The habit-reversal technique in treating trichotillomania

doi:10.1016/S0005-7894(81)80085-8

Behavior Therapy

Volume 12, Issue 4, September 1981, Pages 473-481

https://doi.org/10.1016/S0005-7894(81)80085-8 Get rights and content

Four clients with relatively mild cases of trichotillomania were treated with the habit-reversal technique developed by Azrin & Nunn (1973, 1977). In each case hair pulling was markedly reduced following a single treatment session and was eliminated within the following 3 weeks. Hair pulling remained at a zero level throughout 6- and 12-month follow-ups. These results extend the generality of the habit-reversal technique as an effective method for treating hair pulling.

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Cited by (44)

Extended follow-up of a comprehensive behavioral (ComB) treatment sample during the COVID-19 pandemic
2022, Journal of Obsessive-Compulsive and Related Disorders
This study provides the longest follow-up yet for comprehensive behavioral (ComB) treatment of trichotillomania (TTM) (M = 24.59 months after pre-treatment and 15.92 months after the last follow-up point in a recent clinical trial (Carlson et al., 2021), which had shown ComB to be significantly more efficacious than minimal attention at post-treatment). This study also examined changes in TTM severity from before to during the COVID-19 pandemic. Participants (N = 23) completed a survey assessing current TTM symptoms, the impact of the pandemic on their coping with TTM, and their experience with ComB treatment. Self-reported symptom severity at this follow-up evaluation fell between the scores obtained at the clinical trial’s pre-treatment assessment and at its last follow-up before the pandemic and did not significantly differ from either time point. Most participants (73%) reported some change in their TTM management since onset of the pandemic, with changes to their environment/routine (61%) and in anxiety (32%) being the most common. Pandemic-related changes were associated with variable outcomes, improving symptoms and management for some while worsening them for others. Use of strategies from ComB had declined since the most recent follow-up, but more than half (55%) of participants reported that strategies from ComB remained useful.
Measuring the role of psychological inflexibility in Trichotillomania
2014, Psychiatry Research
Citation Excerpt :
Supporting this idea, Diefenbach et al. (2002) found that people with TTM report reductions in anxiety, tension, and boredom following pulling episodes. The most empirically supported behavioral intervention for TTM is Habit Reversal Training (HRT; Azrin et al., 1980; Rosenbaum and Ayllon, 1981; Tarnowski et al., 1987; Mouton and Stanley, 1996; Stoylen, 1996; Rapp et al., 1998), which consists of awareness training, competing response training, and social support. Unfortunately, evidence suggests that while effective at reducing pulling, HRT does not address the aversive cognitions and emotional states that often trigger pulling episodes (Woods et al., 2006).
Psychological Inflexibility (PI) is a construct that has gained recent attention as a critical theoretical component of Acceptance and Commitment Therapy (ACT). PI is typically measured by the Acceptance and Action Questionnaire-II (AAQ-II). However, the AAQ-II has shown questionable reliability in clinical populations with specific diagnoses, leading to the creation of content-specific versions of the AAQ-II that show stronger psychometric properties in their target populations. A growing body of the literature suggests that PI processes may contribute to hair pulling, and the current study sought to examine the psychometric properties and utility of a Trichotillomania-specific version of the AAQ-II, the AAQ-TTM. A referred sample of 90 individuals completed a battery of assessments as part of a randomized clinical trial of Acceptance-Enhanced Behavior Therapy for Trichotillomania. Results showed that the AAQ-TTM has two intercorrelated factors, adequate reliability, concurrent validity, and incremental validity over the AAQ-II. Furthermore, mediational analysis between emotional variables and hair pulling outcomes provides support for using the AAQ-TTM to measure the therapeutic process. Implications for the use of this measure will be discussed, including the need to further investigate the role of PI processes in Trichotillomania.
Feather damaging behaviour in parrots: A review with consideration of comparative aspects
2009, Applied Animal Behaviour Science
