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Cognitive and Behavioral Practice 17 (2010) 290–300

www.elsevier.com/locate/cabp

Current Treatment Practices for Children and Adults With Trichotillomania:

Consensus Among Experts
Christopher A. Flessner, Bradley/Hasbro Child Research Center/Warren Alpert School of Medicine at Brown University
Fred Penzel, Western Suffolk Psychological Services, Huntington, NY
Trichotillomania Learning Center–Scientific Advisory Board
Nancy J. Keuthen, Massachusetts General Hospital/Harvard Medical School

Very little is known regarding the efficacy of pharmacological and psychosocial treatments for children and adults with trichotillomania
(TTM). Given this dearth of information, the present investigation sought to examine the treatment practices of members of the
nationally recognized Trichotillomania Learning Center–Scientific Advisory Board (TLC-SAB) and practitioners known by members of
the TLC-SAB to possess extensive experience working with this population. The responses of 67 practitioners to an Internet-based survey
were examined. Our results clearly indicate that cognitive-behavioral treatment (CBT) is the treatment of choice for both children and
adults with TTM. In particular, several components of CBT (i.e., awareness training, self-monitoring, competing response training,
habit reversal training, and stimulus control) are implemented most often. Selective serotonin reuptake inhibitors (SSRIs, e.g.,
citalopram, fluoxetine) and serotonin-norepinepherine reuptake inhibitors (SNRIs, e.g., venlafaxine, duloxetine) were prescribed most
frequently; however, these results are preliminary given our small sample of prescribing practitioners (n = 11). Taken together, these
findings are a critical starting point to advancing the understanding of efficacious interventions for the treatment of individuals with
TTM. Clinical and research implications, future areas of research, and study limitations are discussed.

