Passing your National Licensing Exam
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Passing your National Licensing Exam
Untangling Trichotillomania
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Hey there, you brilliant therapists. I know Linton usually kicks these off, but I have absolutely no clue where he is today. My money's on him stress eating sushi from Publix, but that's just a hunch. So I'm your host today, and we're diving into a disorder that's both a tongue twister and one that deserves way more of our attention. Tricotillomania. Go ahead, say it three times fast, I'll wait. All right, let's jump in. I'm gonna start with the DSM stuff, and I promise we'll make it as fun as you can when reading the DSM. So trichotillomania lives in the OCD and related disorders of the DSM, which makes sense when you think about it, right? For a diagnosis, the hair pulling has to be recurrent, and we're talking noticeable hair loss here, not just absent-minded twirling while you're re-watching the office, one of my favorites for the millionth time. We're talking actual hair loss that people can see. Your client has tried to stop, and this is crucial. They've made repeated attempts to decrease or stop the behavior. This isn't someone who just enjoys at an eyebrow pluck. It's also affecting their life in significant ways, causing distress or impairment in relationships, work, social situations, or other important areas. Think about clients canceling dates because of visible patches, wearing hats in the office year-round, or avoiding the pool at all costs. Time matters too. Symptoms must persist for at least 12 months to be considered chronic. This isn't a phase. You also need to rule out the medical angle as well. The hair pulling can't be due to a dermatologic condition or another psychiatric disorder. Make sure it's not happening in the context of psychosis or other mental health conditions. And here's something super important for you as a therapist. You've got to distinguish this from normal grooming behaviors. We all deal with our hair on a daily basis. This is different because it results in significant hair loss and functional impairment. So let's talk about where clients are actually pulling from because location matters. A scalp is the MVP of pulling sites, the most frequently affected area. Your clients might create specific patterns or pull from multiple spots. Cue the strategic hairstyling, hats, and that one specific angle, they always turn their head in photos. Eyebrows, oh, this one's tough. Eyebrows are so visible, and the distress and social anxiety that come with this can be intense. You might see clients who've become makeup wizards out of necessity, drawing on eyebrows that would make a YouTube beauty influencer jealous. And then there are eyelashes. Possibly the most distressing because it's right there in everyone's face. Literally, you can't really hide it, and repeated pulling can cause permanent follicle damage. Imagine explaining to literally everyone why you're not wearing mascara. Now, here's something you absolutely need to understand for your practice and for your licensing exam: the hair pulling cycle. Think of this as the trichotillomania trilogy that keeps your clients stuck. In phase one, there's increasing tension, that mounting anxiety or urge right before pulling, or when they're white knuckling it, trying to resist the impulse. Phase two is the actual hair pulling, the act itself, whether it's from the scalp, eyebrows, eyelashes, or wherever. Then comes phase three, the relief or gratification, that sense of release, satisfaction, or pleasure after pulling. Here's the kicker. This cycle is maintained by negative reinforcement. The relief from tension strengthens the connection between pulling and emotional regulation. Your clients have essentially trained their brains to associate pulling with relief. Understanding this pattern is essential for developing competing responses and disrupting the behavior's automaticity. File this away for your licensing exam. You're welcome. Okay, so now let's talk about the two different types of pulling because they require different treatment approaches. First, there's focused pulling. This is the deliberate intentional kind. Your client knows exactly what they're doing. It's often linked to specific triggers like stress, frustration, like that client who keeps canceling, or boredom, scrolling through Instagram for the 47th time today. A strong urge usually comes first. And there might be rituals involved, such as searching for specific hair textures and examining the pulled hairs. Some clients describe it as almost meditative. Treatment here targets emotional regulation and identifying those triggers. Then there's automatic pulling. This is the ninja version. It happens outside conscious awareness. Your client is deep into a Netflix binge of suits, scrolling through their phone or working on progress notes, and boom, suddenly they notice a pile of hair in their lap or that their hand hurts. This unconscious form is trichotillomania because they don't even realize they're doing it. You need heightened self-monitoring and awareness training here. Environmental modifications and competing responses are your best friends. Now let's talk about the real impact of this disorder because it's significant. The emotional consequences are profound. Let's be real. The shame is deep, soul-crushing shame about both the pulling and the visible results. This leads to social withdrawal, ghosting becomes a habit, tanked self-esteem, and avoiding situations where their hair loss might be visible. Swimming? Nope. Windy days? Hard pass. Intimate relationships? Terrifying. The mental load of constantly hiding and managing this is exhausting. Functional impairment is serious too. This disorder really interferes