Feather damaging behaviour (also referred to as feather picking or feather plucking) is a behavioural disorder that is frequently encountered in captive parrots. This disorder has many characteristics that are similar to trichotillomania, an impulse control disorder in humans. Unfortunately, to date much of the information regarding the aetiology and treatment in both syndromes is based on ‘expert’ opinion rather than on experimentally founded results. Comparative research in humans and parrots might therefore be mutually beneficial.
Feather damaging behaviour (FDB) may also share similarities with behavioural disorders present in other bird species. Feather pecking (FP) in poultry is of particular interest in this case. Because of the major impacts on welfare and economy, the disorder has been thoroughly investigated. It has been shown that genetic, socio-environmental and neurobiological factors all play a role in FP. Several theories have been postulated about the different motivational systems that affect the behaviour, of which (redirected) foraging appears to be the most generally accepted.
FDB may result from similar motivations and underlying mechanisms, but has also been regarded as a grooming disorder. Grooming or preening is behaviour that serves both physical and social purposes. In the presence of stressors, such as novelty, so-called displacement grooming may develop that can result in excessive grooming when chronic stress is experienced (maladaptive behaviour). Adrenocorticotropic hormone, opiate, dopaminergic and serotoninergic systems have been shown to influence the onset, development and maintenance of this behaviour.
Primary brain dysfunction (malfunctional behaviour) may also explain the occurrence of various abnormal behaviours. Differences in neurotransmitter levels and distribution have been found between high and low feather pecking lines of laying hens, and psychopharmacological interventions in humans and parrots suggest similar alterations. The exact pathways via which neurotransmitters influence the execution of these behaviours have not been identified. It is also not clear which brain areas are involved in this dysfunction, and why the behaviour sometimes persists despite intervention. For these purposes it is important to consider the current system-level insights on different types of abnormal repetitive behaviour, to which these disorders may be classified.
Prototype awareness enhancing and monitoring device for trichotillomania
2008, Behaviour Research and Therapy
Citation Excerpt :
Several studies spanning over 25 years have established a clear scientific foundation for the value of HRT. The effectiveness of HRT has been established via case reports (De Luca & Holborn, 1984; Rosenbaum & Ayllon, 1981; Stoylen, 1996), uncontrolled group trials (Lerner, Franklin, Meadows, Hembree, & Foa, 1998; Rothbaum, 1992) and in randomized trials comparing HRT to psychosocial control treatments (Azrin et al., 1980), anti-depressant medication (van Minnen, Hoogduin, Keijsers, Hellenbrand, & Hendriks, 2003; Ninan, Rothbaum, Marsteller, Knight, & Eccard, 2000), and placebo pills (van Minnen et al., 2003; Ninan et al., 2000). However, although HRT and other related behavioral interventions hold promise in the treatment of TTM, approximately 30–40% of clients in most studies of HRT do not experience clinically significant improvement after acute treatment and maintenance of gains may be especially problematic (Lerner et al., 1998).
Trichotillomania is an impairing condition that involves repetitive hair pulling. Habit reversal therapy is helpful for many persons with this disorder. Unfortunately, habit reversal therapy is not helpful for everyone and maintenance of gains is often problematic. Successful habit reversal therapy requires the individual to be aware of hair pulling and handling. Unfortunately, most people with trichotillomania report that much of their plucking occurs outside of awareness. Monitoring of trichotillomania behaviors is also problematic. The present project involved a pilot study of a prototype awareness enhancing and monitoring device aimed at increasing the effectiveness of habit reversal therapy. The device included a watch, bracelet, magnetic necklace, and a pager that was hard-wired for remote activation of a vibrating alert when hair pulling behaviors occurred. Following structured diagnostic assessment, three female participants were randomly assigned to be initially observed for varied lengths of time without the device followed by observation with the device in place. The results indicated a marked reduction in trichotillomania behaviors when the device was in place. Semi-structured interviews revealed that the device was very effective in enhancing awareness and monitoring of trichotillomania related behaviors and enthusiastic acceptance of the device was provided by all participants.