T RICHOTILLOMANIA (TTM) is characterized by the

recurrent pulling out of one's hair resulting in
noticeable hair loss and is presently classified as an
Impulse Control Disorder in the DSM-IV-TR (American
Psychiatric Association, 2001). Among adults, prevalence
estimates for TTM range from 0.6% to 3.4%, and the
disorder is more common among females (Christenson,
Pyle, & Mitchell, 1991). In children and adolescents
(hereafter referred to as children), prevalence is less
certain but TTM may be more common (Mehregan,
1970) and the gender distribution more balanced (Cohen
et al., 1995).
Treatment options for adults with TTM are limited.
Generally, results of most pharmacological and cognitive-
behavior therapy (CBT) or behavior therapy (BT)
[hereafter referred to as CBT] treatment studies have
been hindered by a myriad of methodological limitations,
including small sample sizes, lack of patient randomiza-
tion to treatment conditions, and/or reliance on self-
report measures. A variety of pharmacological agents
have been examined, including clomipramine (Ninan,
Rothbaum, Marstellar, Knight, & Eccard, 2000; Swedo
1077-7229/10/290–300$1.00/0
© 2010 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
et al., 1989; Swedo, Lenane, & Leonard, 1993), fluoxetine
(Christenson, Mackenzie, Mitchell, & Callies, 1991;
Streichenwein & Thornby, 1995; Van Minnen et al.,
2003), and naltrexone (Christenson et al., 1994). At best,
findings have been mixed regarding efficacy and a recent
meta-analysis suggested that only clomipramine has
demonstrated efficacy greater than placebo (Bloch et al.,
2007).
Research examining the efficacy of CBT is slightly
more encouraging. In general, CBT for TTM has
historically incorporated a variety of techniques, includ-
ing awareness training, self-monitoring, aversion, cogni-
tive strategies, covert sensitization, relaxation training,
habit reversal training (HRT), social support, stimulus
control, and more recently, acceptance-based strategies
(Elliott & Fuqua, 2000; Woods, Wetterneck, & Flessner,
2006). Recent adult TTM research suggests that CBT is
superior to wait-list (Van Minnen et al., 2003; Woods et al.,
2006), pharmacotherapy (Ninan et al., 2000; Van Minnen
et al., 2003), pill placebo (Ninan et al.), and supportive
therapy (Diefenbach, Tolin, Hannan, Maltby, & Crocetto,
2006). Few studies have sought to compare the efficacy of
various components of CBT; however, past research has
suggested that HRT, a package treatment combining
competing response training with several techniques
noted above (e.g., awareness training, self-monitoring),
 Treatment of Trichotillomania
is more effective than at least one other form of behavior
therapy (i.e., massed negative practice; Van Minnen et al.,
2003; Azrin, Nunn, & Frantz, 1980). Additionally, a recent
meta-analysis by Bloch and colleagues (2007) found that
HRT was superior to pharmacotherapy with clomipra-
mine. Preliminary research suggests that components of
the HRT package (i.e., awareness training, competing
response training, social support, stimulus control) and
Acceptance and Commitment Therapy (ACT) may be
useful elements in the treatment of adults with TTM
(Flessner, Busch, Heideman, & Woods, 2008). However,
among those who utilize CBT, it is important to identify
what practitioners identify as the most important compo-
nent(s) to CBT (e.g., HRT, individual elements to HRT
such as self-monitoring, stimulus control, relaxation
training, etc.). This information can be used along with
available data from both scientists and practitioners to
enhance or modify existing approaches to treatment or
develop new treatments. Alternatively, this evidence may
provide avenues for further research (e.g., dismantling
studies) to identify those specific components to CBT that
are most important in providing efficacious and effective
treatment for TTM.
To date, no pharmacological studies have been
conducted among children with TTM. In contrast,
however, there is some limited evidence from single
subject experimental designs (Rapp et al., 1998) and one
open-label CBT trial with 22 child pullers (Tolin,
Franklin, Diefenbach, Anderson, & Meunier, 2007)
suggesting that children may benefit from CBT. In the
latter study, 77% and 66% of children were classified as
treatment responders at posttreatment and 6-month
follow-up, respectively. However, methodological limita-
tions (e.g., lack of a control group, absence of an
independent evaluator) highlight the need for caution
in interpreting these results. It would be useful at this
juncture to obtain a better understanding of the
treatment strategies currently being used to help children
(and their families) afflicted with this disorder. Inquiry
regarding the approaches employed by those with
expertise in treating TTM provides an appropriate
starting point for informing the development of more
efficacious treatments for children with TTM.
Clearly, knowledge is limited regarding the best
treatments for children and adults with TTM. However,
available evidence suggests that CBT currently has the
greatest degree of empirical support for efficacy in the
treatment of both children and adults with this disorder.
Unfortunately, however, general practitioners, pediatri-
cians, psychiatrists, psychologists, and other providers are
generally uninformed about TTM (Franklin et al., 2008;
Marcks, Wetterneck, & Woods, 2006; Woods et al., 2006).
In fact, Marcks and colleagues found that general
practitioners were able to accurately answer only 61% of
291
general knowledge items from a survey about TTM (e.g.,
diagnostic criteria, gender differences, whether TTM is a
subtype of obsessive-compulsive disorder, etc.). Perhaps
due to this general lack of knowledge, 72% of providers
thought that pharmacological agents were an effective
treatment for TTM, whereas only 54% thought CBT was
an effective treatment option. Given the paucity of
treatment outcome research in this area, current treat-
ment practices of those with expertise in TTM may be an
appropriate starting point for working with both children
and adults.
A small but growing body of research has examined
what general practitioners know or believe about the
treatment of a variety of psychiatric conditions including
posttraumatic stress disorder (Becker, Zayfert, & Ander-
son, 2004), OCD (Valderhaug, Gotestam, & Larsson,
2004), Tourette's disorder (Marcks, Woods, Teng, &
Twohig, 2004), and TTM (Marcks et al., 2006). However,
no study to date has examined the treatment choices of
clinicians and clinical researchers with known expertise in
the field of TTM treatment. Given the paucity of existing
research, understanding what TTM experts endorse as
effective treatment in combination with, or in lieu of,
existing empirical evidence may accelerate the treatment
development process and better help those afflicted with
