Habit Reversal Training and Stimulus Control Techniques for Trichotillomania
Habit reversal training (HRT) combined with stimulus control techniques are the first-line behavioral treatments for trichotillomania, particularly effective when hair pulling occurs with lowered awareness or automatically.1
Understanding Trichotillomania
Trichotillomania is characterized by predominantly automatic behavior rather than deliberate action, with most hair-pulling occurring outside of full awareness as a habitual response to urges or sensory triggers 2. This automatic nature distinguishes it from other conditions like OCD, where behaviors are more deliberate and purposeful.
Habit Reversal Training Components
1. Awareness Training
- Self-monitoring: Have patients keep a detailed log of hair-pulling episodes, including:
- Time and location of pulling
- Bodily sensations before pulling (tingling, tension)
- Thoughts or emotions preceding pulling
- Environmental triggers (watching TV, studying, etc.)
- Heightened awareness exercises: Train patients to recognize early warning signs of pulling urges 3
- Mirror exercises: Practice identifying subtle hand movements toward hair
2. Competing Response Training
- Incompatible behaviors: Teach specific physical actions that make hair pulling impossible, such as:
- Making a fist rather than picking or pulling 4
- Clasping hands firmly together for 1-3 minutes when urges occur
- Putting hands in pockets or sitting on hands
- Squeezing a stress ball or fidget toy
- Posture modification: Changing sitting positions that facilitate pulling
Stimulus Control Techniques
1. Environmental Modifications
- Trigger identification: Identify specific situations, locations, or activities associated with pulling
- Barrier methods:
- Wearing gloves or bandages on fingers during high-risk times
- Covering or protecting hair areas with hats, scarves, or bandanas
- Using bitter-tasting nail polish to discourage finger-to-mouth behaviors after pulling
2. Sensory Substitution
- Tactile stimulation alternatives: Provide similar sensory experiences without damage:
- Textured fidget toys that mimic hair texture
- Stress balls or putty for manual stimulation
- Soft fabrics to stroke instead of hair
3. Activity Scheduling
- High-risk period management: Identify times when pulling is most likely and schedule alternative activities
- Behavioral activation: Increase engagement in activities requiring both hands
- Exercise routines: Incorporate regular physical activity to reduce stress and tension
Implementation Strategy
- Initial assessment: Determine if pulling is primarily automatic/unconscious or focused/deliberate 2
- Tailored approach:
- For automatic pulling: Emphasize awareness training and stimulus control
- For focused pulling: Add emotional regulation strategies and cognitive techniques
Augmentation Strategies
- Acceptance and Commitment Therapy (ACT): Particularly helpful when negative emotions trigger pulling 1
- Dialectical Behavior Therapy (DBT): Useful for emotional regulation when distress triggers pulling 1
- Pharmacological support: N-acetylcysteine (NAC) should be considered as an adjunct treatment given its moderate benefit and low side effect profile 1, 5
Common Pitfalls to Avoid
- Insufficient practice: Competing responses must be practiced repeatedly to become automatic
- Incomplete awareness training: Rushing to competing responses before awareness is fully developed
- Neglecting maintenance: Not planning for long-term maintenance and relapse prevention
- Overlooking comorbidities: Failing to address anxiety or depression that may trigger pulling episodes
By implementing these specific habit reversal training and stimulus control techniques, patients with trichotillomania can develop greater awareness of their pulling behaviors and establish effective strategies to interrupt and replace the hair-pulling cycle.