What is the treatment for trichotillomania?

Treatment of Trichotillomania

Initiate habit reversal training (HRT) as first-line treatment for all patients with trichotillomania, delivered over 10-20 sessions of cognitive-behavioral therapy, with N-acetylcysteine as the preferred first-line medication when pharmacotherapy is needed. 1

First-Line Treatment: Behavioral Therapy

Habit reversal training demonstrates superior efficacy compared to all pharmacological interventions (effect size -1.14 vs -0.68 for clomipramine vs 0.02 for SSRIs) and should be the initial treatment approach. 2

Core Components of Habit Reversal Training

• 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 when the urge to pull hair emerges—patients learn to substitute pulling with incompatible physical actions. 1

• Self-monitoring helps patients track pulling episodes, urges, and contextual factors to increase awareness of the behavior pattern. 3

• Stimulus control procedures modify the environment to reduce pulling opportunities by avoiding or altering high-risk situations. 3

• Relapse prevention planning identifies personal triggers, warning signs, and specific action steps to maintain treatment gains long-term. 1

Treatment Structure and Delivery

• Deliver 10-20 sessions of individual or group cognitive-behavioral therapy, with both formats showing efficacy. 1

• In-person or internet-based delivery are both effective options, allowing flexibility based on patient access and preference. 1

• Group cognitive-behavioral therapy produces significantly greater reduction in hair-pulling behavior compared to supportive therapy alone. 4

Critical Success Factor

Patient adherence to between-session homework exercises is the most robust predictor of both short-term and long-term treatment success. 1 Emphasize this to patients from the outset and monitor homework completion at each session.

Pharmacotherapy: When and What to Use

First-Line Medication: N-Acetylcysteine

N-acetylcysteine is the preferred first-line pharmacological treatment due to significant benefits and low risk of side effects. 1, 5 Three out of five randomized controlled trials demonstrated superiority to placebo. 1

Second-Line Medication: Clomipramine

• Clomipramine shows moderate efficacy (effect size -0.68) and is superior to placebo, unlike SSRIs which show no evidence of efficacy over placebo. 2

• Requires at least 8-12 weeks at maximum tolerated dose before declaring treatment failure—premature discontinuation is a common pitfall. 1

• Monitor for serious adverse effects including seizures, cardiac arrhythmias, and serotonin syndrome, especially when combined with other serotonergic agents. 1

SSRIs: Limited Evidence

• SSRIs (including sertraline) show no evidence of superiority to placebo in monotherapy for trichotillomania. 2

• However, dual modality treatment combining sertraline with HRT produces larger gains and higher responder rates than either approach alone. 6

Treatment Algorithm

1. Start with HRT as monotherapy for all patients (10-20 sessions). 1

2. Add N-acetylcysteine if HRT alone produces insufficient response after adequate trial. 1, 5

3. Consider clomipramine if N-acetylcysteine augmentation fails, ensuring 8-12 weeks at maximum tolerated dose. 1

4. Dual modality approach (HRT + medication) demonstrates superior outcomes compared to single modality treatment and should be considered for patients not responding adequately to behavioral therapy alone. 6

Treatment Duration and Maintenance

• Continue successful interventions for at least 12-24 months after achieving remission given the chronic nature of trichotillomania. 1

• The high relapse rate necessitates extended treatment duration beyond initial symptom improvement. 1

Common Pitfalls to Avoid

• Do not prematurely discontinue clomipramine trials before completing 8-12 weeks at maximum tolerated dose—this is the most common medication error. 1

• Do not use SSRIs as monotherapy expecting significant benefit, as evidence shows no superiority to placebo. 2

• Do not neglect homework adherence—this is the strongest predictor of success, so actively monitor and problem-solve barriers to completion. 1

• Do not adopt a judgmental attitude—patients often deny the habit and require an empathic, nonjudgmental, and inviting approach to engage in treatment. 5