this disorder.
Consequently, we sought to examine treatment
choices among members of the Trichotillomania Learn-
ing Center–Scientific Advisory Board (TLC-SAB), as well
as clinicians known by members of the TLC-SAB to
possess expertise in the treatment of children and/or
adults with TTM. Given the myriad of existing CBT
techniques and different pharmacological agents, we
sought to examine which specific components of CBT
and, in a preliminary analysis, types of medications,
experts view as the treatment(s) of choice.
Methods
Participants
Sixty-seven respondents to an Internet-based survey
were recruited via a link to the TLC's homepage (www.
trich.org). TLC is a nonprofit organization dedicated to
providing information, support, and treatment resources
to TTM sufferers. Potential respondents (clinicians and
clinical researchers) were selected upon the basis of their
known expertise within the field of TTM treatment.
Expertise was defined as either being a member of the
SAB of the TLC, or someone selected by a member of the
TLC-SAB, who in their opinion would be considered to
have expertise in the treatment of TTM. The TLC-SAB is
composed of psychologists, psychiatrists, professional
counselors, geneticists, and animal behaviorists with
knowledge of TTM and, in most cases, contributions to
the field of TTM treatment. Practitioners with TTM
292 Flessner et al.
expertise were nominated at an annual SAB meeting and
via the SAB mailer. Surveys were not sent to individuals if
there was dissension among SAB members regarding
their level of expertise. Due to the nature of the study,
institutional review board approval was not obtained.
Participants ranged in age from 28 to 77 years
(M = 47.5, SD = 10.6). Our response rate for questionnaire
completion was 89.3% (67 respondents/75 surveys sent).
Upon inspection, no duplicate surveys (e.g., surveys
containing identical information on all items) were
found. We are unable to quantify how many TLC-SAB
members were survey respondents given the anonymous
nature of this survey. At the time this survey was
developed, there were 18 members of the TLC-SAB;
thus, at least 49 survey respondents were not TLC-SAB
members. The majority of respondents endorsed CBT as
their theoretical orientation (n = 49, 73.1%). This finding
was not totally unexpected given the predominant CBT
orientation of TLC-SAB members and the likelihood that
colleagues endorsed as TTM experts would share a similar
orientation. Respondents reported practicing in a range
of settings including group private practice (n = 18,
26.9%), solo private practice (n = 17, 25.4%), medical
center (n = 17, 25.4%), university setting (n = 12, 17.9%),
and “other” (e.g., community mental health center; n = 3;
4.5%). The majority of respondents (n = 60, 89.6%)
reported directly treating a minimum of 50 clients with
TTM. Sixty-one percent of respondents (n = 41) reported
a Ph.D. as their highest degree received, followed by M.D.
(n = 11, 16.4%), Psy.D. (n = 7, 10.4%), and “other” (e.g.,
Ed.D., M.A., M.Ed., M.S., or M.S.W.; n = 8, 12%).
Instrument
Current Practices Survey (CPS)
The CPS was developed by the second author (FP)
based on a review of the available literature regarding
“current practice” surveys. The Expert Consensus Panel
for OCD (March et al., 1997) was the existing survey
utilized as a model for development of our survey. This
previous landmark survey had collected responses from
69 international experts in the field of OCD treatment
selected by the National Institute of Mental Health. It
covered a domain of 10 different guidelines relating to
both psychological and pharmacological treatments for
OCD, and was the first such survey in that particular field.
It, in turn, had been based upon the Rand Method that
was developed as a means of synthesizing expert opinions
and using them to rate the appropriateness of medical
procedures (Brook et al., 1986).
The CPS is a 55-item questionnaire designed to examine
a variety of domains relevant to the treatment of individuals
(both children and adults) with TTM. Domains assessed via
the CPS include treatment modality of choice (e.g., CBT,
ACT, psychopharmacology, etc.), components of CBT
used most frequently (e.g., HRT as a combined treatment
package or individual treatment components such as
competing response training, stimulus control, relaxation
training, etc.), assessment strategies (e.g., whether the
practitioner conducted a comprehensive behavioral assess-
ment), modes of treatment (e.g., individual, group, etc.)
and treatment schedules (e.g., weekly, bi-weekly, etc.). It
also assessed variability in treatment practices employed as
a function of TTM severity. Those practitioners authorized
to prescribe medication were asked questions regarding
classes of medications (e.g., SSRIs, SNRIs, etc.), specific
medications (e.g., fluoxetine, naltrexone, clomipramine,
etc.), and schedules of treatment maintenance for patients
with TTM.
Procedures
The CPS was linked to the TLC website for a 3-month
period from March to June, 2008. E-mails directing
respondents to the survey link were sent from the TLC
to practitioners on its contact list. Prior to completing the
CPS, respondents were informed of the project's purpose
(e.g., to better understand the treatment standards of
clinicians and clinical researchers in the field of TTM).
The entire survey took approximately 30 minutes to
complete. The CPS was developed and data were
collected and stored using surveymonkey.com.1 The first
author subsequently downloaded these data into a format
suitable for analysis using the Statistical Package for the
Social Sciences, version 16.0 (SPSS-16.0).
Results
Assessment of Treatment Approaches
Table 1 provides descriptive data regarding respon-
dents' preferences for different treatment modalities
among children and adults with TTM. Of those respond-
ing, CBT was overwhelmingly ranked as the treatment of
choice for adults and children, respectively. The compo-
nents of CBT the respondents used most frequently for
treatment of TTM (in descending order) were awareness
training, self-monitoring, competing response training,
HRT, and stimulus control, regardless of client age. In the
case of children with TTM, reward systems were also
frequently employed. Of those respondents endorsing
HRT, self-monitoring, awareness training, competing
response training, and stimulus control procedures were
most frequently noted. Other components sometimes
ascribed to HRT (e.g., relaxation training, social support)
were employed less often.
Seventy-six percent (n = 51) of respondents indicated that
they routinely conducted a comprehensive assessment of
triggers and consequences associated with pulling prior
1
Surveymonkey.com is an internet-based company designed to aid
researchers in development and storage of web-based surveys.
 Treatment of Trichotillomania 293

