Expanding the Scope of Treatment for Trichotillomania: Treatment Modalities and Interpersonal Context

The objective of this project was to lay the groundwork for expanding the scope of treatment for trichotillomania (TTM; hair pulling disorder) by focusing on key modalities of pulling behavior and also patients’ contexts, such as interpersonal functioning. The first study of this project aimed to concretize and pilot test the Comprehensive Behavioral Model (ComB), with the ultimate goal of rigorous testing of the efficacy of the model. The ComB treatment manual was drafted and revised based on patient and therapist feedback; an intervention choice study demonstrated that therapists could reliably select interventions consistent with the manual; therapist adherence and competence measures were developed; and a preliminary examination of the efficacy of the treatment was completed. Participants found the ComB treatment highly acceptable, and TTM severity and impairment improved across all measures, with large effects. The second study investigated interpersonal functioning among adults with TTM as another approach to learning more about expanding the scope of treatment for trichotillomania. The objective was to contribute data for future development of components of treatment that focus on interpersonal functioning. This was done through a survey about relationships and related difficulties among people with trichotillomania. Hypotheses were supported that greater TTM severity is associated with lower relationship satisfaction, perceived social support, and greater perceived criticism, perceived risk in intimacy, and social interaction anxiety, though these correlations were small. TTM-by-proxy urges were reported by 54% of participants and 37% of participants reported having actually pulled hair from other people. Higher levels of TTM-by-proxy urges were associated with “focused” pulling and perfectionistic thinking, yet for individuals with current urges, there was no association with greater functional impairment. Approximately one-quarter of survey respondents had not told their closest friend about their trichotillomania, and one-fifth had not told their spouse or long-term romantic partner. Among individuals who reported having asked other people to pull hair for them (7% of sample), there was increased endorsement of “focused” pulling episodes. Researchers should consider these issues in developing treatments, as the need to individualize based on treatment modalities and interpersonal functioning might hold promise for adults with TTM.