CBT for Trichotillomania & Other Obsessive Compulsive Spectrum Disorders

Presenter: Martin E. Franklin, Ph.D.
View this webinar by clicking here

Download this webinar’s corresponding slides here.
Dr. Franklin described a cognitive-behavioral approach of TTM applicable to children, adolescents, and adults, and discussed treatment strategies. Individuals who attended the Webinar came away with: (a) a working knowledge of these disorders and their underlying causes; (b) became familiar with the state-of-the-art methods of assessing the disorders; and (c) became familiar with cognitive behavioral techniques that are employed in treatment.


  1. mznjm says

    Skin picking – for my 4 year old. Do you recommend she see someone to talk too? We do try not to yell at her, but it is hard because she is picking her face and it is getting a bad scare between her eyes.

    • Dr. Franklin says

      Probably too young to do CBT, but you can use some of the principles of CBT to help make the environment less conducive to picking – figure out by monitoring when she’s doing it, provide some substitutions (e.g., something else to play with in high risk situations), lower stress, keep nails short, etc. Harry Wright’s work is instructive here – he’s written about these youngsters perhaps more than anyone else.

  2. louala says

    My 10 yr old son has been pulling his lashes since he was 6+/-. Seems to revolve around school testing. He initially pulled all lashes & brows. This behavior has come and gone over the last few years. Attemped treatment but not successfully. Now he has started lash pulling again and has been engaging in nail bitting and skin picking over the last yr +. He denies that he pulls but I see him bitting and picking. No docs here know how to treat. Should I consider Duke – which is 2+ hours away??


    • Dr. Franklin says

      First I’d see if he’s willing to acknowledge the problem and interested in working on it; if not then the timing of intervention may not be right. Duke Psychiatry has some folks who know CBT for kids, as does UNC (Jon Abramowitz’ clinic)

  3. gatorgirl says

    Are you near the Charlotte, NC area? There is an expert in Habit Reversal Training, TS, Trich, and more.

    • Dr. Franklin says

      No I am in the Philadelphia Area. Check with the Trichotillomania Learning Center for doctors familiar with TS in NC. http://www.trich.org/

  4. Mary Jo says

    My daughter has been pulling since she was 8. She was seeing a therapist at the time, but the therapist gave her the idea to hide it. She hid it from me for five years, and only came clean this past summer. We got her into therapy immediately. She wanted to stop, but didn’t know how. She has been seeing a woman in nearby Springfield since Sept. She is covered by our insurance, but I am very well aware that it can sometimes take several years/therapist before finding the right one. She likes this woman very much. She is now 14, turning 15 in about 2 months. The problem I have is that I have to frequently write her a note for school b/c her hwk will be late coming in. she gets stressed out easily. Either she didn’t understand it(she’s a bright kid, and a good student). Her teachers at the middle school have been accommodating w/o the Section 504. Her therapist doesn’t seem to think that she needs to have a 504. Her response is, why give it to her if she doesn’t need it? I disagree. I totally think that she does/will need it, especially going into the high school in Sept. Our public high school is academically challenging. She wishes to participate in volleyball in the fall, and she will play softball in the spring. I know that once her sport starts, getting hwk. complete will be challenging. This is my third child going through the school system, so I know what is in store, and I know what it’s all about. The problem is is that the therapist is from the Hackensack area, and I believe is not familiar with the prestige of our schools. It is not fair to my daughter to not be able to participate in the sports that she loves, which I believe is also a stress reliever for her. I cannot obtain the 504 without the psychologists input. I’ve seriously considered changing psychologists, that’s how strongly I feel about this. She really likes this woman, and trusts her. From what I understand, they are working on her not pulling twice a week. I haven’t heard how that’s working out either from the psychologist or my daughter. Although, we did have a setback recently. There was a death in the family, and as a result, we will be moving. I don’t know what else to say to this woman for her to understand that she really needs to have this 504. My son has OCD. We were forced, in his junior year of HS, to get him a 504 b/c one of his teachers felt that w/o a legal document, she did not have to accommodate him, and wouldn’t. I know this is what we will be up against in at least one of her four years of high school. It wasn’t fair to him to be penalized for his issues, and it’s not fair for her to be penalized either. What do I do? I really do not want to go through the school’s psychologist. I’d like to deal with this privately.

    • Dr. Franklin says

      I’m not an expert in NJ state laws, but you may want to find an educational consultant who is in order to advocate for the 504. Important to do so for all of the reasons described above.