Table 1
Treatment Modality and Treatment Component(s) of Choice for Treatment of Children and Adults with TTM

Survey Item Adults Children

Please rate your preference for treatment components you would employ in the treatment of an adult/child with TTM in the range of moderate severity. Rank answers
1 (highest) to 9 (lowest). Choose “N/A” if you would NOT employ this method in any case.
CBT 1.36 (1.41); n = 50 1.46 (1.68); n = 39
Psychodynamic talk therapy 6.82 (2.55); n = 28 7.62 (1.72); n = 21
Hypnosis 6.11 (6.50); n = 28 6.78 (2.53); n = 18
Acceptance and Commitment Therapy (ACT) 3.84 (2.17); n = 44 4.62 (2.17); n = 34
Psychopharmacology 4.09 (2.10); n = 47 5.11 (2.07); n = 36
Nutritional Therapies 7.39 (2.44); n = 33 6.67 (2.73); n = 24
Dialectical Behavior Therapy (DBT) 4.89 (4.50); n = 38 6.33 (1.71); n = 27
Family Therapy 5.62 (2.26); n = 45 3.24 (2.01); n = 38
Other 2.38 (1.51); n = 8 2.00 (1.83); n = 7

Please rank the following components of CBT in the order you most frequently employ for the treatment of adult/child patients with moderately severe TTM. Rank
answer 1 (highest) to 9 (lowest). Choose “N/A” if you would NOT employ this method in any case.
HRT 2.02 (2.16); n = 45 1.94 (2.00); n = 33
SC 2.13 (1.75); n = 46 2.19 (1.93); n = 36
Exposure + Response Prevention 4.58 (2.61); n = 40 4.93 (2.92); n = 28
Cognitive Restructuring 3.30 (2.03); n = 47 3.69 (2.35); n = 36
Satiation 8.06 (1.64); n = 17 7.17 (2.52); n = 12
Relaxation Training 3.53 (1.97); n = 43 3.80 (2.03); n = 35
Self-monitoring 1.83 (1.72); n = 47 1.95 (1.56); n = 37
Competing Response Training 1.89 (1.86); n = 45 1.74 (1.36); n = 35
Reward Systems 4.04 (1.95); n = 45 2.00 (1.77); n = 36
Guided Imagery 5.50 (2.14); n = 34 5.54 (2.10); n = 26
Awareness Training 1.82 (1.42); n = 49 1.73 (1.19); n = 37
Additional CBT techniques to address TTM 2.77 (1.97); n = 35 2.70 (2.10); n = 23

If you, yourself, employ habit reversal training (HRT) as a treatment technique, which components do you routinely include? (check as many as apply).
Motivation (inconvenience review) 55.2% (n = 37)
Awareness Training 64.2% (n = 43)
Competing Response Training 62.7% (n = 42)
Stimulus Control 59.7% (n = 40)
Relaxation Training 50.7% (n = 34)
Social Support 49.3% (n = 33)
Practice at home 47.8% (n = 32)
Symbolic rehearsal 17.9% (n = 12)
Display of improvement (seeking out situations previously avoided) 41.8% (n = 28)
Self-monitoring 64.2% (n = 43)
Identification of habit-prone situations 41.85 (n = 28)
Note. Samples for each treatment component vary because responses of “N/A” were coded as missing values. In addition, respondents were
asked to skip items pertaining to populations (e.g., adults, children) that they did not treat.

to treatment. Of those responding “yes” to this item, all
or nearly all respondents reported that this included
assessing internal/external triggers associated with pull-
ing (100%, n = 51), activities/situations avoided due to
pulling (100%, n = 51), whether they pulled while alone
or around others (100%, n = 51), selection of particular
hairs to pull (98.0%, n = 50), what they do with their hair
after they pull (98.0%, n = 50), use of implements to pull
(96.1%, n = 49), awareness of pulling (96.1%, n = 49), and
shame associated with pulling (94.1%, n = 48).
Table 2 provides descriptive data regarding style,
number, and frequency of sessions most often employed
for the treatment of children and adults with TTM.
Results suggested that individual therapy was ranked as
the most frequently employed treatment format for both
adults (M = 1.19, SD = 0.67) and children (M = 1.27,
SD = 0.65), although individual plus concurrent family
therapy was also a popular treatment format for children
(M = 2.06, SD = 1.23). Results indicated that 11 to 15
sessions was the most frequently employed number of
sessions for both children and adults with TTM. Similarly,
weekly, in-office sessions with homework were ranked the
highest regarding frequency of sessions for treatment of
both children and adults.
294 Flessner et al.

Table 2
Style, Number, and Frequency of Sessions Employed for the Treatment of Children and Adults with TTM

Survey Item Adults Children

Please rate, in terms of effectiveness, treatment formats you employ for providing CBT to an average adult/child patient with TTM. Rank answers from 1 (highest) to
5 (lowest). Choose “N/A” if you would not employ this method in any case.
Individual Therapy 1.19 (0.67); n = 48 1.27 (0.65); n = 37
Group Therapy 2.79 (1.29); n = 33 3.04 (1.27); n = 24
Individual + Concurrent Family Therapy 2.88 (1.24); n = 33 2.06 (1.23); n = 34
Behavioral Family Therapy 3.13 (1.41); n = 30 2.39 (1.22); n = 33
Interactive “telephone therapy” 3.75 (1.18); n = 28 3.95 (1.35); n = 19
Other 2.00 (1.73); n = 3 2.00 (1.41); n = 4

Please rate EACH of the following selections in terms of reasonableness of the number of CBT sessions typically required to treat the average uncomplicated adult/child
TTM patient. Rank answer from 1 (highest) to 6 (lowest).
1-5 sessions 4.12 (1.39); n = 34 3.93 (1.53); n = 30
6-10 sessions 2.53 (1.34); n = 40 2.47 (1.38); n = 34
11-15 sessions 1.98 (0.96); n = 41 1.94 (0.79); n = 36
15-20 sessions 2.23 (1.39); n = 40 2.44 (1.39); n = 32
20-40 sessions 3.29 (1.56); n = 38 3.61 (1.59); n = 31
Unlimited sessions 5.19 (1.40); n = 31 5.24 (1.27); n = 25

