Habit reversal training for trichotillomania.

Trichotillomania is characterized by the repeated urge to pull out hair, leading to noticeable hair loss, distress, and social or functional impairment. Most of the cases present initially to dermatologists with complaints of loss of hair and is often confused with other dermatological conditions like alopecia areata, tinea capitis, traction alopecia, and loose anagen syndrome. It is a chronic condition and difficult to treat. No formal treatment algorithm is present for trichotillomania and no drug has been found to be universally effective. We present a case report of a 22-year-old single female diagnosed with trichotillomania, with complaints of recurrent hair pulling resulting in noticeable hair loss since the age of 8 years. She was treated with Habit Reversal Training with Stimulus Control over a period of 12 weeks and attained complete remission. The effectiveness of HRT plus for the treatment of Trichotillomania is ascertained.

INTRODUCTION

Trichotillomania is an impulse control disorder characterized by intense and repeated urge to pull out hairs with a mounting tension before and a sense of relief afterwards.[1] It presents in multiple ways in the clinical setting and, in most aspects, remains a poorly understood entity.[2] Most of the cases present to psychiatrists only after multiple visits to dermatologists and general physicians with complaints of hair loss and remains undetected for a long time. Differential diagnosis includes other dermatological conditions like alopecia areata, tinea capitis, traction alopecia, and loose anagen syndrome. Studies on the pharmacotherapy of trichotillomania remain inconsistent,[3-5] with no individual drug or group of drugs found to be clinically effective constantly. Behavior therapy in the form of Habit Reversal Training and Stimulus Control (HRT Plus) has been found to be an effective treatment.[6-8] It has also proven effective in treating children.[9] However, no formal treatment algorithm for trichotillomania can be formulated.[10]

We present a case report detailing clinical data taken during the course of outpatient treatment of a patient who sought treatment for symptoms of Trichotillomania. The patient was resistant to a range of drugs and was started on treatment with HRT Plus. The treatment approach is described in detail and relevant outcome reported.

CASE REPORT

Ms. JK, a 22-year-old single female, an unemployed engineering graduate belonging to a nuclear family of middle socioeconomic status was referred to the Psychiatry out patient department by the dermatology clinic where she presented with complaint of alopecia. She gave history of recurrent pulling out of her hair resulting in noticeable hair loss since the age of 8 years. She used to develop an urge and a sense of tension immediately before pulling out the hair or when attempting to resist the behavior which got relieved on pulling out the hair. Hair pulling was only from the scalp, but never from any other site of the body. She always checked the roots of the hair before discarding it. There was no history of biting or swallowing of the hair. Due to the baldness arising due to her hair pulling, the patient started using a scarf which she would wear throughout the day. She developed decreased self-confidence due to her problems and started avoiding social gatherings. She did not take up a job despite being called for many interviews due to hesitation in facing anyone due to her growing baldness. A diagnosis of Trichotillomania was made as per International Statistical Classification of Diseases and Related Health Problems, 10th Revision criteria.[1]

Treatment history revealed visit to multiple dermatologists and then referral to psychiatrists for treatment. She was treated with various antidepressants including fluvoxamine, sertraline, clomipramine, and antipsychotics like haloperidol, risperidone, and quetiapine, with no significant improvement over 8 years underlying the drug resistance in this case. There was no relevant family history of any psychiatric illness. Physical examination revealed patchy baldness all over the scalp. No hair loss was present at any other site. No other abnormality was detected on General Physical Examination and Systemic Examination. Laboratory tests revealed normal hemogram, renal function, and liver function.

Ms. JK was given the treatment options of Pharmacotherapy, HRT Plus, and a combination of the two. She selected the option of HRT plus. A therapeutic contract was signed and it was agreed to have one session per week.

In the 1st session, Ms. JK was educated about the diagnosis of trichotillomania, its prevalence, etiology, and course. The concept of HRT and SC was then explained to the patient along with the expected course of treatment. She acknowledged that her hair pulling had caused her significant distress over the years. She completed a focused questionnaire related to her hair-pulling behaviors, antecedents, and consequences. A self-monitoring form was given [Table 1]. She agreed to fill it on a daily basis and maintain it throughout the therapy period.

Table 1

Self-monitoring form

The Massachusetts General Hospital Hair Pulling Scale (MGH-HPS) was applied to assess the severity of trichotillomania over last one week. It is a self-rated scale containing seven items and has good psychometric properties.[11]

In the second session, feedback of previous session was taken and self-monitoring form was assessed which revealed that pulling occurred in a limited number of situations and settings, typically when she was involved in sedentary activities. She had developed an awareness of the habit and often resisted pulling. Certain idiosyncratic behaviors within the pulling sequence involving stroking and manipulation of the hair prior to pulling and checking of roots later were present. Skin sensations provided significant cues for pulling. The patient was taught progressive muscular relaxation and diaphragmatic breathing and was asked to do both on a daily basis.

The third session constituted of teaching the “Competing response” which is acquiring of a muscle tensing activity which is somewhat opposite to, and incompatible with hair pulling. She was taught to make a clenched fist with the hand she uses to pull hair, to bend the arm at the elbow 90ˌ, and to press the arm and hand firmly against her side at waist level. She was then instructed that whenever and wherever she gets the urge to pull, she was to (in order) relax herself, do diaphragmatic breathing for 60 seconds, and the competing response for 60 seconds.

In the fourth session, replacement behaviors including cue-controlled relaxation and postural variations such as not holding her head in her hand while working or driving; placing her hands behind her head and under the pillow while lying in bed, watching television were agreed upon for environmental situations in which the problem behavior was most likely to occur. It was recommended to increase the distance between her hands and head at all times and hold a pen in whichever hand was idle while she was working.

Over the next eight sessions, treatment strategies were monitored for effectiveness and modified as needed. Review of the rationale and types of replacement or competing behaviors that would help decrease her symptoms was constantly done. Focus was also directed toward any associated cognitive symptoms.

The patient showed significant improvement from session 4 onward. The MGH-HPS score which was 22 (max: 28) in first session became 0 by sixth and remained so throughout the remaining sessions. The patient did not even pull a single hair over the rest of the treatment sessions. She became all set to appear for job interviews and described herself fully confident for it. Her hair has started growing back and she stopped using her scarf to cover her head anymore. The therapy sessions were terminated with mutual consent between the therapist and the patient after 12 weeks. The patient remained on regular follow ups thereafter.

DISCUSSION

This case highlights the efficacy of behavior therapy in trichotillomania even in cases resistant to multiple drugs. The treatment model presented in this paper attends to the diverse and idiosyncratic nature of factors that encourage and maintain hair pulling. Symptom improvement could have been due to the indirect benefits of relaxation by reducing emotional distress and value-laden self-judgments about having psychiatric symptoms. The therapist must decide, in consultation with the client, which therapeutic techniques to employ, in what order, and at what pace. By carefully monitoring the impact of these techniques, the client and therapist can revise and refine the individualized treatment program to enhance its effectiveness. However, the importance and severity of the medical complications of trichotillomania should not be underestimated.

This model has its limitations as well as it does not address distal determinants of hair pulling such as biological vulnerability or family dysfunction. Also, comorbid conditions (depression, Tourette's syndrome) remain unaddressed in this model and needs additional treatment.

Increased awareness of this disorder at a primary healthcare level should be encouraged. HRT Plus appears to be an effective mode of treatment for Trichotillomania. There is a need to educate the primary care physicians and dermatologists, to whom such cases primarily present to, about this therapy. However, more studies comparing HRT and pharmacotherapy are needed to evaluate their relative efficacy. Dual treatment options must also be evaluated.