    • gatorgirl says

      I cannot imagine WHY a psychologist would suggest a 504 is “enabling” your daughter! I say go for an IEP! A Section 504 is not as heavily regulated as the IEP and therefore, teachers know they don’t have to follow all the rules like with an IEP.
      My son has TS+, extreme anxiety, and Trich. He’s 10 and pulls his eyelashes. In N.C., it doesn’t matter (really) what your private psychologist says, it is up to the school psychologist to determine what is needed, usually through testing or a Functional Behavioral Assessment.
      CLEARLY, your daughter NEEDS the 504 since she hasn’t improved – especially since this person told your daughter to “hide it”. I understand “trust” with a therapist, but this sounds like malpractice. Why WOULDN’T you want to equip your daughter with EVERYTHING possible to help make her life easier and have less stress? Go with your gut – trust your instincts. You are her best advocate! The bottom line is this: What is more important? That this therapist is right? Or Wrong? Or that your daughter gets the help she truly needs?
      Accommodations LEVEL THE PLAYING FIELD! They do not give your child an advantage over the other students – but that is quite often the thought process.

  5. holincol says

    I only started picking my scalp at age 51, 9 years ago. If this disorder is about the “wiring” in my brain, why would it show up so late in life? Also the pain in my back, arms, shoulders is very intense. Any suggestions (other than obvious – pain pills, massage, etc) to alleviate pain?

    • Dr. Franklin says

      Later onset is less common and does raise some interesting questions about the etiology of picking, a course of CBT to address the antecedent behaviors before they occur might prove useful. Not sure that I have the necessary expertise to address the pain management question, though a discussion with the primary care doc would be important as there have been some recent developments in the field of pain management.

    • mznjm says

      holincol – what is the pain from? The extension of your arms over your head? Something else? Have you tried acupuncture?

      • holincol says

        Yes, the pain is from extending my arms over my head and the repetitive picking, giving me really bad tendonitis in my elbows.
        I have tried acupuncture for the picking (no results), but not for the pain. Thanks for the suggestion.

        • mznjm says

          You’re welcome. Hope it works for you.

  6. KelleyT says

    I wonder if there are any people past menopausal age to have trich. any connections to being hormonal… since mostly women?What is correlation for occurences in USA to other countries?.. mostly females in other countries?

    • Dr. Franklin says

      There are some postmenopausal case onsets but they’re rare; in mice and in humans there have been some associations between TTM & puberty; more is known about this phenomenon in mice than in humans. Not enough information available to do cross cultural comparisons, but what we do know is that in most clinical samples TTM is predominantly female, regardless of the study’s setting.

  7. bwviolette says

    I have been shaving my 8 year old son’s head when his pulling leaves him half bald, even though is is half bald where the hair has not grown back. Is this harmfull to him in any way? It does seem to curb his pulling. Love the hint about the bandaids going to try it!

    • Dr. Franklin says

      not harmful – many kids go with this style anyway for other reasons without any untoward effects

  8. agnes wohl says

    have you had any experience with the use of hair extensions?

    • Dr. Franklin says

      yes – some girls and women use them to disguise the alopecia and like them for that reason; they also serve a stimulus control function when they’re covering areas that are common pulling sites. More common that a hairpiece serves this function more effectively (better coverage), but if they help someone feel more comfortable and thus function better then I’m all for them.

  9. Dann says

    Could you please repeat the name of the natural vitamin shown in studies to help patients with trich. Thank you

    • Dr. Franklin says

      N-Acetyle-L-Cysteine is the vitamin that was mentioned during the webinar. Dr. John Grant of University of Minnesota did the adult trial with this supplement.

  10. KelleyT says

    Q: TIMING: Why is it that some people suffer from TTM on a daily basis and for others it only occurs seasonally or a few times during the year – what causes the difference?

    • Dr. Franklin says

      good questions, not enough known yet to answer it; presumably stress, environmental cues, setting events, can have some influence over the course of TTM, but we just don’t know enough yet

  11. KelleyT says

    Is splitting split ends a common manifestation of trichotillomania?

    • Dr. Franklin says

      less common but sometimes seen; less damaging probably as well; we don’t know though what % of people who split split ends actually pull the hair out to do so, or what % of folks with TTM don’t touch split ends.

  12. KelleyT says

    What is the brain basis for this disorder? How do you explain TTM to patients?

    • Dr. Franklin says

      Very complex question, and there are some nice explanations of TTM’s neurobiology available – I’d recommend looking at TLC’s website, also the book I did with Dave Tolin to get a summary of how we present the etiology, maintenance, and treatment of TTM

  13. KelleyT says

    With CBT, and successful reductions in pulling, do the urges get less strong? Or is it just a matter of continuing to muster the energy to keep motivated to fight the urges (that sounds hard)?

    • Dr. Franklin says

      Like most urge-driven disorders, urges go up in the initial phases of resistance but then gradually reduce as resistance is more successful; job gets easier in the presence of weakened urges, which improves success, which further weakens urges. Wide range of report about how long this process takes, but this is essentially the model.

  14. KelleyT says

    How would you deal with this problem: when stimulus control (bandaids, etc) do reduce pulling, but causes the pulling to be MORE SEVERE when the bandaids, gloves, etc. are not on.

    • Dr. Franklin says

      All the more reason to go heavy with the competing response/HRT if this is the case

  15. KelleyT says

    eating the folical off the hair.. is that just as bad as eating the hair itself?