Please rate the therapeutic effectiveness of EACH of the following treatment schedules for an initial trial of CBT in an average adult/child patient with TTM in the
range of moderate severity. Ranks answers from 1 (highest) to 8 (lowest)
Weekly Office therapy sessions with homework for patient to her own/her own 1.19 (1.02); n = 48 1.06 (0.24); n = 35
Every other week office sessions with homework for patient to her own/her own 2.30 (1.05); n = 44 2.19 (0.78); n = 32
Self-help book plus weekly telephone follow-up only to assign and monitor 3.31 (0.95); n = 39 3.37 (0.89); n = 30
CBT homework
Self-help book plus every other week telephone follow-up to assign and 4.57 (0.77); n = 37 4.63 (0.96); n = 30
monitor CBT homework
Self-help website plus weekly telephone follow-up only to assign and 4.47 (0.92); n = 38 4.38 (1.01); n = 32
monitor CBT homework
Self-help website plus every other week telephone follow-up to assign 5.65 (0.92); n = 40 5.67 (0.76); n = 30
and monitor CBT homework
Self-help book only 7.28 (0.72); n = 39 7.40 (0.50); n = 30
Self-help website only 7.29 (1.37); n = 41 7.47 (0.97); n = 30

Referral for Pharmacological Treatment as a Function
of CBT Response and Treatment Duration
Respondents were asked how many weeks they would
allow of poor or no response to CBT alone prior to referring
an adult or child with TTM for medication. Respondents
indicated that for patients with mild to moderate TTM, they
would wait before medication referral a median of 10 (for
adults) and 12 (for children) weeks with poor response to
CBT and 8 weeks (for both adult and child) with no
response to CBT. Similarly, respondents indicated that they
would wait before medication referral a median of 10 weeks
with poor response to CBT and 7 weeks with no response to
CBT for both adults and children with moderate to severe
TTM. Table 3 provides data regarding the method of
treatment experts would be most likely to try first to treat
varying degrees of TTM severity. Again, CBT was the
unanimous choice.
Table 4 provides descriptive data regarding (a) reasons
to refer patients for pharmacological intervention (appli-
cable to all survey respondents) and (b) pharmacological
interventions used most often for the treatment of TTM
(applicable only to those respondents able to prescribe
medication). Results clearly suggest that SSRIs were the
most commonly employed medication. Within this class of
medications, citalopram and fluoxetine (both ranked
highest), escitalopram, and sertraline were used frequently
and ranked highly by most experts. In descending order,
antipsychotics, SNRIs, and opiate blockers2 were also
frequently employed more often than other classes of
medications. Of note, tricyclic antidepressants (e.g.,
2
The CPS was developed with the expectation that tricyclic
antidepressants would be considered one of the primary pharmacolo-
gical treatments of choice for TTM alongside SSRIs, antipsychotics, and
SNRIs. Consequently, in an attempt to minimize burden to respondents,
follow-up questions were only developed for tricyclic antidpressants
rather than opiate blockers (which were ranked higher).
 Treatment of Trichotillomania 295

Table 3
Most Appropriate Method(s) for Initiating Treatment Among Children and Adults of Varying Degrees of Severity with TTM

Survey Item Mean (Std. Dev.)

For ADULTS with mild to moderate TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating treatment.
CBT alone 1.53 (0.75); n = 47
Combined CBT and medication begun together 2.82 (0.49); n = 45
Medication alone 4.77 (0.48); n = 44
CBT first w/ medication if needed 1.72 (0.74); n = 47
Medication first w/ CBT if needed 4.14 (0.51); n = 44

For ADULTS with moderate to severe TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating treatment.
CBT alone 2.11 (0.99); n = 46
Combined CBT and medication begun together 2.29 (0.82); n = 45
Medication alone 4.77 (0.48); n = 43
CBT first w/ medication if needed 1.76 (0.90); n = 46
Medication first w/ CBT if needed 4.12 (0.50); n = 43

For PREPUBESCENT CHILDREN with mild to moderate TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating
treatment.
CBT alone 1.37 (0.49); n = 35
Combined CBT and medication begun together 3.03 (0.31); n = 32
Medication alone 4.77 (0.56); n = 31
CBT first w/ medication if needed 1.77 (0.84); n = 35
Medication first w/ CBT if needed 4.16 (0.37); n = 31

For PREPUBESCENT CHILDREN with moderate to severe TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating
treatment.
CBT alone 1.69 (0.99); n = 35
Combined CBT and medication begun together 2.74 (0.71); n = 34
Medication alone 4.76 (0.56); n = 33
CBT first w/ medication if needed 1.71 (0.67); n = 35
Medication first w/ CBT if needed 4.09 (0.47); n = 32

