Treatment of Trichotillomania
Habit reversal training should be initiated as the first-line treatment for all patients with trichotillomania, demonstrating superior efficacy (effect size -1.14) compared to both clomipramine (effect size -0.68) and SSRIs (effect size 0.02). 1, 2
First-Line Treatment: Behavioral Therapy
Habit Reversal Training Components
Awareness training teaches patients to identify specific triggers, high-risk situations, and early warning signs that precede hair-pulling episodes 1
Competing response training involves practicing alternative behaviors (such as clenching fists, sitting on hands, or manipulating objects) when the urge to pull hair emerges 1
Relapse prevention planning must identify personal triggers, warning signs, and specific action steps to maintain treatment gains 1
Treatment Structure and Delivery
Deliver 10-20 sessions of cognitive-behavioral therapy, either individually or in group format 1
Both in-person and internet-based delivery formats demonstrate equivalent effectiveness 1
Group cognitive-behavioral therapy produces significantly greater reduction in hair-pulling behavior compared to supportive therapy alone 3
Patient adherence to between-session homework exercises is the most robust predictor of both short-term and long-term treatment success 4
Pharmacotherapy: Second-Line or Adjunctive Treatment
When to Consider Medication
Add pharmacotherapy when patients are unwilling or unable to comply with behavioral therapy 5
Consider combination therapy (behavioral + medication) for patients who fail to respond adequately to habit reversal training alone after 12 weeks 6
Dual modality treatment (sertraline plus habit reversal training) produces larger symptom improvements and higher responder rates than either approach alone 6
First-Line Pharmacological Agent
N-acetylcysteine is the preferred first-line medication due to significant benefits and low risk of side effects 1, 5
Three out of five randomized controlled trials demonstrated superiority of N-acetylcysteine over placebo 1
This glutamate-modulating agent should be considered before tricyclic antidepressants or SSRIs 5
Second-Line Pharmacological Agent
Clomipramine demonstrates moderate efficacy (effect size -0.68) and is superior to SSRIs for trichotillomania 2
Requires 8-12 weeks at maximum tolerated dose before declaring treatment failure 1
Monitor for serious adverse effects including seizures, cardiac arrhythmias, and serotonergic syndrome, especially when combined with other serotonergic agents 1
Common pitfall: Prematurely discontinuing clomipramine before completing the full 8-12 week trial at maximum tolerated dose 1
SSRIs: Limited Evidence
Meta-analysis shows no evidence that SSRIs are more efficacious than placebo for trichotillomania (effect size 0.02) 2
Despite limited efficacy as monotherapy, sertraline combined with habit reversal training may be beneficial for partial responders 6
Treatment Algorithm
Initiate habit reversal training (10-20 sessions) as primary treatment for all patients 1
Assess response at 12 weeks: If inadequate improvement, add N-acetylcysteine as first-line pharmacotherapy 1, 5
If N-acetylcysteine fails or is not tolerated: Switch to clomipramine and continue for full 8-12 weeks at maximum tolerated dose 1, 2
For partial responders to either modality: Combine behavioral therapy with pharmacotherapy (dual modality approach) 6
Maintain treatment: Continue successful interventions for at least 12-24 months after achieving remission, given the chronic nature of the condition 4, 5
Critical Clinical Considerations
Trichotillomania is classified as an obsessive-compulsive related disorder, not an impulse control disorder, which informs treatment selection 1
Maintain a nonjudgmental, empathic, and inviting attitude, as patients often deny the habit 5
In pediatric cases, educate parents that negative feedback and punishment for hair pulling will not produce positive results 5
Social and familial support is essential for successful habit reversal training 5
Avoid premature discontinuation: Both behavioral therapy and pharmacotherapy require adequate trial duration before switching approaches 1, 2