October 19, 2025 • 11 mins
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:07):
Hey there, you brilliant therapists.
I know Linton usually kicksthese off, but I have absolutely
no clue where he is today.
My money's on him stress eatingsushi from Publix, but that's
just a hunch.
So I'm your host today, andwe're diving into a disorder
that's both a tongue twister andone that deserves way more of
our attention.
Tricotillomania.
Go ahead, say it three timesfast, I'll wait.
(00:29):
All right, let's jump in.
I'm gonna start with the DSMstuff, and I promise we'll make
it as fun as you can whenreading the DSM.
So trichotillomania lives in theOCD and related disorders of the
DSM, which makes sense when youthink about it, right?
For a diagnosis, the hairpulling has to be recurrent, and
we're talking noticeable hairloss here, not just
(00:50):
absent-minded twirling whileyou're re-watching the office,
one of my favorites for themillionth time.
We're talking actual hair lossthat people can see.
Your client has tried to stop,and this is crucial.
They've made repeated attemptsto decrease or stop the
behavior.
This isn't someone who justenjoys at an eyebrow pluck.
It's also affecting their lifein significant ways, causing
(01:12):
distress or impairment inrelationships, work, social
situations, or other importantareas.
Think about clients cancelingdates because of visible
patches, wearing hats in theoffice year-round, or avoiding
the pool at all costs.
Time matters too.
Symptoms must persist for atleast 12 months to be considered
chronic.
This isn't a phase.
(01:33):
You also need to rule out themedical angle as well.
The hair pulling can't be due toa dermatologic condition or
another psychiatric disorder.
Make sure it's not happening inthe context of psychosis or
other mental health conditions.
And here's something superimportant for you as a
therapist.
You've got to distinguish thisfrom normal grooming behaviors.
We all deal with our hair on adaily basis.
(01:55):
This is different because itresults in significant hair loss
and functional impairment.
So let's talk about whereclients are actually pulling
from because location matters.
A scalp is the MVP of pullingsites, the most frequently
affected area.
Your clients might createspecific patterns or pull from
multiple spots.
Cue the strategic hairstyling,hats, and that one specific
(02:17):
angle, they always turn theirhead in photos.
Eyebrows, oh, this one's tough.
Eyebrows are so visible, and thedistress and social anxiety that
come with this can be intense.
You might see clients who'vebecome makeup wizards out of
necessity, drawing on eyebrowsthat would make a YouTube beauty
influencer jealous.
And then there are eyelashes.
(02:39):
Possibly the most distressingbecause it's right there in
everyone's face.
Literally, you can't really hideit, and repeated pulling can
cause permanent follicle damage.
Imagine explaining to literallyeveryone why you're not wearing
mascara.
Now, here's something youabsolutely need to understand
for your practice and for yourlicensing exam: the hair pulling
(03:01):
cycle.
Think of this as thetrichotillomania trilogy that
keeps your clients stuck.
In phase one, there's increasingtension, that mounting anxiety
or urge right before pulling, orwhen they're white knuckling it,
trying to resist the impulse.
Phase two is the actual hairpulling, the act itself, whether
it's from the scalp, eyebrows,eyelashes, or wherever.
(03:21):
Then comes phase three, therelief or gratification, that
sense of release, satisfaction,or pleasure after pulling.
Here's the kicker.
This cycle is maintained bynegative reinforcement.
The relief from tensionstrengthens the connection
between pulling and emotionalregulation.
Your clients have essentiallytrained their brains to
associate pulling with relief.
(03:42):
Understanding this pattern isessential for developing
competing responses anddisrupting the behavior's
automaticity.
File this away for yourlicensing exam.
You're welcome.
Okay, so now let's talk aboutthe two different types of
pulling because they requiredifferent treatment approaches.
First, there's focused pulling.
This is the deliberateintentional kind.
(04:04):
Your client knows exactly whatthey're doing.
It's often linked to specifictriggers like stress,
frustration, like that clientwho keeps canceling, or boredom,
scrolling through Instagram forthe 47th time today.
A strong urge usually comesfirst.
And there might be ritualsinvolved, such as searching for
(04:25):
specific hair textures andexamining the pulled hairs.
Some clients describe it asalmost meditative.
Treatment here targets emotionalregulation and identifying those
triggers.
Then there's automatic pulling.
This is the ninja version.
It happens outside consciousawareness.