with work and school. Think about all the time spent finding the right angle for Zoom calls, perfecting concealers and makeup, and dealing with the anxiety and distress. All of this reduces productivity and keeps people from fully engaging in their lives. And then there are physical complications. Some clients don't just pull, they examine, bite, or swallow the hair. That's called trichophagy. In severe cases, this can create trichobezors, hairballs, yes, like cats, that require surgical intervention, not fun. Let's talk about what else you might see alongside trichotillomania. Depression, generalized anxiety disorder, and OCD are frequently part of the trichotillomania disorders. These comorbidities make everything more complicated, and you'll need an integrated, comprehensive treatment approach. You can't just treat the polling in isolation, you've got to address the whole picture. So what actually works? Let's talk about evidence-based treatments. CBT is your gold standard here, the most well-suppressed psychological treatment. You're working on identifying specific triggers. Is it stress from work, scrolling TikTok, that one difficult client? You're also increasing awareness of urges and behaviors moment by moment, and developing competing responses that interrupt the pulling cycle. Habit reversal training or HRT is highly effective and superstructured. You're teaching clients to recognize the earliest signs of the urge, that tingly feeling, hand moving toward head, and substitute the behavior with something physically incompatible, like clenching fists, squeezing a stress ball, or manipulating fidgetys. SSRIs and Nacetylcysteine, that's NAC, show moderate evidence for helping with symptoms. The research shows that these work better when combined with behavioral treatments, especially for clients dealing with significant anxiety or depression on top of the trichotillomania. Now let me give you some specific techniques to add to your toolbox. First up is cognitive restructuring, which systematically challenges those irrational beliefs about control, perfectionism, or self-amuse that keep the pulling going. If I can't stop pulling, I'm a failure, needs to become this is a disorder, not a character flaw. Next is stimulus control, which involves reducing exposure to triggers. If pulling happens during screen time, maybe they need to keep their hands busy with a fidget toy. If it's in the bathroom mirror, maybe the lighting needs to change. Competing response training is about developing alternative behaviors that make pulling physically impossible. Can't pull if your hands are clenched into fists, or busy playing with putty. Self-managering helps build awareness through tracking when, where, what emotion, and how many hairs. This data is gold for treatment planning. And finally, mindfulness-based regulation helps clients sit with distressing emotions without needing to do something about them. The urge isn't the enemy, the pulling is what we're working on. Let me walk you through how to actually implement treatment with your clients. We start with a comprehensive assessment. Get the full picture by evaluating focused versus automatic pulling patterns, identifying specific triggers and high-risk situations, assessing how much this is impacting their life, and screening for other conditions that need attention. Then you move into psychoeducation and engagement. This is where you normalize the experience and reduce shame. Education is powerful. Help them understand they're not alone, they're not crazy, and this is a real disorder with real treatments. Build that therapeutic alliance and get them invested in treatment through shared decision making. Now you're ready for the core intervention phase. You implement habit reversal training and competing response development while introducing self-monitoring tools and awareness training. Apply cognitive restructuring for those maintaining beliefs and integrate stimulus control strategies. And you're not done yet. The final piece is consolidation and relapse prevention. Keep practicing those skills, develop strategies for managing high-risk situations, address any lingering symptoms, and create a maintenance plan. Regular check-ins are key. All right, we're finally ready for the key takeaways, especially for your licensure exam. Number one, trichotillomania is complex. It's not just stop pulling your hair. They're behavioral, cognitive, and emotional factors all interacting. You need a comprehensive assessment and individualized treatment planning. Number two, evidence-based approaches work. CBT and HRT have strong research backing. Combining behavioral interventions with medication can boost outcomes for complex cases. Number three, address shame and stigma like your job depends on it. Because honestly, the therapeutic alliance does. Psychoeducation reduces shame, enhancing engagement, and supporting sustained change. You can't skip this step. And number four, always monitor for complications, assess for comorbid psychiatric conditions, social and occupational impairment, and physical complications. Here's the thing about trichotillomania. It's one of the disorders that's way more common than people think, but clients often suffer in silence because of shame. As therapists, you have the privilege of being the person who says, this is real, this is treatable, and you deserve support. If you have a client struggling with trichotillomania, approach with curiosity and compassion, not judgment. The shame is already there. Your job is to be the safe space where healing can actually happen. So there you have it. Everything you need to know about trichotillomania. Thanks for being with me today. Hopefully, Lytton resurfaces next week. Probably with sushi induced regrets that he missed this one. Till then, remember, it's in there.
