CBT | Trichotillomania Treatment

A 36-year-old female partner in a law firm pulled her scalp hair since early childhood. In the last five years, she had an increase in the amount of twisting and pulling. She reported pulling at least 100 hairs per day on a daily basis and had around five episodes of pulling a day . She admitted on the first session that she was somewhat skeptical about how treatment would help to control her hair pulling urge. However, by the second session, she had 100% remission in her hair pulling behaviors. She claimed that once she reached day 7 of no pulling, she felt that stopping the urge to pull and twist was not difficult. By the third session, she stated “it feels bizarre to do it”. By session 5, her urges were gone and she had marginal touching.

A 46-year-old male attorney presented with a history of hair pulling of the scalp and eyebrows that dates back ten years but can recall a lifetime of playing with his hair. He also bit his nails compulsively. He reported that his children struggle with similar body focused repetitive behaviors. He expressed that he had a very low expectation for recovery given that it is part of his stubborn biology, He claimed to pull most days, around 5 to 10 per day and engaged in incessant touching of scalp and eyebrow hair. Despite his lack of optimism, he reached his goal of complete remission of hair pulling and nail biting by session 4. At 2 year follow-up, he remained free of these behaviors.

A 23-year-old registered nurse pulled her hair since 12 years old. Most days she had between 6 and 10 episodes and pulled out about 50 hairs per day. Sometimes she would spend hours per day engaged in this behavior. By the second week of treatment she stopped pulling completely but continued to have the urge. It took a total of 8 sessions to stop all the hair stroking behaviors and the urges. At 2 year follow-up, she remained pull-free.

A 25 year old who works as a recruiter for a non-profit organization came to us after a 2-year battle with hair pulling and a long history of nail biting. She would pull her shorter hairs until it created a groove in her nail and then she would chew her nails in an attempt to make them even. She pulled every day and would chew off the bulb of the hair. It took the first 8 sessions to break down her resistance to habit reversal and stimulus control techniques, but by session 9 she reported about one week of no hair pulling and marked improvement in nail biting and stroking her hair . She directly correlated her success to her level of compliance in treatment. By session 13, she reported 100% improvement in nail biting and hair pulling and 80% reduction in her hair touching. It took 4 more sessions for her to be completely stroke-free.

A 25-year-old law school student came to us after a 12-year history of hair pulling. She pulled her hair daily and often relied on a hairpiece to hide the damage. Like many people who struggle with this problem, she kept it a secret from her loved ones, including her fiancé. She was desperate to get the problem under control before her wedding day. She showed immediate improvement within the first several weeks of treatment, decreasing the behavior by 90%. She continued to have very minor episodes (1 or 2 hairs per week) for the next 4 months. By the end of her 4th month, she was completely pull and touch free.

A 34-year-old fitness franchise owner arrived for treatment after an 18 year battle with pulling his eyebrows. He reported pulling most days of the week and would pull for up to an hour a day. He would often be in a trance when he would pull from his eyebrow and would then intentionally pull from the other brow to achieve symmetry. He would use eyebrow pencil, a baseball cap or hat pulled over his eyes, and sunglasses to hide his missing brows. He avoided going swimming because he didn’t want his eyebrow pencil to be washed off. He had poor eye contact and decreased sociability due to his embarrassment. He also reported that the pulling caused him mild carpal tunnel and calluses on his fingers. By the second session, he was able to stop the pulling completely. He reported no pulling, no touching and no urge by week 3 of treatment.

A 10-year-old girl arrived to treatment with missing eyelashes and eyebrows. She had been in treatment with another psychologist for a year but was unable to stop pulling. She reported pulling on the bus, in camp, at home in her bed, and on the couch watching tv. Her mother and grandmother repeatedly yelled at her to stop but were unable to get her to stop touching her eyes. By the second session, she reported an entire week of no pulling and only a minimal urge. In the weeks that followed, she had one to two episodes of pulling a week. By session 13, she was completely pull, touch and urge free. She maintained her progress at a 2 year follow-up and a 5 year follow-up.

A 29-year-old corporate litigator has had hair pulling for the last 4 years. By her second session she was pull-free. By fourth session she maintained her progress and reported no pulls and minimal stroking.