Your client is deep into aNetflix binge of suits,
scrolling through their phone orworking on progress notes, and
(04:47):
boom, suddenly they notice apile of hair in their lap or
that their hand hurts.
This unconscious form istrichotillomania because they
don't even realize they're doingit.
You need heightenedself-monitoring and awareness
training here.
Environmental modifications andcompeting responses are your
best friends.
Now let's talk about the realimpact of this disorder because
it's significant.
(05:08):
The emotional consequences areprofound.
Let's be real.
The shame is deep, soul-crushingshame about both the pulling and
the visible results.
This leads to social withdrawal,ghosting becomes a habit, tanked
self-esteem, and avoidingsituations where their hair loss
might be visible.
Swimming?
Nope.
Windy days?
Hard pass.
Intimate relationships?
(05:29):
Terrifying.
The mental load of constantlyhiding and managing this is
exhausting.
Functional impairment is serioustoo.
This disorder really interfereswith work and school.
Think about all the time spentfinding the right angle for Zoom
calls, perfecting concealers andmakeup, and dealing with the
anxiety and distress.
All of this reduces productivityand keeps people from fully
(05:50):
engaging in their lives.
And then there are physicalcomplications.
Some clients don't just pull,they examine, bite, or swallow
the hair.
That's called trichophagy.
In severe cases, this can createtrichobezors, hairballs, yes,
like cats, that require surgicalintervention, not fun.
Let's talk about what else youmight see alongside
(06:11):
trichotillomania.
Depression, generalized anxietydisorder, and OCD are frequently
part of the trichotillomaniadisorders.
These comorbidities makeeverything more complicated, and
you'll need an integrated,comprehensive treatment
approach.
You can't just treat the pollingin isolation, you've got to
address the whole picture.
So what actually works?
Let's talk about evidence-basedtreatments.
(06:34):
CBT is your gold standard here,the most well-suppressed
psychological treatment.
You're working on identifyingspecific triggers.
Is it stress from work,scrolling TikTok, that one
difficult client?
You're also increasing awarenessof urges and behaviors moment by
moment, and developing competingresponses that interrupt the
pulling cycle.
(06:54):
Habit reversal training or HRTis highly effective and
superstructured.
You're teaching clients torecognize the earliest signs of
the urge, that tingly feeling,hand moving toward head, and
substitute the behavior withsomething physically
incompatible, like clenchingfists, squeezing a stress ball,
or manipulating fidgetys.
SSRIs and Nacetylcysteine,that's NAC, show moderate
(07:18):
evidence for helping withsymptoms.
The research shows that thesework better when combined with
behavioral treatments,especially for clients dealing
with significant anxiety ordepression on top of the
trichotillomania.
Now let me give you somespecific techniques to add to
your toolbox.
First up is cognitiverestructuring, which
systematically challenges thoseirrational beliefs about
(07:40):
control, perfectionism, orself-amuse that keep the pulling
going.
If I can't stop pulling, I'm afailure, needs to become this is
a disorder, not a characterflaw.
Next is stimulus control, whichinvolves reducing exposure to
triggers.
If pulling happens during screentime, maybe they need to keep
their hands busy with a fidgettoy.
(08:01):
If it's in the bathroom mirror,maybe the lighting needs to
change.
Competing response training isabout developing alternative
behaviors that make pullingphysically impossible.
Can't pull if your hands areclenched into fists, or busy
playing with putty.
Self-managering helps buildawareness through tracking when,
where, what emotion, and howmany hairs.
(08:22):
This data is gold for treatmentplanning.
And finally, mindfulness-basedregulation helps clients sit
with distressing emotionswithout needing to do something
about them.
The urge isn't the enemy, thepulling is what we're working
on.
Let me walk you through how toactually implement treatment
with your clients.
We start with a comprehensiveassessment.
(08:42):
Get the full picture byevaluating focused versus
automatic pulling patterns,identifying specific triggers
and high-risk situations,assessing how much this is
impacting their life, andscreening for other conditions
that need attention.
Then you move intopsychoeducation and engagement.
This is where you normalize theexperience and reduce shame.
Education is powerful.
(09:04):
Help them understand they're notalone, they're not crazy, and
this is a real disorder withreal treatments.
Build that therapeutic allianceand get them invested in
treatment through shareddecision making.
Now you're ready for the coreintervention phase.
You implement habit reversaltraining and competing response
development while introducingself-monitoring tools and
awareness training.
