Trichotillomania: Identification and Treatment

Counselors must be prepared to work with clients with diverse symptoms and educate themselves regarding clients' presenting problems to best serve their clients (American Counseling Association, 2005). Trichotillomania (TTM) is an underrecognized disorder associated with both distress and impaired functioning (Odlaug, Kim, & Grant, 2010). This article serves to provide introductory information to counselors working with clients with TTM. * Description of the Disorder Current prevalence estimates for TTM are largely established through college student surveys and vary between 1% and 13.3% (Duke, Keeley, Geffken, & Storch, 2010). Duke et al. (2010) estimated that three million individuals in the United States are affected by TTM (using the conservative 1% frequency). According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000), TTM is distinguished by repeated hair pulling to reduce anxiety. The DSM-IV-TR requires five criteria for the diagnosis of TTM: (a) "recurrent pulling out of one's own hair that results in noticeable hair loss," (b) "increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior," (c) "pleasure gratification or relief when pulling out the hair," (d) "the diagnosis is not given if the hair-pulling is better accounted for by another mental disorder," and (e) "the disturbance must cause significant distress or impairment in social, occupational, or other important areas of functioning" (American Psychiatric Association, 2000, p. 677). There is some contention about the second (tension before pulling) and third (reduction of tension after pulling) criteria, and there is a proposed revision for the DSM-5 (scheduled for publication in 2013) to exclude these two criteria (American Psychiatric Association, 2010; Stein et al., 2010). Studies have been published using the strict DSM-IV-TR criteria as well as the more lenient definition proposed for the DSM-5 (Duke et al., 2010). Some assessments have been created to help evaluate the impairment of TTM. The Trichotillomania Impact Survey (Neal-Barnett et al., 2010), for example, is designed to identify the phenomenology as well as the impact of hair pulling and the treatment outcome. The Massachusetts General Hospital Hairpulling Scale (Keuthen et al., 2007) is another survey designed to assess the severity and impact of hair pulling on the life of the individual. Phenomenology The ways individuals pull hair can vary. Hair-pulling sites are most commonly the scalp, but pulling may occur anywhere on the body, including the common pull sites of the face and pubic region (Duke et al., 2010). There is a difference in pull sites among ethnic lines: Caucasians have reported pulling from lashes and eyebrows more often than racial/ethnic minorities (Neal-Barnett et al., 2010). Age is also a factor in the phenomenology of TTM; the number of places that clients with TTM pull from increases with age (Flessner, Woods, Franklin, Keuthen, & Piacentini, 2008). Hair may be pulled one strand at a time (most common) or in clumps (Duke et al., 2010) and is most often pulled with fingers, tweezers, combs, or brushes (Walther, Ricketts, Conelea, & Woods, 2010). Researchers have identified three subsets of hair pulling: early onset, automatic, and focused. Early onset TTM occurs in children 8 years or younger and is generally self-correcting without therapeutic intervention (Duke et al., 2010). Automatic hair pulling is unconscious and happens while the individual is focused on something else (e.g., watching television or reading), whereas individuals with focused hair pulling are aware of the pulling. Focused hair pulling is characterized by urges and tension often associated with obsessive-compulsive disorder (OCD; Duke et al., 2010). These three subsets are not exclusive; an individual may have co-occurring hair-pulling types (Duke et al. …