    • Dr. Franklin says

      Probably not in terms of the likelihood of a trichobezoar, but if this is the behavior that the person finds most reinforcing then it can strengthen urges regardless of whether the entire hair is eaten or not

  16. KelleyT says

    How should a child respond to other kids when asked why do you have hair missing, like in the front of their head.

    • Dr. Franklin says

      Depends on the age of the kids, the relationship with those kids, comfort level of the kid being asked the questions; I’d suggest giving little information but not telling stories (e.g., saying the child is being treated for a serious illness like cancer, which unfortunately has been the response that some families have chosen)

  17. KelleyT says

    What percent of adults who’ve been pulling for decades actually are able to remit the disorder into a successful level of remission?

    • Dr. Franklin says

      Unclear as yet, since the research lit is underdeveloped with respect to long-term follow-up

  18. KelleyT says

    Is there evidence of dopamine level involvement? Why have so few studies been undertaken to examine the role of hormones in this disorder given its prepubescent onset and increased symptomology premenstrually or durng ovulation phases?

    • Dr. Franklin says

      Hormonal hypotheses have been posed; neurotransmitter involvement is complex, but dopamine may well be involved given the potential role of the basal ganglia in movement disorders more broadly speaking.

  19. KelleyT says

    if somebody has mild TTM and SP for 4 years, could this become more serious over the years ?

    • Dr. Franklin says

      It could, though we don’t know for sure. Guess is that mild symptoms leave the door opened for worsening under stress, but we don’t have enough data to be certain.

  20. KelleyT says

    my daughter is 10 and has trich. It seems she is under a lot of stress with friends at school. ive been talking with her everyday, but it’s got worse. Im seeking professional help, but i have times where i blow up on her. How can i handle this hard time in my life? My husband and i are burnt out my the end of the day…it has taken a toll on our marriage as well..any advice you can give will help…i blew up on her again last night

    • Dr. Franklin says

      A heart to heart with your daughter about the problems you’re having with coping would be a good place to start – tell her you love her, that you know it’s not her fault, and that you’ll do everything you can as a family to try to reduce stress around pulling and in general and, if and when she’s ready, to identify people who know about this problem and can help her with it, but only if she’s ready. I’d suggest that be a conversation between the three of you – her continuing pulling is not as important as your relationship with her, and so that’s the priority right now.

  21. KelleyT says

    My daughter is taking Lexapro 30mg, Risperdone 2mg and is still pulling. Do you think we should remove these drugs and move toward a natural approach? She is 14 and has removed all her hair on her scalp which began in February ’09.

    • Dr. Franklin says

      Not a physician so I don’t want to venture beyond the scope of my license, but the questions to ask are whether the Lexapro and RIS are being prescribed for TTM specifically & to revisit whether they are working. Grant et al 2009 describes a study of a product called NAC that has been found efficacious for TTM in adults – would be useful to raise that with the physician to see what they have to say.

  22. KelleyT says

    Are there any toddler type books with animation that I can use as a fun way to read, learn and help with a child with pulling?

    • Dr. Franklin says

      Not that I’m aware of, but the TLC website would be the best place to look for such resources.

  23. KelleyT says

    Is it unusual for a child who pulled and thumb sucked as a baby to later begin pulling again in response to academic stress or is it something that goes hand in hand with his Inattentive ADD diagnosis? If it is due to the ADD diagnosis, will your treatment suggestions be effective?

    • Dr. Franklin says

      Not unusual to see this progression; ADHD could interfere with CBT and thus might be targeted first.

  24. karen duffy says

    I am dealing with my six year old who has been pulling out her eyelashes (completely) for about 7 months. On occasion she has pulled eyebrows, hair on her arm or legs out as well. We have been seeing a social worker, had one visit with a pyschologist would believes this is only caused by anxiety. We are now looking into homepathy.
    We have used Dr.Ruth Golomb’s book with initial success of 3-4 weeks pull free, followed by a relapse during the last four months.
    I am having trouble finding the cause of this behavior. She really relates well to others and her school work is above average. I do not see anxiety about anything specific. She chews on her band-aids, and clothing and gloves. It seems to me that she has a general nervous energy that is causing the chewing and pulling. I am having a hard time understanding when she engages in the pulling behavior, as it seems to have no real pattern, and can be at any time of the day. It happens in school, in front of others, when she is alone, when she is tired but also when she is active.I have seen her pull in a trance and I have witnessed pulling in a mirror to which she was very aware of what is is doing. I cannot locate any specialists in my area,which is Prince Edward Island,Canada. Do you have a questionaire that I could follow to help understand my daughters pulling habits and causes for her pulling. With this information I could then determine her best form of treatment.
    I should mention that she no longer is showing real interest in stopping this behavior. I am concerned that the she may move to other locations (ex.scalp) if we cannot correct this
    behavior. Also is it true that the longer she engages in this habit,the harder it will be to quit when she is ready?
    Thank you for you most informative seminar,
    Karen Duffy

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