For ADOLESCENTS with mild to moderate TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating treatment.
CBT alone 1.44 (0.55); n = 39
Combined CBT and medication begun together 3.00 (0.34); n = 36
Medication alone 4.81 (0.53); n = 36
CBT first w/ medication if needed 1.62 (0.63); n = 39
Medication first w/ CBT if needed 4.14 (0.36); n = 35

For ADOLESCENTS with moderate to severe TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating treatment.
CBT alone 1.79 (1.01); n = 39
Combined CBT and medication begun together 2.72 (0.62); n = 36
Medication alone 4.78 (0.54); n = 36
CBT first w/ medication if needed 1.59 (0.68); n = 39
Medication first w/ CBT if needed 4.09 (0.45); n = 35
Note. Respondents were asked to skip items pertaining to populations (e.g., adults, prebuscent children, adolescents) that they did not treat.

clomipramine) were not ranked within the top half of
medications prescribed. However, within this class, clomi-
pramine was clearly the medication of choice.
Respondents indicated that 4 and 12 weeks were the
median lower and upper limits for the period of time
practitioners would allow before increasing the dosage for
an “average” patient with TTM experiencing little or no
response to treatment. Respondents indicated that they
would complete a median of two trials of different
medications from the same class before recommending
a trial of medication from a different class. In addition,
results suggested that 12 weeks was the median duration
of time for an adequate trial of the respondent's initial
choice of medication (administered at the highest
dosage) before the respondent would change medication
or suggest adding an augmenting drug. Antipsychotics
296 Flessner et al.

Table 4
Approaches to the Pharmacological Treatment of Adults and Children with TTM

Survey Item Mean (SD)

Please rate EACH of the following (from 1-7) in terms of the order of importance as a reason to refer a patient with TTM for psychopharmacological treatment. Choose
“N/A” if you would NOT employ this method in any case. ⁎⁎
Poor or no response to treatment 2.15 (1.47); n = 48
Comorbid disorder 1.77 (1.31); n = 47
Lack of motivation for CBT treatment 3.40 (1.51); n = 45
Limited insurance coverage 5.21 (1.53); n = 34
Functioning is severely impaired by TTM 2.56 (1.50); n = 45
A high level of family, work, or environmental stress 4.40 (1.53); n = 42
Other 3.50 (3.54); n = 2

Assume you have decided that a medication trial is indicated. Please rate your preference for EACH of the following medication classes to use as a single-drug approach
(monotherapy) for treatment of TTM. Choose “N/A” if you would NOT employ this method in any case. ⁎⁎
ADHD medication 5.80 (5.02); n = 5
Antihypertensive (e.g., guanfacine, Clonidine) 7.80 (4.82); n = 5
Benzodiazepines 4.25 (0.96); n = 4
MAO inhibitors 13.00 (1.41); n = 2
Mood stabilizers (e.g., lithium, anticonvulsants) 5.33 (4.04); n = 3
Norepinephrine-Dopamine Reuptake Inhibitors
(e.g, .Buproprion) 6.33 (4.16); n = 3
Antipsychotics 2.71 (1.11); n = 7
Opiate Blockers 3.43 (1.13); n = 7
SNRIs 3.00 (2.16); n = 7
SSRIs 1.86 (1.86); n = 7
Tricyclic antidepressants 6.50 (5.80); n = 4
Other antidepressants 4.00 (3.00); n = 3
Other anxiolytics (e.g., buspirone) 4.00 (2.45); n = 4
Other medication (e.g., Clomipramine, “I would use any medication”) 2.00 (1.41); n = 2

