Passing your National Licensing Exam
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Passing your National Licensing Exam
Demystifying Disorders: Trichotillomania
Ready to unravel the mysteries of trichotillomania? Prepare to be enlightened as we, your hosts, Stacy and Linton, travel through the Greek roots of this body-focused repetitive behavior disorder, and reveal not only its hidden intricacies but also its potential treatment strategies. Stitch by stitch, we uncover the diagnostic criteria, prevalent features, and potential co-existing disorders. Along this journey, we also use the cycle of abuse theory as an unforgettable mnemonic device, illuminating the repetitive and compulsive nature of hair-pulling urges.
As we journey deeper into the heart of trichotillomania, we shed light on a plethora of treatment avenues. From habit reversal training, contingency management, to additional interventions like Cognitive Behavioral Therapy (CBT), Dialectal Behavior Therapy (DBT), and Acceptance Commitment Therapy (ACT), we examine them all. Join us as we explore how habit reversal training can replace the hair-pulling habit with a competing response. As we reach the end of this enlightening expedition, we extend our heartfelt gratitude to you, our dedicated listeners, for your commitment to creating a happier, healthier world. So set aside your fears and misconceptions, and step into the world of trichotillomania with us. This is more than just another episode; it's a journey into understanding, acceptance, and hope.
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Welcome therapists to our Licensure Exams podcast. I'm Stacy.
LINTON:And I'm Linton, and today we'll be demystifying a disorder called trichotillomania, which is a body-focused repetitive behavior disorder characterized by the recurrent urge to pull out one's hair, despite trying to resist the urge.
STACY:You know, linton, for some reason trichotillomania that's a word that rolls off my tongue like serendipity or lexadazical.
LINTON:Well, here's a fun fact the word trichotillomania is derived from the Greek roots of tricot, which means hair, tylo, which means to pull, and mania, which means madness. So you see, the Greek roots aptly describe the critical components of constantly feeling compelled to pull out one's hair.
STACY:Well, that certainly makes it easier to remember. So let's start by going over the diagnostic criteria in the DSM-5TR or trichotillomania, all right.
STACY:All right, starting with recurrence pulling out of one's hair, resulting in hair loss, repeated attempts to decrease or stop hair pulling. The hair pulling causes clinically significant distress or impairment in relational, occupational, social or educational functioning. And there's that rose memory device of yours, linton, to remember the areas of functioning. The hair pulling or hair loss is not caused by a medical condition, and the symptoms of another mental disorder, such as an attempt to rectify a perceived physical defect that you might see with body dysmorphic disorder, do not better explain the hair pulling.
LINTON:Right, and those are basically the key features that you'll find in the DSM-5TR. Trichotillomania tends to develop when.
STACY:So it often starts during early adolescence, when an individual is going through puberty, and there's some hypotheses that suggest hormonal changes during puberty might trigger trichotillomania in biologically vulnerable individuals, and the condition can persist for months or years if it's not treated. Periods of remission may occur, but relapse is pretty common.
LINTON:Exactly. Stress, anxiety, boredom and depression tend to worsen symptoms. Let's go over some of the features that may accompany trichotillomania.
STACY:Of course. So individuals typically feel rising tension immediately before pulling hair or when trying to resist the urge to pull hair. The hair pulling may be preceded by an itchy or a tingling sensation in the scalp. Hair pulling then leads to an immediate sense of gratification, pleasure or relief. However, those feelings quickly give way to disappointment or frustration.
LINTON:That description reminds me of Lenore Walker's cycle of abuse theory, which has three stages. So the person starts with a tension-building phase In the cycle of abuse. Tension builds as stressors accumulate and the abuser feels frustrated and angry. Similarly, with trichotomania, the tension and anxiety build before it urged to pull at the hair intensifies. Next comes the explosive phase, or hair-pulling episode. The abuser explodes in anger and violence to release tension, taking out their emotions on the victim. With trichotomania, the client pulls out their hair for emotional relief and gratification. And finally, then there's the honeymoon phase. The abuser apologizes and he also makes promises to change. The client with trichotomania feels regret, self-loathing over hair-pulling and vows to stop pulling at their hair.
