“I Can't Stop Pulling My Hair!” Using Numbing Cream as an Adjunct Treatment for Trichotillomania

Trichotillomania (TTM) is classified as an impulse control disorder within the DSM-IV-TK (American Psychiatric Association, 2000). The main features of the disorder include recurrent hair pulling with noticeable hair loss or thinning; tension or uncomfortable feelings (for example, itch or urge) prior to pulling; and some sense of pleasure, gratification, or relief as a result of the pulling. TTM is not as rare as once thought. Lifetime prevalence rates of 0.6 percent were found for both men and women; however, subclinical symptoms of "noticeable hair loss" increase the lifetime rates to 3.4 percent for women and 1.5 percent for men (Christenson, Pyle, & Mitchell, 1991). Some researchers believe that these numbers are underestimated because of the secretive nature of the disorder (Tay, Levy, & Metry, 2004). TTM can have a significant negative impact on a person's life if left untreated. Diefenbach and colleagues (2005) found individuals with TTM report having a higher degree of distress than do individuals without hair-pulling problems, and individuals with TTM are comparable to other individuals with psychiatric disorders on reported distress levels. Consistent with this research, two studies by Wetterneck and colleagues (2006) found that TTM sufferers experience both social and economic disadvantages related to having the disorder, contributing to a higher reported distress level. Individuals with TTM demonstrate social avoidance, affecting not only their social lives, but also their academic and financial ones. Individuals with TTM report avoiding school, work, and social activities because of hair pulling. This could result in poor academic performance or retention, job loss or demotion, and social isolation and sadness. They also found that these individuals spend large amounts of time and money trying to conceal the effects of hair pulling (for example, purchasing hair extensions). There is a lack of awareness by clinicians in diagnosing and treating the disorder and a paucity of research on effective treatment. A study of 1,697 individuals with TTM conducted by Woods and colleagues (2006) found that of the people who sought help, 27 percent reported that their treatment provider had no knowledge of TTM. In another study, researchers found that only 61 percent of providers polled responded correctly to general questions about TTM (Marcks, Wetterneck, & Woods, 2006). In addition to the lack of TTM knowledge, a large percentage of the providers surveyed did not have resources or referral information available for TTM clients (Marcks et al., 2006). There is a paucity of research for TTM, and the evidence-based treatments that are available are considered only moderately effective (Elliott & Fuqua, 2000). The two main treatment approaches include cognitive-behavioral therapy (CBT) and serotonin reuptake inhibitors (SRIs) (Keijsers et al., 2006). CBT and the SRIs were evaluated individually. Both showed promise, but relapse is common (for example, follow-up effect sizes decreased 70 percent at the two-year follow-up), and the current treatments offer relief to only some of those who suffer from TTM (Keijsers et al., 2006). In summary, TTM has a significant negative effect on individuals socially, psychologically, and economically. This is compounded by poor identification by clinicians, lack of research, and inadequate treatments when TTM sufferers finally seek help. The purpose of this article is twofold: to call attention to this condition and to describe an exploratory study aimed at improving treatment outcomes for individuals with TTM by using a numbing cream, such as Lanacane[R], as an adjunct to CBT treatment for trichotillomania. CASE HISTORY Carol, a girl who was almost 16 years old, asked her mother for professional treatment because of repeated hair pulling. Upon meeting her, I noted that she did not have any eye brows or eye lashes. She reported a history of hair pulling from her scalp, but currently she was pulling from her eye brows and eye lashes exclusively, and the pulling had become more severe. …