A 10-year-old girl was brought to treatment by her mother who reports that her daughter has been pulling since 5 or 6 years old. The girl had notable thinning on the top back of her scalp and most of her eyelashes were missing. By the second week of treatment, the girl was reporting no scalp pulling. By the fourth session, she reported no pulls from either scalp or eyelashes. She maintained her progress for the next month, with no pulls, touches or urges and graduated treatment.

A 9-year-old girl presented with eyelash pulling for the last four months. The patient’s mother reported that trichotillomania runs in the family and recalls her own sister pulling out eyelashes as a child. The mother anxiously challenged our techniques, stating that she has read that trichotillomania is a chronic and incurable problem. She also politely questioned why we felt that a low dose of an anxiety medication is not warranted for her daughter. By the second session, the girl stopped pulling and remained pull-free and almost touch-free through termination at session 12.

A 31-year-old public policy analyst came to us with a history of hair pulling that occupied hours of her day, every day. After she pulled her hair, she would break off the ends with her teeth. By second session she stopped pulling from the root. By the seventh session she stopped pulling her split ends apart. Upon one month follow-up, she maintained her progress of no pulling or splitting her ends.

A 25-year-old fashion designer with a history of trichotillomania since 12 years old came to treatment after a coworker pointed out to her the bald spot she created due to her incessant pulling. She reported pulling every few minutes at work, with over 30 episodes per day. She estimated that she pulled around 50 hairs per day every day, both alone and in public. By the third session, she excitedly reported being pull free. But she recognized that her hand continued to go to her head frequently. By the fourth session, she continued to be pull-free and reduced her touching behaviors by 60%. She struggled with her urge to pluck the few strands of grey hair that she would occasionally find, but learned to tolerate the discomfort without surrendering to her urge to pull. At session 12, she continued to be pull-free, reported no urge to pull and minimal touching. At 2-year follow-up, she remained pull-free

A 7 year old girl came to treatment after struggling with trichotillomania and compulsive thumb sucking since she was 6 months old. The young girl pulled at home and in school and made frequent attempts to pull her mother’s hair. She always pulled and thumb sucked simultaneously and heavily relied on these behaviors to help her fall asleep each night. Her parents admitted to losing patience with her behaviors. They had tried several techniques to disable these compulsions, to no avail. Within 2 months time, the habit reversal and stimulus control methods enabled the patient to be completely free of all hair pulling and thumb sucking rituals.

A 28-year-old woman who works as a vessel planner decided to seek treatment for the first time after a 10-year fight with trichotillomania. She pulled from her scalp using her fingers and tweezers and would bite off the root after pulling. She estimated pulling about 100 hairs per day every day and claimed she would pull from the time she came home from work til bedtime. She demonstrated marked improvement in hair pulling by the fifth session and took a total of 15 sessions to be completely pull-free. At 5-year follow-up, she remained pull free.

A 28-year-old architect has had trichotillomania and dermatillomania since she was a pre-teen. She would spend approximately 40 minutes per day engaged in these body focused repetitive behaviors and was often late to work because of it. She reported having tried very hard to stop these rituals on her own by setting time limits, delaying urges, using acrylic nails, not wearing clothes that reveal her skin, $1500 on electrolysis to cut down on compulsive tweezing, shutting off bathroom lights, etc. However, she has not been able to gain enough control over her urges to have any sustained improvement. After the first week of treatment, she reported a 30 to 40% reduction in skin picking and hair picking. By the fourth session, she had a 70% reduction in her behaviors. As her confidence grew, she felt ready to conquer a weight loss goal and lost 10 pounds in 12 weeks. During her time in treatment, she had several work-related and personal stressors that would ordinarily set her progress back. However, she continued to control her urges to pick and overeat. By session 6, she was 90% improved. She even had a break out of acne and was able to leave her blemishes alone. By session 9, she reported 99% improvement.

A 37 year old saleswoman arrived to treatment after a 24 year battle with trichotillomania. She had no eyelashes or eyebrows and reported pulling every day. Some days she would have over 30 episodes of pulling. The week after her evaluation, she reported being pull-free and remained pull-free at 18 month follow up.

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