Rank EACH medication within the _________ class you would use in the acute treatment of TTM. Choose “N/A” if you would NOT employ this method in any
case. ⁎⁎
Selective Serotonin Reuptake Inhibitors (SSRIs)
Citalopram 2.14 (1.35); n = 7
Escitalopram 2.17 (1.50); n = 6
Fluoxetine 2.14 (1.22); n = 7
Fluvoxamine 3.29 (1.25); n = 7
Paroxetine 4.57 (1.81); n = 7
Sertraline 2.57 (1.51); n = 7
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Duloxetine 1.57 (0.54); n = 7
Venlafaxine 1.00 (0.00); n = 7
Antipsychotics
Aripiprazole 1.80 (1.30); n = 5
Chlorpromazine 10.0 (0.00); n = 1
Fluphenazine 6.00 (4.24); n = 2
Haloperidol 6.20 (3.34); n = 5
Olanzapine 5.00 (3.00); n = 3
Pimozide 4.50 (0.71); n = 2
Quetiapine 2.50 (1.64); n = 6
Risperidone 2.00 (1.16); n = 7
Paliperidone 7.00 (0.00); n = 1
Thioridazine 11.00 (0.00); n = 1
Ziprasidone 2.80 (1.10); n = 5
 Treatment of Trichotillomania
Table 4 (continued)
Survey Item
Tricylic antidepressants
Amitriptyline
Clomipramine
Desipramine
Doxepin
Imipramine
Nortripyline
Protripytline
Trimipramine
For patients who have NOT shown a sufficient response to a particular medication, and where TTM is present without comorbidities, please rank the following
choices of medications you might use to augment the first medication. Choose “N/A” if you would NOT employ this method in any case. ⁎⁎
ADHD medication
Antihypertensive (e.g., guanfacine, Clonidine)
Benzodiazepines
Mood stabilizers (e.g., lithium, anticonvulsants)
Antipsychotics
Opiate Blockers (e.g., naltrexone)
Tricyclic antidepressants
Other antidepressants (e.g., buproprion, trazodone, mirtazapine)
Other anxiolytics (e.g., buspirone)
Other medication
Note. Sample size varies because responses of “N/A” were coded as missing values. In addition, respondents unable to prescribe medication
were asked to skip items specific to the classes or specific medications he/she would be likely to use.
represented the respondents' top choice for an augment-
ing medication (see Table 4).
Table 5 provides descriptive data regarding course of
pharmacological treatment. Results indicate that a
maintenance visit schedule of 1 to 2 months was most
appropriate for highly improved TTM patients, with 3 to
5 months and every 6 months ranked as second and third
options. Conversely, maintenance visit schedules of 1 to
3 weeks (first) or 1 to 2 months (second) were clearly
viewed as most appropriate for those patients with only
partially improved TTM symptoms.
Discussion
The current study is the first to query experienced TTM
clinicians and clinical researchers regarding recom-
mended treatment techniques and their specific compo-
nents. Evidence from the current study clearly indicates
that those with expertise in the treatment of TTM view
CBT to be the first line treatment for both children and
adults. This finding is in line with preliminary evidence
from the child TTM literature (Tolin et al., 2007) and a
larger, though still small, body of adult TTM research
(Diefenbach et al., 2006; Van Minnen et al., 2003; Woods
et al., 2006). Again, given that our pool of respondents
consisted of TLC-SAB members and those endorsed by
them as TTM experts, it is not surprising that CBT was the
orientation endorsed by the majority of respondents. Our
study found that self-monitoring, awareness training,
297
Mean (SD)
3.50 (3.54); n = 2
2.17 (2.59); n = 6
2.00 (1.41); n = 2
5.00 (0.00); n = 1
1.50 (0.71); n = 2
2.50 (2.12); n = 2
7.00 (0.00); n = 1
8.00 (0.00); n = 1
7.50 (2.12); n = 2
5.00 (3.08); n = 5
3.60 (3.72); n = 5
7.50 (2.12); n = 2
1.86 (0.69); n = 7
3.71 (3.15); n = 7
4.67 (2.89); n = 3
5.00 (2.83); n = 2
4.40 (1.52); n = 5
–
competing response training, HRT, and stimulus control
were the most frequently employed treatment compo-
nents and should be considered the core components of
CBT for individuals with TTM at this time. In contrast to
the available empirical literature, tricyclic antidepressants
were utilized seldom by our sample of practitioners able to
prescribe medication (n = 11). Among those using tricyc-
lics, clomipramine was the most utilized tricyclic. Collec-
tively, these findings provide important information for
the development of more efficacious interventions for the
treatment of both children and adults with TTM.
Additional results with respect to medication use
among practitioners are mixed. Given that only a small
subset of respondents was able to prescribe medication,
extreme caution is warranted in interpreting our medica-
tion findings. Our preliminary findings, however, suggest
that four classes of medications (e.g., SSRIs, SNRIs, opiate
blockers, and antipsychotics) were used most frequently as
monotherapy. However, the efficacy of only one SSRI
(e.g., fluoxetine) and one opiate blocker (e.g., naltrex-
one) has ever been tested for the treatment of TTM in a
controlled trial (Christenson et al., 1993; Christenson et
al., 1994). Fluoxetine was tied with citalopram as the first
SSRI of choice, yet the efficacy of citalopram for the
treatment of TTM has never been examined in a
controlled fashion. Furthermore, tricyclic antidepressants
were not highly regarded as a medication class for use
among those with TTM, though in a recent meta-analysis,
298
Table 5
Descriptive Data regarding Course of Pharmacological Treatment
Survey Item
Please rank the appropriateness of EACH of the following medication maintenance visit schedules for a highly improved patient who has just responded to a course of
medication (WITH concurrent CBT) and who plans to remain on medication.
1-3 weeks
1-2 months
3-5 months
Every 6 months
Once a year
Return only with recurrent symptoms
Please rank the appropriateness of EACH of the following medication maintenance visit schedules for a partially improved patient who has just responded to a course
of medication (WITH concurrent CBT) and who plans to remain on medication.
1-3 weeks
1-2 months
3-5 months
Every 6 months
Once a year
Return only with recurrent symptoms
clomipramine was the only medication tested in a placebo-