(09:25):
Apply cognitive restructuringfor those maintaining beliefs
and integrate stimulus controlstrategies.
And you're not done yet.
The final piece is consolidationand relapse prevention.
Keep practicing those skills,develop strategies for managing
high-risk situations, addressany lingering symptoms, and
create a maintenance plan.
Regular check-ins are key.
(09:46):
All right, we're finally readyfor the key takeaways,
especially for your licensureexam.
Number one, trichotillomania iscomplex.
It's not just stop pulling yourhair.
They're behavioral, cognitive,and emotional factors all
interacting.
You need a comprehensiveassessment and individualized
treatment planning.
Number two, evidence-basedapproaches work.
(10:07):
CBT and HRT have strong researchbacking.
Combining behavioralinterventions with medication
can boost outcomes for complexcases.
Number three, address shame andstigma like your job depends on
it.
Because honestly, thetherapeutic alliance does.
Psychoeducation reduces shame,enhancing engagement, and
(10:28):
supporting sustained change.
You can't skip this step.
And number four, always monitorfor complications, assess for
comorbid psychiatric conditions,social and occupational
impairment, and physicalcomplications.
Here's the thing abouttrichotillomania.
It's one of the disorders that'sway more common than people
think, but clients often sufferin silence because of shame.
(10:50):
As therapists, you have theprivilege of being the person
who says, this is real, this istreatable, and you deserve
support.
If you have a client strugglingwith trichotillomania, approach
with curiosity and compassion,not judgment.
The shame is already there.
Your job is to be the safe spacewhere healing can actually
(11:10):
happen.
So there you have it.
Everything you need to knowabout trichotillomania.
Thanks for being with me today.
Hopefully, Lytton resurfacesnext week.
Probably with sushi inducedregrets that he missed this one.
Till then, remember, it's inthere.
Hey there, you brilliant therapists.
I know Linton usually kicksthese off, but I have absolutely
no clue where he is today.
My money's on him stress eatingsushi from Publix, but that's
just a hunch.
So I'm your host today, andwe're diving into a disorder
that's both a tongue twister andone that deserves way more of
our attention.
Tricotillomania.
Go ahead, say it three timesfast, I'll wait.
(00:29):
All right, let's jump in.
I'm gonna start with the DSMstuff, and I promise we'll make
it as fun as you can whenreading the DSM.
So trichotillomania lives in theOCD and related disorders of the
DSM, which makes sense when youthink about it, right?
For a diagnosis, the hairpulling has to be recurrent, and
we're talking noticeable hairloss here, not just
(00:50):
absent-minded twirling whileyou're re-watching the office,
one of my favorites for themillionth time.
We're talking actual hair lossthat people can see.
Your client has tried to stop,and this is crucial.
They've made repeated attemptsto decrease or stop the
behavior.
This isn't someone who justenjoys at an eyebrow pluck.
It's also affecting their lifein significant ways, causing
(01:12):
distress or impairment inrelationships, work, social
situations, or other importantareas.
Think about clients cancelingdates because of visible
patches, wearing hats in theoffice year-round, or avoiding
the pool at all costs.
Time matters too.
Symptoms must persist for atleast 12 months to be considered
chronic.
This isn't a phase.
(01:33):
You also need to rule out themedical angle as well.
The hair pulling can't be due toa dermatologic condition or
another psychiatric disorder.
Make sure it's not happening inthe context of psychosis or
other mental health conditions.
And here's something superimportant for you as a
therapist.
You've got to distinguish thisfrom normal grooming behaviors.
We all deal with our hair on adaily basis.
(01:55):
This is different because itresults in significant hair loss
and functional impairment.
So let's talk about whereclients are actually pulling
from because location matters.
A scalp is the MVP of pullingsites, the most frequently
affected area.
Your clients might createspecific patterns or pull from
multiple spots.
Cue the strategic hairstyling,hats, and that one specific
(02:17):
angle, they always turn theirhead in photos.
Eyebrows, oh, this one's tough.
Eyebrows are so visible, and thedistress and social anxiety that
come with this can be intense.
You might see clients who'vebecome makeup wizards out of
necessity, drawing on eyebrowsthat would make a YouTube beauty
influencer jealous.
And then there are eyelashes.
(02:39):
Possibly the most distressingbecause it's right there in
everyone's face.
Literally, you can't really hideit, and repeated pulling can
cause permanent follicle damage.
Imagine explaining to literallyeveryone why you're not wearing
mascara.
