Trichotillomania: Behavioral Assessment and Treatment Interventions

By Kell, Brandy L.; Kress, Victoria E. | The International Journal of Behavioral Consultation and Therapy, Spring 2006 | Go to article overview
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Trichotillomania: Behavioral Assessment and Treatment Interventions

Kell, Brandy L., Kress, Victoria E., The International Journal of Behavioral Consultation and Therapy


This article examines the behavioral treatment of Trichotillomania. A brief overview of the diagnosis and assessment of Trichotillomania is provided. Guidelines for a structured clinical evaluation when working with people diagnosed with Trichotillomania are supplied. The most effective behavioral interventions and treatments for working with client's diagnosed with Trichotillomania are discussed.

Keywords: Trichotillomania, Behavioal Assessment,Behavior Treatment


The reported incidence of Trichotillomania is rising with an estimated prevalence rate of 1%, suggesting that nearly 2.5 million people in the United States have this disorder (Diefenbach, Reitman, & Williamson, 2000). Increased attention should be given to the assessment and treatment of Trichotillomania to fulfill the escalating needs of those dealing with this mental disorder. There is a tendency for the severity of this disorder to be overlooked due to the underestimation of prevalence, and high rate of comorbidity with other psychological disorders (Mulinari-Brenner & Bergfeld, 2001). This article will provide suggestions for the behavioral assessment and treatment of Trichotillomania.

It is helpful for individuals to become familiar with the diagnostic features of Trichotillomania to establish the proper assessment and treatment of this disorder. The disorder was introduced in 1987 as an impulse control disorder (American Psychiatric Association, 1987). Trichotillomania is currently defined in the DSM-IV TR (American Psychiatric Association [APA], 2000) as the recurrent pulling out of one's own hair resulting in noticeable hair loss, in which an individual experiences persistent tension prior to pulling out the hair or when attempts are made to resist the behavior. Once the behavior is occurring or has occurred, the individual may feel pleasure, gratification, or relief. For the disorder to be considered clinically significant, that is not a result of a general medical condition or another mental disorder (American Psychiatric Association, 2000).

Trichotillomania often begins or is recognized in late childhood or early adolescence with an average age of onset at 13 years (Christenson, Mackenzie, Mitchell, & Callies, 1991; Simeon et al., 1997; Stein, Christenson, & Hollander, 1999; Walsh & McDougle, 2001). Despite the early onset, there is no consensus over the etiology of Trichotillomania (Diefenbach et al., 2000; Stein et al., 1999). Various explanations have been offered, that include viewing it as a feature of Obsessive Compulsive Disorder (OCD) as evidenced in the high comorbity rates (Christenson, Mackenzie, & Mitchell, 1991; Elliott & Fuqua, 2000), psychoanalytic perspectives (Diefenbach et al., 2000; Stein et al., 1999) and neurobiological factors (Ashton, 2001; Ravindran, Lapierre, & Anisman, 1999).

For the purpose of this article, trichotillomania will be addressed from a behavioral perspective and behavioral assessment and treatment interventions will be reviewed. Behaviorists believe that Trichotillomania is basically a coping behavior that develops in response to stressful stimuli. The hair pulling behavior is reinforced through classical and operant conditioning that culminates in an individual reverting to hair pulling as a technique used to reduce tension (Diefenbach et al., 2000; Stein et al., 1999). In the remainder of this article, effective behavioral interventions will be reviewed.

Behavioral Assessment of Trichotillomania

As in the assessment of all mental and emotional disorders, the clinician should conduct a clinical interview that provides a thorough assessment of a multitude of factors. Emphasis may be given to age of onset, frequency (e.g., does hair pulling occur daily, is it persistent or only present in times of distress, does it follow a pattern) and quantity (i.e., pulling hair strands or clumps), emotional state (before, during and after hair pulling), self employed efforts to reduce or stop the behavior, past treatment interventions and family patterns (Bordnick, 1997; Christenson, Mackenzie, & Mitchell 1991; Mulinari-Brenner & Bergfeld, 2001; Simeon & Favazza, 2001; Stein et al.

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