Trichotillomania: An ACT-enhanced Behavior Therapy Approach

[BeeKeeper]

From Oxford University Press: Treatments that Work Series Douglas W. Woods, Michael P Twohig   copyright 2008

This is a 10 week program to be done with a therapist.

Soon, I'll be posting Table of Contents, Assessments, and Goals-in general. I will not be posting my own progress in particular.  I am re-visiting the subject after 2020 and beyond re-activated this distressing habit; it may be valuable to at least one other person on the forum.

[BeeKeeper]

This post contains various assessments to define your own starting point and measure subsequent progress. They are in the appendix and also found on the internet as pdf files. I've included them here for convenience.

the Milwaukee Inventory of Subtypes of Trichotillomania Scale-Adult (MIST-A)
https://www.oxfordclinicalpsych.com/view/10.1093/med:psych/9780195336054.001.0001/med-9780195336054-interactive-pdf-027.pdf

the Acceptance and Action Questionnaire (AAQ) - this rates beliefs not related to any symptoms
https://www.oxfordclinicalpsych.com/view/10.1093/med:psych/9780195336054.001.0001/med-9780195336054-interactive-pdf-028.pdf


the Acceptance and Action Questionnaire for Trichotillomania (AAQ-4TTM)
https://www.oxfordclinicalpsych.com/view/10.1093/med:psych/9780195336054.001.0001/med-9780195336054-interactive-pdf-029.pdf

[BeeKeeper]

Chapter 1: Session I: Introduction to the Program

Goals:

• To learn about trichotillomania
• To learn about this program and what you can expect
• To learn about habit reversal training (HRT) and stimulus control
• To begin self-monitoring

Section headings:

Weekly Assessment
What is Trichotillomania
Prevalence
Gender Differences
Associated Problems
Age of Onset
Patterns of Hair Pulling
Genetic and Biological Factors
Automatic and Focused Hair Pulling
Overview of Treatment
Expectations for Treatment
Introduction to Habit Reversal Therapy and Stimulus Control Procedures
Self-Monitoring

I will focus on anything I believe applies to the general population here, as this behavior is not isolated from trauma and coping with trauma. I will gladly take questions or comments as we go along.

[Blueberry]

Thank you for posting this Beekeeper. I've never actually seen that much information on trichotillomania all in one place. The questionnaires are interesting to read, maybe I'll actually do them tomorrow.

[BeeKeeper]

You're welcome Blueberry. A comment about the Acceptance and Action Questionnaire: the main purpose is to measure flexibility/inflexibility. The scoring is confusing with no explanation, but I found more info elsewhere on the web.

An additional online resource is TRICH Education| Stop Pulling
https://www.stoppulling.com/trich-education/

Dr. Fred Penzel wrote The Hair Pulling Problem, copyright 2003.
https://global.oup.com/academic/product/the-hair-pulling-problem-9780195149425?cc=us&lang=en&

[BeeKeeper]

Stimulus Control Prevention Recommendations

Setting with possible intervention:

Bathroom:
Keep the bathroom door open
Remove bright lights from the bathroom
Use a timer to limit the amount of time in the bathroom

Watching TV/Playing Video Games
Sit in the middle of a couch or on a chair with no armrests
On top of the television, place a timer that you have to reset by getting up every 10 minutes (to increase effort to start and stop pulling)
Hold a furry object or stress ball in your hands

Reading
Sit in the middle of a couch or on a chair with no armrests
Hold the book with both hands
Hold a book in one hand and a furry object or stress ball in the other

Bedroom
Keep the bedroom door open
Lie in bed only when you're ready to sleep
Remove chairs with armrests

Use of Tweezers, Needles, Safety Pins or Sharp Objects
Remove these objects from the house and from your purse

Use of Mirrors
Remove magnifying mirrors or lighted mirrors
Remove small mirrors from your purse
Cover mirrors in the bathroom
Limit use of mirror to 1 minute

Please note: The mean age of onset is approximately 13 years. Hair pulling is sometimes preceded by a stressful life event or change in environmental conditions, but in most cases there is no clear reason for its beginning.

Many more adult women present for trichotillomania treatment than men. In children gender differences may be closer to equal, but a greater number of adult women seek treatment.

