Psychiatric comorbidity is common—if not the norm—in adults with TTM. Although axis I comorbidity is also seen in children and adolescents, their hair pulling is frequently uncomplicated. Jane meets criteria for TTM, as determined by the Trichotillomania Diagnostic Interview,16 but her history does not support a comorbid disorder. After discussing the diagnosis with Jane and her parents, the psychiatrist begins treatment with CBT alone.
MEDICATION OR CBT?
SSRIs. Literature on TTM pharmacotherapy is very limited and equivocal. Medications that have helped adults with TTM have been described,17 but the lack of a single, randomized, controlled trial in pediatric TTM severely limits treatment recommendations for children.
Selective serotonin reuptake inhibitors (SSRIs) have shown efficacy for treating anger and other impulse control problems but not for TTM. Some practitioners use SSRIs for TTM because of the belief that TTM is a variant of OCD. However, TTM may be maintained by positive reinforcement rather than compulsive tendencies and thus may not respond to SSRIs.
CBT. Evidence on CBT justifies cautious recommendations for pediatric TTM. In randomized trials, CBT reduced hair pulling in adults and was more effective than SSRIs or placebo.18,19
REDUCING THE URGE
Obtain detailed information about a child or adolescent’s hair-pulling episodes (Table 1), as recognizing triggers and reactions is vital to effective CBT. Explain to the patient that:
- the pleasure or satisfaction she derives from pulling reinforces the urge to pull
- she can reduce the urge by learning and using awareness training, stimulus control, and habit reversal (Table 2).
Awareness training involves patient self-monitoring to gain awareness of urges to pull and of pulling behavior. The child must become alert to every hair pulled and to response precursors, such as placing her hand on her head. For a patient such as Jane, a useful technique is to post reminders on the TV and school notebook and in the bedroom and bathroom—wherever pulling typically occurs.
A “PULLING CALENDAR”
Jane begins a daily “pulling calendar” in which she records each time she pulls a hair while watching TV or doing homework. She is asked to include the total number of hairs pulled and the intensity of the “itch to pull” on a scale of 1 to 10.
Stimulus control. Most patients can identify high-risk situations, such as time in the bathroom, talking on the phone, watching TV, driving, reading, or while falling asleep. Boredom, frustration, anxiety, and sadness may serve as pulling cues.
With stimulus control, the patient tries to reduce her ability to freely engage in pulling behavior in high-risk situations. For instance, you might encourage a child who pulls hairs while doing homework to stick Band-Aid®-type adhesive strips on her thumb and index finger tips before she starts studying as an impediment to gripping hairs. Such “speed bumps” may allow her to delay pulling and reach for tools that assist in habit reversal.
TREATMENT THAT APPEALS
Jane agrees to apply adhesive strips to her fingers and understands why. Because she is a fan of Peter Pan, we place Peter Pan stickers on her books and notebooks and on the TV remote control as reminders not to pull.
Table 2
CBT strategies to reduce the hair-pulling urge
| Awareness training | Increases patient’s awareness of pulling |
| Stimulus control | Establishes an environment less conducive to pulling |
| Habit reversal/ response | Patient develops alternate activities that provide competing positive reinforcement comparable to that gained from pulling |
Habit reversal and competing response procedures provide pleasurable physical stimulation as an alternative to pulling. The most effective methods engage the same motions as used in hair pulling. Examples include sculpting with clay, hulling sunflower seeds, and playing with Koosh® balls—small rubbery balls filled with a jellylike plasma and covered with hundreds of soft “tentacles.”
‘CALMER, HAPPIER’
We explain habit reversal to Jane and instruct her to use the Koosh ball a few times a day. She enjoys pulling its rubber strands, an action that uses the same muscles as hair pulling. Because she will need Koosh balls during all identified high-risk situations, we instruct her to buy one for her book bag and to leave one near the couch where she watches TV.
Over time, Jane reports a gradual decrease of hair pulling with the use of awareness training and stimulus control techniques. Using the Koosh ball (habit reversal) helps her improve. By the 10th week, Jane and her parents report a 70% decrease in hair pulling, based on the pulling calendar entries and other objective evidence of treatment response. All report feeling “calmer and happier.”
CONCLUSION
Cognitive and behavioral strategies are useful and safe for treating pediatric TTM. Enlisting the parents and patient in identifying problem situations and applying creative solutions may increase the chances of success.