pulling reduction techniques
A group of scientists from the Department of Clinical Psychology
at the University of Nijmegen, in The Netherlands conducted
a study on techniques to reduce trichotillomania hair pulling
Obsessive-compulsive hair pulling is also called trichotillomania.
Trichotillomania affects the young and old alike and the Massachusetts
General Hospital, USA has created a scale to measure the severity
of hair pulling. Different types of therapies have been suggested
and tested to reduce this problem. This study references the
previously discovered successes of both behavioral therapy and
serotonin uptake inhibitors in controlling trichotillomania.
In the view of the authors, this study was necessary because
the comparison between behavioral techniques and pharmaceutical
techniques is needed to discover which is more effective in
The patient-group in the study was found from respondents who
called in after a nationally televised show about trichotillomania.
Of these respondents, 50 were initially selected although in
the end only 40 were ultimately used. The other 10 either declined
the treatment or had to leave part way through the study for
personal reasons. By the end, the patient-groups were made up
of 14 behavioral therapy recipients, 11 fluoxetine recipients,
and a control group of 15. Patients were over the age of 16
and had to be free of a variety of conditions (as varied as
brain disease and pregnancy).
Prior to the beginning of the treatment, two clinical interviews
were conducted within an hour of each other in which the patients
were diagnosed and categorized. After that, they were randomly
assigned to one of the three groups: the behavioral therapy
group, the fluoxetine group, or the control group, which was
called the waiting-list group. These three groups were monitored
for 12 weeks and a post-treatment interview was conducted.
Here is what each of the three groups did during their 12 weeks
The Behavioral Therapy Group
The members of the behavioral therapy group each underwent an
individual 45 minute manual-based session every other week
for the 12 weeks. The purpose of the session was to develop
self-control. They did this with three methods:
stimulus control (making sure the environment is conducive to
supporting their behavior modification – like putting
on gloves to eliminate the ability to tear out hair).
stimulus response intervention (interrupting the chain of response
with other activities – such as going for a walk or calling
response consequences (giving rewards for being successful -
this included allowing the hair to be pulled only after a tedious
task had been done, like cleaning the bathroom).
The Fluoxetine Group
The members of the fluoxetine group were given daily doses of
fluoxetine in the amount of 60 mg per day. Thirty minutes
were spent with a psychiatrist every other week to monitor
their progress. They were also given no other treatments,
homework, or suggestions, in order to make sure that they
were not using a combination of behavioral therapy and fluoxetine
which could throw off the results. Throughout the course of
the treatment analysis revealed that by the end of the treatment
seven patients reported mild symptoms of fatigue, headache,
insomnia, and weight loss and moderate to severe sexual side
effects. One patient had to have their dosage reduced by one
third because of severe, prolonged insomnia.
The Waiting List Group
The waiting list group was a control group that underwent no
therapy during the 12 weeks, but was simply told they were
on a waiting list.
After the results were analysed, behavioral therapy was proven
to be much more successful at reducing hair pulling than the
fluoxetine group or the waiting list group experienced. As measured
by the Massachusetts General Hospital hair pulling scale, 64%
of the behavioral therapy group experienced significant improvement,
while 9% of the fluoxetine group experienced significant improvement,
and a surprising 20% of the waiting list group experienced significant
Unfortunately, none of the treatments displayed any significant
improvement in the overall disorder, but simply in the amount
of hair pulled. While behavioral therapy can reduce hair pulling
significantly, neither it nor the pharmaceutical solution were
successful in improving the depressive symptoms.
The study was also honest enough to point out some areas where
the results may be skewed. They make the following clarifications:
Fluoxetine treatment was shown to be ineffective in this experiment
but it has been proven more effective in other experiments.
This discrepancy could be result of the dosage or the length
of time in which the patients were observed in this study compared
to other studies.
The surprising improvement in the waiting list control group
can be attributed to the expectancy of forthcoming treatment
as well as the top of the mind awareness that came from the
pre-experiment information on trichotillomania provided to all
participants of the experiment. It was also assumed that perhaps
they picked up some treatments from the leaflet provided. Conversely,
the fluoxetine group experienced so little improvement perhaps
because they were relying solely on the pharmaceutical solution
and therefore did not look to the leaflets for any other suggestions.
Another problem that could skew the results of this experiment
is that many of the successes and failures of the behavioral
therapy group were self monitored and self-reported.
Another potential problem was that the participant group was
made up of 40 people who telephoned into the experiment in response
to a television show, so they are self referring participants.
In spite of these clarifications, the scientists who performed
the study were confident that their findings still held true:
that behavioral therapy is the most effective means available
so far of reducing trichotillomania.
pulling reduction techniques references
- van Minnen A, Hoogduin KA, Keijsers GP, Hellenbrand I, Hendriks
GJ. Treatment of trichotillomania with
behavioral therapy or fluoxetine: a randomized, waiting-list
Arch Gen Psychiatry. 2003 May;60(5):517-22.