OBSERVATIONS: The researchers and treatment providers (I've seen) are all men. Therefore some of the interventions may seem out of touch with not only women's need for privacy, but also may grate on the sensibilities of those in this forum.

I was able to devise my own intervention with handling my hair when I'm home. I comb it out only sitting in a chair in the bathroom. This accomplishes several things. Clean up can be easier with a wet sponge, no struggling with the vacuum and it creates an association that I "only" have my hands in my hair at a specific time and specific place. Similar to no eating at the kitchen counter, only at the table.

[CactusFlower]

I think that's a very telling observation, good catch. With the expectations of women and appearance in today's society, I would argue the mirrors thing is impossible. Of the people I know who wear makeup, none can adequately do it in 60 seconds. Also, what if you need tweezers in the house for medical reasons? I have wood furniture and hardwood floors in an old house. Not having something to remove splinters is asking for trouble. Having things to hold to keep your hands occupied is more realistic, just my opinion.

[BeeKeeper]

 

Cactus Flower,
I'm in total agreement, especially about tweezers. I personally have 6 pair, (who's counting?)  but consider them tools for sewing and craft work. These are the kinds of things that cause regret when I buy "treatment" books. Your other point about makeup is on the money. Heck yeah!  Just doing one eye  with shadow, liner, mascara, takes about 15 minutes! I was skeptical about the value of the book before purchase and knew that I would probably find a very small % beneficial. That's true so far. 

In whatever fairness I can muster for the two young authors, I believe their intent was innocently helpful, and they may be writing for those on the far end of the spectrum which are unable to modify their behavior significantly. In its worst and most debilitating phase, this urge is pretty devastating.

I would liken it to a chronic smoker, unable to resist any urges. Instead, hair is pulled from various body parts to the point of baldness. I've been there, I could not stop, I didn't want to and there was sadly nothing in my life to give comfort or distraction. At the beginning of adolescence with all kinds of identity issues, and finding a place in social circles, having a huge bald spot on your scalp is not recommended.

Some go farther and then realize their intentional "disfigurement" is shocking, therefore, they avoid socialization entirely. Again, the inability to control, manage or limit self-destructive activities takes a toll. Over time this seems to morph into ritualized and environment specific behavior, and given enough time (decades) it wanes periodically.

The bigger, more important issue, IMO is that this is in therapeutic "awareness" now, getting attention and starting to be "investigated" by academics, researchers, and health providers. Western medicine is slow to do anything, but the first step is getting that critical spotlight.

[Armee]

Thanks for sharing this Bee and Sage. I had the same thought and it's one big reason why I don't want to work on this in therapy. I do not want to be forbidden something that feels necessary. I want to dial it down. But that happened once I dealt with the issues that were causing it. I'm not real sure how much behavior modification would have worked before then because it's like a trance to deal with the unsolvable issues I was trying to solve. Once I really got a handle on the underlying psychological issue, the behavior reduces greatly. I guess we are supposed to substitute the harmful  habit for a non harmful one.

[BeeKeeper]

Armee,

Yes, making things "forbidden" puts it in another category.  Dialing down 

it's like a trance

Affirmative, it IS a trance.
If you do things outside awareness, the authors' term is "automatic" but if you know what you're doing, then they say it's focused."

Correct, a succinct way of putting habit reversal training 

I guess we are supposed to substitute the harmful  habit for a non harmful one.

Tara Brach brings up the word "trance" specifically related to ways to living life. Not just episodes now and then. In the short time I've had this book, I have gone from wanting to work on it in therapy to not wanting to work on it in therapy.

[CactusFlower]

Agreed, "forbidden" often doesn't work. You can't just cut out something soothing or even pleasurable or anxiety-reducing and not replace it with something useful and have the change be sustainable. It's a huge reason for why diets or cold-turkey smoking cessation doesn't work. We have to re-form those neural pathways towards something else. Telling someone or telling yourself "just stop" isn't realistic.  And I get you about the "trance" thing. I had no idea how much I did these habits until I learned they WERE a habit, an automatic reaction.

[BeeKeeper]

Sage,

Agreed! Cold turkey is not doable for 99.99% of people.

This book has gone into the closet now, and I'll ask my T one or two questions before abandonment. If I continue this it will be with Dr. Penzel's writings. He's the best.