Anxiety and Depression Association of America

La Jolla, California 2013

Ruth Golomb, LCPC
Suzanne Mouton-Odum, Ph.D.
DISCLOSURE

Ruth Golomb and Suzanne Mouton-Odum

have both authored books and may financially
benefit from the sales.

Suzanne Mouton-Odum has created several

websites and a phone app and may financially
benefit from the sales.
OBJECTIVES

• Attendees will learn about the onset and phenomenology of Body

Focused Repetitive Behaviors (BFRBs)
• Attendees will become familiar with the complexities of these
disorders
• Attendees will learn about current treatment approaches for
treating hair pulling, skin picking, and other BFRBs
• Attendees will receive information about local and national
resources that provide expert information for professionals and
sufferers
TRICHOTILLOMANIA- 312.39

• Recurrent pulling of one’s own hair resulting in noticeable hair

loss
• Experience of tension prior to pulling or when attempting to resist
the behavior
• Pleasure, gratification or relief during pulling
• The disturbance is not accounted for by another disorder
(alopecia areata, schizophrenia)
• The disturbance causes significant distress or impairment in
social, occupational, or other important areas of functioning
PROPOSED DIAGNOSTIC CRITERIA FOR SKIN
PICKING

• Recurrent skin picking resulting in noticeable damage

• Preoccupation with or experience of urges to pick skin
• Feelings of tension, anxiety, or agitation prior to picking
• Feelings of pleasure, relief, or satisfaction during picking
• The behavior is not accounted for by another illness (delusions of
parasitosis, substance induced skin picking)
• Results in significant impairment in social, occupational or other
areas of functioning
PROBLEMS WITH THE DIAGNOSTIC CRITERIA

• Not all people have noticeable hair loss or skin lesions, but the
behavior can still be clinically significant
• While most people report tension prior to pulling or picking at
least some of the time, a preponderance of people report other
emotional states that precede an episode (boredom, sadness,
anger, frustration)
• Many people do not experience pleasure or gratification during
pulling or picking
BODY FOCUSED REPETITIVE BEHAVIORS

• Trichotillomania (hair pulling)

• Onychophagia (nail biting)
• Dermatillomania (skin picking)
• Compulsive nose picking
• Biting of the inside of the cheek
• Lip biting or picking
• Knuckle cracking
MODELS OF BFRBS
• Psychoanalytic model
• OCD model
• Tension-reduction model
• Modeling
• Integrative model
• Disorder of habit
• Biological/genetic models
• Disorder of grooming
ATTEMPTS AT SUBTYPING BFRBS
• Automatic behavior- done with little awareness,
usually during some other activity (watching TV,
reading, driving)
• Deliberate or focused- focus of the activity is on the
behavior, usually preceded by an urge
• A combination of both- most people report that
sometimes they are aware and focused on pulling or
picking while other times they are unaware of their
behavior
PRIMARY SITES FOR HAIR PULLING

Location Percentage
Scalp 79
Eyebrows 65
Eyelashes 59
Pubic Area 59
Legs 30
Arms 17
Other 25

Woods et al, 2006

CO-MORBIDITY
• 55% of adults with trichotillomania have a comorbid
psychiatric diagnosis
• 26% have an obsessive-compulsive disorder
• 23% have major depression
• 23% have generalized anxiety disorder

Woods et al, 2006

IMPACT OF BFRB BEHAVIOR
Medical
• Alopecia
• Infection
• Scarring
• Trichobezoar
• Repetitive strain injury
• Tendonitis
• Eye irritation
• Problems resulting from avoidance of doctor visits (poor pre-natal
care, vision issues, gynecological problems)
IMPACT OF BFRB BEHAVIOR
Psychological

• Low self-esteem
• Diminished sense of attractiveness
• Shame and embarrassment
• Anxiety resulting from worrying about the disorder
• Depression or mood problems
IMPACT OF BFRB BEHAVIOR
Social- Avoidance of certain activities
• Hair cuts
• Swimming
• Being outside on windy days
• Sports
• Sexual intimacy
• Well lit areas
• Short sleeves
• Short pants
COMB: A FUNCTIONAL MODEL
Five Core Components

• Education, Assessment and Functional Analysis

• Identify and Target Modalities
• Identify and Select Relevant Strategies
• Evaluation and Modification
• Maintenance and Relapse Prevention
COMB: A FUNCTIONAL MODEL
Education, Assessment and Functional Analysis
Goals of this Component:
• Educate
• Validate
• Destigmatize
• Instill hope
• Set realistic goals
• Address motivation for treatment
COMB: A FUNCTIONAL MODEL
Education, Assessment and Functional Analysis cont.
Goals of this Component:
• Functional domains will be explained to the client
• Sensory
• Cognitive
• Affective
• Motor
• Place
COMB: A FUNCTIONAL MODEL
Identify and Target Relevant Domains
• Sensory
• Cognitive
• Affective
• Motor
• Place