STACY:You know, lyncin, that's actually a really great memory recall strategy for the criteria for trichotomania. You've compared it to a well-established theory, like you were talking about, with this cycle of abuse, and I think that analogy really crystallizes the repetitive and compulsive nature of the hair-pulling urge.
LINTON:So very true, Stacey, and it demonstrates how the gratification from giving into destructive urges, whether lashing out in violence or pulling one's hair, it is always short-lived. This cycle will continue to persist without intervention.
STACY:Exactly so. Some other features that may accompany hair-pulling include rituals like pulling hair with a specific texture, pulling the hair out in a certain way, or examining or playing with the hairs, and some clients even ingest the hairs, which can accumulate into dense masses called trichobizors.
LINTON:Wow, that sounds like something out of Harry Potter.
STACY:Yes, that the goat bazaar that Harry used as an antidote to save Ron when he drank the poison weed. Well, this is a little bit different. You know how cats get hairballs when they groom themselves.
LINTON:Yeah, not from personal experience, but yes, you know, I know what you're talking about.
STACY:Yes, well, a tricobozare is a human hairball.
LINTON:That's quite the image, Stacey. Thanks for sharing.
STACY:Yes, and you can imagine the gastrointestinal complications that can arise from that.
LINTON:No kidding, what about common comorbidities for tricotomanias?
STACY:Well, major depressive disorder and excreation or skin picking disorder are the most common, and many clients with tricotillomania also engage in other repetitive body-focused behaviors like nail biting and lip chewing, for example. All right, Linton. So what kinds of evidence-based treatment options are available for clients with tricotillomania?
LINTON:Well, habit reversal training, or HRT, is considered the forerunner in treating tricotillomania. Hrt helps clients become more aware of hair-pulling urges and replaces the habit with an alternative, competing behavior. Hrt operates on the premise that tricotillomania is a learned, automatic behavior that can be unlearned and replaced through awareness training and competing response practice.
STACY:Okay, makes sense so far. So how exactly does HRT work? What does that look like?
LINTON:Well with HRT. The first goal is helping the client to recognize the stimuli and situations triggering their hair-pulling urge. This makes the habit more conscious rather than automatic Very important. The next step is to teach the client to implement a competing response, a behavior that makes pulling hair impossible as soon as the urge strikes.
STACY:Okay, so can you give some examples of these competing responses?
LINTON:Yeah sure. Simple responses like sitting on your hands wearing gloves or bandages or squeezing a stress ball prove physical barriers making hair-pulling impossible at the moment. Another one is combing your hair instead of pulling it out.
STACY:Okay, I see. So it literally provides a competing or basically like a substitute behavior to disrupt the hair-pulling sequence.
LINTON:Exactly. The key is making the competing response as ingrained habit by repetition, so that it replaces hair-pulling as the automatic go-to behavior when the urges arrive.
STACY:Okay. Well, replacing hair-pulling with a competing response seems like it would be unsuccessful if you're just doing a like a one-off therapy session with the client. So I imagine that clients really need to practice that competing response for quite a while before it becomes automatic.
LINTON:That is correct, though there isn't a set time frame. As you know, every client is different. It typically takes two to four months to build up the client's skills through repeated rehearsal until the competing response becomes automatic and naturally interrupts their pulling sequence. Overlearning is vital. Clients must repeat competing response practice across multiple setting until the new habit displaces hair-pulling. The first few weeks are typically the most difficult for a client, but small milestones like 30, 60, 90 days will give the client and you a good indication that the new behavior is likely on track to become well-established and long-term. Consistency is the key throughout the whole process.