controlled study to show superiority to placebo for
treatment of adults with TTM (Bloch et al., 2007). Of
note, safety concerns regarding the use of clomipramine,
particularly among children, may explain this discrepancy
between available empirical evidence and the prescribing
practices of respondents to the CPS. Also, since the meta-
analysis of Bloch and colleagues and development of this
survey, N-acetyl cysteine (NAC) has demonstrated a robust
response in a placebo-controlled study of adults with TTM
(Grant, Odlaug, & Kim, 2009). The study results for NAC
were made available after the CPS was developed and
placed online, and will likely influence the choice of
pharmacological agents in the future.
Several clinical and research implications arise from the
present study's findings. First, CBT should be the first line of
treatment for both children and adults with TTM. Again,
this finding is not totally unexpected given the overwhelm-
ingly strong CBT orientation of respondents to this survey.
As such, it is important to emphasize the specific CBT
strategies employed by these respondents. Our findings
suggest that self-monitoring, awareness training, competing
response training, HRT, and stimulus control are the most
commonly used components to CBT for children and
adults with TTM. Although these components are used
most often by current practitioners with expertise in the
treatment of TTM, researchers should continue to examine
the development of better therapeutic interventions. In
fact, it is very likely that additional CBT components, as yet
untested or undeveloped, may be necessary for more
efficacious treatment of this disorder. It may also be
particularly helpful to employ dismantling studies to obtain
a more comprehensive analysis of those components of
Flessner et al.
Mean (SD)
3.71 (1.50); n = 7
2.00 (1.20); n = 8
2.14 (0.69); n = 7
2.71 (1.38); n = 7
4.57 (0.79); n = 7
5.86 (0.38); n = 7
1.57 (0.79); n = 7
1.63 (0.52); n = 8
2.86 (0.38); n = 7
4.00 (0.00); n = 7
5.00 (0.00); n = 7
6.00 (0.00); n = 6
CBT demonstrating the greatest utility. Additionally, given
the heterogeneity of TTM, clinicians and researchers
should also examine the utility of matching a broad range
of treatment components to the specific TTM symptom
profile in individual patients (e.g., Mansueto, Stemberger,
Thomas, & Golomb, 1997).
Furthermore, additional research is clearly needed to
examine the efficacy of various pharmacological interven-
tions for TTM. Results from the current study suggest that it
may be worthwhile to also examine the efficacy of other
classes of medications, such as antipsychotics and SNRIs,
with placebo-controlled studies. Again, as noted earlier, our
small sample size restricts interpretation of our data on
medication treatment practices. Lastly, researchers should
further explore combined treatment approaches (e.g.,
medication + CBT) as done in the study of sertraline and
CBT for TTM (Dougherty, Loh, Jenike, & Keuthen, 2006).
Despite the important clinical implications noted
above, several limitations to the current study are
noteworthy. First, the current sample (n = 67) is quite
small and prohibits more comprehensive analyses
examining differences in treatment practices across
(e.g., psychology vs. psychiatry) and/or within (Ph.D.
vs. Psy.D. vs. “other”) disciplines. However, it is our
belief that the present sample adequately reflects
clinicians and clinical researchers with expertise in
the treatment of TTM who (1) frequently conduct
research and/or (2) are known to members of the
TLC-SAB as clinicians experienced in the treatment of
TTM. Future research may wish to examine current
practices for treatment of TTM across a more
representative sample of practitioners across diverse
theoretical orientations and levels of expertise. Second,
 Treatment of Trichotillomania
because data were not collected via a face-to-face
format, we could not confirm the accuracy of the
responses provided to the CPS. However, available
research suggests that data collected from Internet-
sampling procedures provide results consistent with
traditional methods (Gosling et al., 2004). In addition,
due to the relative dearth of practitioners specializing
in the treatment of TTM, Internet-sampling procedures
may represent the best and most efficient means by
which to collect information on this topic.
Despite the limitations described above, the current
study provides the largest sample of practitioners special-
izing in the treatment of TTM ever collected. It is
imperative, however, that researchers continue to strive
for a better understanding of this disorder and more
efficacious treatments for adults and children with TTM.
It is only by continued research examining the essential
components to CBT, appropriate pharmacological inter-
ventions, and the combination of these two approaches
that caregivers will be better able to effectively treat this
debilitating and often misunderstood disorder.
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300
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We would like to express our appreciation for the Trichotillomania
Learning Center's assistance in data collection and financial support for this
project.
In addition to CAF, FP, and NJK, Trichotillomania Learning
Center (TLC)-Scientific Advisory Board (SAB) members providing
feedback for the current study include Darin D. Dougherty, M.D.,
MSc, Ruth Golomb. M.Ed., Charles Mansueto, Ph.D., Carol Novak, M.
D., Suzanne Mouton-Odum, Ph.D, John Piacentini, Ph.D., Dan Stein,
Flessner et al.
M.D., Barbara Rothbaum, Ph.D., Douglas W. Woods, Ph.D., and Harry
Wright, M.D.
Address correspondence to Christopher A. Flessner, Ph.D., Rhode
Island Hospital, Department of Child and Adolescent Psychiatry,
Bradley Hasbro Children's Research Center, 1 Hoppin St., Suite 204,
Coro West, Providence, RI 02903; e-mail: cflessner@lifespan.org.
Received: August 3, 2009
Accepted: October 13, 2009
Available online 15 March 2010