Behavioural therapy

Many behavioural techniques are effective for treating trichotillomania. (1.I9,) However, most of the behavioural literature is limited to case reports and case series lacking randomized controlled methodologies. Behavioural approaches have included self-monitoring, therapist praise, token economy, differential reinforcement of other behaviours, relaxation training, rational emotive therapy, self-instruction, and covert desensitization. Punishment/aversive techniques include self-administered rubber band snaps, faradic shock, aromatic ammonia inhalation, hand slaps, and response cost. The mildly aversive techniques of overcorrection and facial screening have been used with the developmentally disabled. Painting aversive-tasting substances on to the thumb has been successful in treating both thumb sucking and hair pulling when these behaviours covaried in young children. Aversive techniques have generally been used only when other approaches have failed, or where the patient has a limited capability in co-operating with the treatment plan (very young children and the developmentally disabled). Very short haircuts have also been effective in ameliorating trichotillomania, but this is generally discouraged due to the potential negative effects on the patients self-esteem.

Habit reversal

Habit reversal is the only behavioural technique to have been evaluated using a controlled, randomized group design. (1, ,2.°) Habit reversal is a multicomponent treatment package comprising the principal components of behaviour monitoring, relaxation, and competing-response training. A competing response is a behaviour that is incompatible with hair pulling. The patient performs the competing response (e.g. clenching a fist for 3 min), when faced with urges to pull hair or when catching themselves pulling out hair. Habit reversal was shown to be substantially superior to a comparison technique (negative practice) in a study of 34 patients. (29 More than a 90 per cent reduction in hair pulling was noted at 4 months. However, several aspects of this study's methodology have been criticized. Variations on habit reversal in both individual and group formats remain the most popular treatment for adults with trichotillomania.

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