STACY:Yes, and then social support training, also called contingency management, is eventually added into the mix also, right?
LINTON:Right. The social support, training or contingency management component engages someone in the client's environment to bolster their habit of reversal training. This support person is coached to provide positive reinforcement every time the client successfully utilizes their practiced competing response to interrupt the hair-pulling. Additionally, the support person generally draws attention to early cues or warning signs that indicate that escalation is building so the client can deploy their competing responses.
STACY:Oh, I got you Okay. So this could be like a spouse or someone that lives in the same household or something, someone that could be the person to help reinforce the client. You know what they're doing correctly and then also kind of let them know when there's a little red flag they need to be aware of.
LINTON:Right, right.
STACY:Okay. So another behavioral intervention that can be added to the mix is something called stimulus control strategies, which are used to reduce exposure to triggering cues and make engaging the actual hair pulling behavior more difficult. This is where you're going to work with the client to minimize their exposure to environmental and situational triggers that are contributing to the hair pulling compulsions. A common example is you know, if watching TV is identified as a trigger that precedes hair pulling urges, because it's kind of a mindless activity, have the client remove TV access during high risk times. Eliminating triggers disrupts conditioned cues associated with the hair pulling habit. Another strategy is to make the hair pulling more difficult to perform. So how about having the client wear fake long nails, for example, linton?
LINTON:Well, you know you would think that would help. But I saw a lady at Publix with two inch long nails who didn't see any trouble with fine motor skills. She was typing on her phone and grabbing items off the shelves like she spent a lot of time there.
STACY:Ah yes, like someone we know, linton Well, that is a good point. Maybe some thick gloves or mittens might be a better option. I personally can't even put on my hat when I've got my winter gloves on. So a few other enhanced behavior therapy protocols that you can use along with HRT to address the urges or negative emotions that underlie tricotillomania include cognitive therapy to identify and change dysfunctional beliefs like I can't have any gray hairs, or I'll just pull one hair and then I'll stop. Dialectical behavioral therapy, which utilizes mindfulness, distress tolerance and emotional regulation skills training to help clients better manage overwhelming urges without self-judgment, acceptance and commitment therapy to increase willingness to endure distressing thoughts, feelings or sensations related to hair pulling urges without reacting by automatically pulling hairs a form of experiential escape or emotional regulation. Then there's motivational enhancement therapy, which can be used to increase the client's motivation to stop the behavior. And then we've got relaxation techniques like progressive muscle relaxation to reduce stress and finally relapse prevention strategies.
LINTON:Wow. Well, there's a lot of options available, aren't there, Stacey? Yes, there certainly are. So how about we just do a summary at this point?
STACY:Sure thing, all right. So taking it from the top, tricotillomania is a body focused, repetitive behavior disorder that's characterized by recurrent urges to pull out one's hair, despite trying to resist. Onset is typically during adolescence. Diagnostic criteria includes recurrent pulling out of one's hair, resulting in hair loss, and repeated attempts to decrease or stop the hair pulling. Hair pulling can be accompanied by different emotional states, for example anxiety or boredom, a sense of tension before pulling out the hair or trying to resist the urge to pull out the hair, a sense of pleasure or relief after the hair is pulled out, and potentially rituals like examining pulled hairs or ingesting them. Tricotillomania has a very high comorbidity, with depression, excreation disorder and other body focused and in terms of treatment.
LINTON:Habit reversal training uses awareness of triggers and competing responses to replace their pulling habit. Contingency management for tricotillomania, also called social support training, involves training as support person to reinforce the client's competing responses and point out warning signs when the client is in a triggered kind of situation. Stimulus control minimizes exposure to triggers, and additional interventions like CBT, dbt and ACT address underlying cognitive and emotional factors that contribute to the pulling of hair. Well, it was great getting you all up to date on tricotillomania for your exam. Thanks for all of your service and dedication, making the world a happier and healthier place.
STACY:And as we always say, it's in there.
