Dr Robert London

Trichotillomania: finding solutions

Clinical Psychiatry News - Volume 32, Issue 9, Page 41 (September 2004)

Some years ago, I treated a woman who had been diagnosed with trichotillomania. This patient, who made her living as a trial attorney, had become courtroom phobic after she began pulling the hairs out of her eyebrows and feeling self-conscious about the awkward look of her face without them.

She thought of penciling in eyebrows, but instead started sending in associates to handle court appearances. Her career was suffering, and this seemingly uncontrollable habit began to damage her self-esteem.

As a pragmatic litigator, she approached the problem in a specific, direct manner. “There must be a medication to help me stop pulling out my eyebrows,” she said. Indeed, she was right. A well-respected psychiatrist prescribed a selective serotonin reuptake inhibitor (SSRI).

The psychiatrist theorized that the eyebrow pulling was a compulsion disorder (not an impulse disorder, as put forth in DSM-IV), which was the rationalization for this pharmacologic intervention. The psychiatrist knew current evidence suggested that medications that alter central serotonin turnover had been effective in treating this disorder. “Concise Textbook of Clinical Psychiatry,” Harold Kaplan and Benjamin Sadock, (Philadelphia: Lippincott Williams & Wilkins, 1996, p. 297).

Furthermore, in this patient's history, it was possible to identify periods of depression before the eyebrow pulling started, if you “looked hard,” according to the treating psychiatrist. The psychiatrist thought the patient had an underlying depression, but she was certain, as was the patient, that this trichotillomania disorder was causing the patient to be depressed, rather than an earlier, undiagnosed depression.

The medication regimen and insight-oriented psychotherapy proved to be helpful. The patient's depressed mood was less pronounced and the eyebrow pulling behavior was reduced, but the behavior was still occurring to the point that her eyebrows were not growing in properly. The treating psychiatrist, realizing that she had gone as far as she could in the treatment of the patient's trichotillomania, suggested a different type of treatment and referred her to me for a short program of behavior modification. The lawyer, having had a good experience in psychotherapy, was more than eager to try something new.

For certain habit patterns, including this patient's hair-pulling behavior, I use what I call the LPA approach, which I developed over the years using education, emotions, relaxation, and behavior-modification techniques. The treatment plan involves three appointments: the Learning visit, the Philosophizing visit, and the Action visit.

In the Learning visit we explore the issues related to the habit on an educated, intellectual level and address theories of how the problem might occur and the various approaches to understanding why the person might have those behaviors.

Contributing factors include stress, anxiety, boredom, depression, neurochemical deregulation, impoverished childhood relationships, pathologic family relationships, the meaning of obsessive-compulsive disorder, lifetime losses, or any other idea that the patient might discover and name as important to her or him.

Too often, the patient is an outsider in the treatment. In other words, the treating clinician identifies a course of action and the patient simply complies with the treatment, many times struggling along unknowingly. In the learning period of the LPA approach, the patient is a partner in the treatment and is involved in its direction.

The second part of LPA is called Philosophizing. At this stage, we explore the unique aspects of the patient's life that could be a direct cause of the hair pulling. This approach examines stressors—real or imagined—that may have influenced this maladaptive behavior. Philosophizing addresses the emotional aspect of the disorder. We try to elicit the feelings that are occurring in the patient's life, moving away from the learning and intellectual process. We go from identifying past specific events to experiencing their current emotional effects.

In the Action phase, the aim is to get a process in place to actually alter the behavior. In the case of the attorney, I directed her to learn how to develop a system of touching her face and not pulling out her eyebrows. I taught her some simple relaxation techniques, allowing her to relax and begin thinking about pleasant life experiences and about her personality assets and strengths, including her level of success as a professional.

As the patient began to relax, I instructed her to move her right hand up toward her eyebrows, but to then touch her cheek instead of pulling her eyebrows. I asked her to verbalize some of the pleasant experiences about which she had been thinking.

By reinforcing her face-touching behavior with positive aspects about who she is without pulling out her eyebrows, she altered a negative experience into a positive one, both physically and mentally. The patient had now incorporated positive feedback into the movement. She was instructed to practice this new technique 10-15 times per day for only 30 seconds to 1 minute, when convenient. This physical change in the movement, coupled with a new thought process, began to alter the habit of hair pulling.

For this patient, the approach worked. Three months later she had a full set of eyebrows. In this partnership approach, it is made clear that the locus of control is placed in their hands. With this in mind, the attorney was able to independently alter my strategy of touching the cheek with her hand. She began touching her hands together to reinforce the non-hair pulling.

The patient remained on the SSRI, went back to the referring psychiatrist, and continued insight-oriented psychotherapy.

Trichotillomania is poorly understood, and the various treatment approaches are not consistently successful. In my experience, a combination of behavior modification and psychopharmacology helps patients to control or eliminate the habit. The disorder is complex, with the possibility of multiple overlapping causes, but we still can offer treatments that work.

Please feel free to write me at cpnews@elsevier.com and let me know your experiences. I'll try to pass them along to our readers.

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