Extended Abstract
Introduction
Trichotillomania disorder, or hair pulling disorder, is a condition in which patients considerably engage in pulling out of their own hair, typically from the scalp, eyebrows, eyelashes, or other body areas. Prior to or while resisting the urge to hair pulling, these individuals often experience a sense of tension or stress, which is relieved by the act of hair pulling. However, not all of these patients undoubtedly experience tension before hair pulling and a feeling of relief afterwards. Trichotillomania is a mental health disorder characterized by the persistent urge to pull out one’s hair, often culminating in dysfunction or distress.
Trichotillomania was previously classified as an impulse control disorder according to the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV); however, in the fifth edition (DSM-V), it was reclassified as an obsessive-compulsive disorder.
Numerous studies have indicated a potential negative impact of trichotillomania on both physical and psychological functioning of patients. Hair loss is a primary physical consequence of this disorder, which may culminate in skin lesions and infections. A group of patients who ingest their hair are at risk of developing trichobezovar, which can result in anorexia, nausea, weight loss, and potentially death. Beyond the mentioned complications, individuals with trichotillomania often experience social difficulties due to avoidance of various social situations and public places.
According to longitudinal studies, spontaneous remission of trichotillomania is exceedingly rare. Clinical literature highlights the use of various therapeutic approaches for trichotillomania, including pharmacotherapy, behavioral therapy, hypnotherapy, cognitive-behavioral therapy (CBT), and acceptance and commitment therapy (ACT).
CBT techniques have demonstrated efficacy in treating trichotillomania, with habit-reversal training (HRT) being the most prominent. HRT involves self-monitoring of behaviors, enhancement of coping strategies, increased social support, and relaxation therapy.
Behavioral interventions for trichotillomania generally consist of three core components: Awareness training, stimulus control, and competing response training. Awareness training involves techniques to improve the patient’s awareness of hair pulling and to better anticipate the urge to pull. Stimulus control employs various methods to reduce the likelihood of the behavior’s initiation. In competing response training, at the first sign of an urge to pull, the patient is taught to engage in a behavior that is physically incompatible with hair pulling for a brief period. Awareness training may involve the use of visual cues, such as large stop signs in locations where the urge to pull is likely to occur. Stimulus control is another crucial component of HRT for trichotillomania. Hair pulling often occurs in a specific situational context, for example, while watching television. Over time, this context often serves as a stimulus for the habit. Stimulus control (e.g., wearing gloves) has been rated as one of the most beneficial techniques in the treatment of trichotillomania. Competing responses, the third major component of HRT, encompass response manipulation and behavioral corrections. Competing responses involve manipulating objects, such as stress balls or stretchy toys. Competing response behaviors should be practiced repeatedly. This article reports on the efficacy of HRT in reducing the severity and distress of trichotillomania.
Case Presentation
The patient, a 13-year-old girl with intellectual disability, was a second-grade student at a special education school and exhibited significant hair loss in the eyebrow area. Based on Wechsler, Leiter, and Goodenough Intelligence Scales, her intelligence quotient (IQ) was determined to be 65. The patient was the firstborn in a family of four. Her younger brother, who had an IQ of 38 and was considered trainable, received more parental attention. As a result, the patient in question received less parental attention. A clinical interview with the patient’s father, conducted using the DSM-V, confirmed the presence of trichotillomania. To rule out any underlying dermatological conditions in the affected areas, the patient was examined by a dermatologist. No clinical skin or hair disorders were identified.
The Massachusetts General Hospital Hair Pulling Scale (MGH-HPS) is a 7-item self-report measure, rated on a 5-point Likert scale, that assesses the severity and distress of hair-pulling urges and behaviors (specifically, eyebrow hair pulling) over the past week. A cut-off score of 17 is used, with higher scores indicating the presence of the disorder. The scale measures the intensity of pressure and distress associated with resisting against hair pulling urges. Given the cognitive characteristics of the student, who had an IQ of 65 and was unable to reliably respond to self-report questions about the nature of self-interests, the parent-report version of the MGH-HPS was employed. This questionnaire, based on a Likert scale, allows for the assessment of severity and distress. Its reliability and validity have been established. Scores on each item range from 0 to 10, with 0 indicating the absence of the disorder and 10 indicating the most severe form. This scale has been adapted and validated in Iranian clinical samples. The reliability and validity of this questionnaire have been calculated in Iranian studies, with internal consistency coefficient of Cronbach's alpha of 0.792. The HRT protocol was adapted from Franklin and Tolin’s article. HRT techniques were administered to the patient individually over eight sessions. Therapy sessions were conducted twice a week (45 minutes each) for one month. The subject was reassessed using the parent-report version of the MGH-HPS at sessions 2, 4, 6, 8, and one month post-treatment.
The implementation of HRT caused a significant reduction in the severity and distress associated with trichotillomania, culminating in a high percentage of symptom improvement. The patient demonstrated a sustained improvement in symptoms throughout the treatment and during a one-month follow-up period.
Conclusion
The efficacy of HRT techniques in reducing the severity and distress associated with trichotillomania in the eyebrow region of the investigated child with intellectual disability was demonstrated.
Ethical Statement
The rationale for treatment was explained to the parents following a diagnostic interview, collecting data from parents, and direct observation of behavior in a clinical setting. Subsequently, they participated in the study after expressing their consent and signing a written informed consent form.
Conflicts of Interest
No conflict of interest.
Acknowledgement
The authors would like to thank the patient who participated in this study and her family. We would also like to thank the esteemed management of the Modarres Exceptional Education Center for their cooperation in conducting this study.
Key message: The implementation of HRT techniques was efficient in reducing the severity and distress associated with trichotillomania in the child with intellectual disability, and a high rate of improvement was observed in the patient.