Questionnaire being developed to identify relevant domains

Identification is also conducted via self-monitoring between sessions
COMB QUESTIONNAIRE FOR HAIR PULLING
Sensory Domain
• Do you like or dislike the way certain hairs feel on your fingers?
• Do you visually search for certain types of hairs?
• Do you examine the root after the hair has been pulled?
• Do you smell the hair after it has been pulled?
• Do you pull when you feel over-stimulated from a busy or hectic day?
• Do you pull when you feel under-stimulated or bored?
• Do you experience any of the following at the pulling site just before
pulling:
• Itching
• Tingling
• Sensitivity
• Pressure
• Irritation
COMB: A FUNCTIONAL MODEL
Identify and Target Relevant Domains

Goals of this component:

• Client will have an understanding of the modalitiy(ies) that are operating with
regard to their TTM.
• Clients will be much more aware of their hair pulling urges and episodes with
awareness happening more often prior to pulling, not during or after.
COMB: A FUNCTIONAL MODEL
Identify and Select Relevant Strategies for Intervention

Sensory: Make sure all 5 senses are addressed

• Sensory substitution- playing with dental floss or doll hair
• Sensory distraction- playing with Play Dough
• Sensory soothing- playing with something smooth, soft
• Address visual triggers
• Address smell triggers
• Address oral triggers- chew on alfalfa sprouts or raw spaghetti
COMB: A FUNCTIONAL MODEL
Identify and Select Relevant Strategies for Intervention

Cognitive
• Identify faulty thinking and use cognitive correction
• Thoughts/beliefs about hair or skin
• Thoughts/beliefs about life problems (worry)
• Permission-giving thoughts
COMB: A FUNCTIONAL MODEL
Identify and Select Relevant Strategies for Intervention

Affective
• Improving coping skills
• Managing stress
• Relaxation training
• Deep breathing
• Mindfulness
• Self-care
• Visual imagery
COMB: A FUNCTIONAL MODEL
Identify and Select Relevant Strategies for Intervention

Motor
• Increase awareness
• Barriers
• Reminders
• Timers
• Retrain muscles
• Alter facilitative postures
COMB: A FUNCTIONAL MODEL
Identify and Select Relevant Strategies for Intervention

Place
• Address environmental triggers
• Cover mirrors
• Dim lights
• Use of hair pulling implements
• Throw away tweezers, needles, razors
• Social inhibitors
• Avoid being alone in high risk situations
• Construct a plan for social support
COMB: A FUNCTIONAL MODEL
Identify and Select Relevant Strategies for Intervention

Organizing the Interventions

• Identify 2-3 high risk situations to begin
• Target 3 strategies to use in each high risk situation
• Strategies should be from different domains
• Strategies should ideally be used prior to entering the
high risk situation
COMB: A FUNCTIONAL MODEL
Identify and Select Relevant Strategies for Intervention

Sample Strategy List:

Family Room
1. Brush hair (S)
2. Wear Band Aids (M)
3. Play with silly putty (S, A, M)
COMB: A FUNCTIONAL MODEL
Identify and Select Relevant Strategies for Intervention

Sample Strategy List:

Bath Room
1. Cover mirrors (MPCS)
2. Use a timer (M)
3. Throw away tweezers (P)
COMB: A FUNCTIONAL MODEL
Identify and Select Relevant Strategies for Intervention

Goals of this Component:

• Specific strategies that are appropriate for each high risk
situation for that client will be identified.
• Clients will agree to try at least 3 strategies for each situation.
• Specific usability issues for strategies will be identified and
problem-solved.
• Weekly goals will be set and monitored for success.
COMB: A FUNCTIONAL MODEL
Evaluation and Modification

• Maintain effective strategies

• Add new strategies
• Delete ineffective strategies
COMB: A FUNCTIONAL MODEL
Maintenance and Relapse Prevention
Goals for Relapse Prevention:

• Therapist will discuss importance of awareness of behavior as therapy ends.

• Client will be able to define lapse and relapse
• Therapist and client will identify potential stressors for the future
• Client will develop a plan to manage hair pulling during future stressful events.
MEDICATION AND BFRBS
• Currently no medications or combinations of medications
that are approved by the FDA for the treatment of BFRBs
• Anti-depressant medications
• Anti-anxiety medications
• Anti-psychotic medications
• Opioid agonists
• Mood stabilizers
• N-Acetyl Cysteine (NAC)
COMMON OBSTACLES TO TREATMENT
• Untreated affective or anxiety disorder
• Readiness issues
• Failure to complete homework
• Failure to try/use strategies
• Unwillingness to experience urges without
pulling/picking
• Complaints that “these strategies don’t work”
RESOURCES
• Trichotillomania Learning enter (TLC)
• “A Comprehensive Model for Behavioral Treatment of
Trichotillomania.” Mansueto et.al. Cognitive and Behavioral Practice
6, 23-43, 1999.
• The Hair Pulling Habit and You: How to Solve the Trichotillomania
Puzzle, Golomb and Vavrichek, 2000.
• A Parent Guide to Hair Pulling Disorder: Effective Parenting
Strategies for Children with Trichotillomania, Mouton-Odum and
Golomb, 2013.
• www.StopPulling.com
• www.StopPicking.com
• Pullfree (mobile app available at the Apple Store April 2013)