StopPulling.com: An Interactive, Self-Help Program for Trichotillomania
2006, Cognitive and Behavioral Practice
Despite the widespread nature and significant impact of trichotillomania (TTM), relatively few controlled studies have evaluated treatment options for people with this disorder. Pharmacological treatment and behavior therapy are the two most widely accepted approaches to treating TTM, but few mental health professionals with appropriate expertise are available to provide care. The cost of treatment also is prohibitive in some cases. A number of self-help books are available for people with TTM, but no empirical data have documented associated outcomes. This paper describes the development and two phases of program evaluation for an alternative, Internet-based self-help treatment strategy for repetitive hair pulling. StopPulling.com is an on-line, interactive self-help approach derived from evidence-based cognitive behavioral models of treatment for TTM. Following program development, an initial test phase elicited feedback from individuals with repetitive hair pulling and professionals with expertise in the treatment of TTM or Web site development. StopPulling.com was modified in accordance with feedback from this initial test phase, and a revised version was made available to the public in January 2003. Preliminary data from 265 users of the program during the first year of public availability suggested significant improvement in symptoms, with some evidence that duration of program use accounted for reductions in symptom severity. Response rates were comparable to long-term follow-up after more intense cognitive behavioral treatment. StopPulling.com may provide a potentially useful self-help alternative or adjunctive strategy for repetitive hair pulling.
A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania
2006, Behaviour Research and Therapy
Citation Excerpt :
Unfortunately, it was not clear that either intervention was superior to simple passage of time, assessments were not conducted by blinded evaluators, and a diagnosis of TTM was not established. Other studies utilizing single-subject or uncontrolled group designs, have generally supported the findings of Azrin et al. in both adults (e.g., Mouton & Stanley, 1996; Rosenbaum & Ayllon, 1981; Stoylen, 1996) and children (Rapp et al., 1998; Tarnowski, Rosen, McGrath, & Drabman, 1987). In the other randomized controlled evaluation of CBT for adults with TTM, van Minnen, Hoogduin, Keijsers, Hellenbrand, and Hendriks (2003) compared behavior therapy to fluoxetine and a wait-list (WL) control in 43 randomly assigned older adolescents and adults (>16 years of age), using psychometrically sound assessments (i.e., Massachusetts General Hospital-Hairpulling Scale; Keuthen et al., 1995) and blinded independent clinical evaluators.
This randomized trial compared a combined Acceptance and Commitment Therapy/Habit Reversal Training (ACT/HRT) to a waitlist control in the treatment of adults with trichotillomania (TTM). Twenty-five participants (12 treatment and 13 waitlist) completed the trial. Results demonstrated a significant reduction in hair pulling severity, impairment ratings, and hairs pulled, along with significant reductions in experiential avoidance and both anxiety and depressive symptoms in the ACT/HRT group compared to the waitlist control. Reductions generally were maintained at a 3-month follow-up. Decreases in experiential avoidance and greater treatment compliance were significantly correlated with reductions in TTM severity, implying that targeting experiential avoidance may be useful in the treatment of TTM. Other implications and suggestions for future research are noted.

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¹: This research was part of the first author's doctoral dissertation in partial fulfillment of the Ph.D. degree under the chairmanship of the second author. The authors wish to express their sincere appreciation to the other committee members, Michael A. Milan and Robert C. Brown. This research was presented in a paper entitled “The Behavioral Control of Trichotillomania Through Habit-Reversal” at the Association for Advancement of Behavior Therapy Convention, San Francisco, December 1979.

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The habit-reversal technique in treating trichotillomania1

Behaviour Research and Therapy

Journal of Behavior Therapy and Experimental Psychiatry

Journal of Behavior Therapy and Experimental Psychiatry

Journal of Pediatrics

Journal of Behavior Therapy and Experimental Psychiatry

Behavior Therapy

Behaviour Research and Therapy

Habit control in a day

Behavior therapy for trichotillomania

Behaviour Research and Therapy