training can be effective and clinicians treating this disorder have also in the past used other approaches besides HRT.
The ComB model is an excellent choice because it’s not only comprehensive, but it’s also client-friendly. When individuals are treated with the ComB model, they feel empowered. There is no question, HRT has been a modality of choice and it will always be an option. The good news is that the ComB model provides an alternative to have a greater chance for optimal success in treating TTM and other BFRBs.
For more details regarding this model, please visit the TLC website.
Mansueto, C. S. (2013). Trichotillomania (Hair-Pulling Disorder): Conceptualization and treatment. Independent Practitioner, 33(4), 120-127.
Mansueto, C. S. (1991). A Comprehensive Model for Behavioral Treatment of Trichotillomania. Retrieved from: http://www.trich.org
Penzel, F. (2003). The Hair-Pulling Problem: A Complete Guide to Trichotillomania. New York: Oxford.