Now, here's something youabsolutely need to understand
for your practice and for yourlicensing exam: the hair pulling
(03:01):
cycle.
Think of this as thetrichotillomania trilogy that
keeps your clients stuck.
In phase one, there's increasingtension, that mounting anxiety
or urge right before pulling, orwhen they're white knuckling it,
trying to resist the impulse.
Phase two is the actual hairpulling, the act itself, whether
it's from the scalp, eyebrows,eyelashes, or wherever.
(03:21):
Then comes phase three, therelief or gratification, that
sense of release, satisfaction,or pleasure after pulling.
Here's the kicker.
This cycle is maintained bynegative reinforcement.
The relief from tensionstrengthens the connection
between pulling and emotionalregulation.
Your clients have essentiallytrained their brains to
associate pulling with relief.
(03:42):
Understanding this pattern isessential for developing
competing responses anddisrupting the behavior's
automaticity.
File this away for yourlicensing exam.
You're welcome.
Okay, so now let's talk aboutthe two different types of
pulling because they requiredifferent treatment approaches.
First, there's focused pulling.
This is the deliberateintentional kind.
(04:04):
Your client knows exactly whatthey're doing.
It's often linked to specifictriggers like stress,
frustration, like that clientwho keeps canceling, or boredom,
scrolling through Instagram forthe 47th time today.
A strong urge usually comesfirst.
And there might be ritualsinvolved, such as searching for
(04:25):
specific hair textures andexamining the pulled hairs.
Some clients describe it asalmost meditative.
Treatment here targets emotionalregulation and identifying those
triggers.
Then there's automatic pulling.
This is the ninja version.
It happens outside consciousawareness.
Your client is deep into aNetflix binge of suits,
scrolling through their phone orworking on progress notes, and
(04:47):
boom, suddenly they notice apile of hair in their lap or
that their hand hurts.
This unconscious form istrichotillomania because they
don't even realize they're doingit.
You need heightenedself-monitoring and awareness
training here.
Environmental modifications andcompeting responses are your
best friends.
Now let's talk about the realimpact of this disorder because
it's significant.
(05:08):
The emotional consequences areprofound.
Let's be real.
The shame is deep, soul-crushingshame about both the pulling and
the visible results.
This leads to social withdrawal,ghosting becomes a habit, tanked
self-esteem, and avoidingsituations where their hair loss
might be visible.
Swimming?
Nope.
Windy days?
Hard pass.
Intimate relationships?
(05:29):
Terrifying.
The mental load of constantlyhiding and managing this is
exhausting.
Functional impairment is serioustoo.
This disorder really interfereswith work and school.
Think about all the time spentfinding the right angle for Zoom
calls, perfecting concealers andmakeup, and dealing with the
anxiety and distress.
All of this reduces productivityand keeps people from fully
(05:50):
engaging in their lives.
And then there are physicalcomplications.
Some clients don't just pull,they examine, bite, or swallow
the hair.
That's called trichophagy.
In severe cases, this can createtrichobezors, hairballs, yes,
like cats, that require surgicalintervention, not fun.
Let's talk about what else youmight see alongside
(06:11):
trichotillomania.
Depression, generalized anxietydisorder, and OCD are frequently
part of the trichotillomaniadisorders.
These comorbidities makeeverything more complicated, and
you'll need an integrated,comprehensive treatment
approach.
You can't just treat the pollingin isolation, you've got to
address the whole picture.
So what actually works?
Let's talk about evidence-basedtreatments.
(06:34):
CBT is your gold standard here,the most well-suppressed
psychological treatment.
You're working on identifyingspecific triggers.
Is it stress from work,scrolling TikTok, that one
difficult client?
You're also increasing awarenessof urges and behaviors moment by
moment, and developing competingresponses that interrupt the
pulling cycle.
(06:54):
Habit reversal training or HRTis highly effective and
superstructured.
You're teaching clients torecognize the earliest signs of
the urge, that tingly feeling,hand moving toward head, and
substitute the behavior withsomething physically
incompatible, like clenchingfists, squeezing a stress ball,
or manipulating fidgetys.
SSRIs and Nacetylcysteine,that's NAC, show moderate
(07:18):
evidence for helping withsymptoms.
The research shows that thesework better when combined with
behavioral treatments,especially for clients dealing
with significant anxiety ordepression on top of the
trichotillomania.
Now let me give you somespecific techniques to add to
your toolbox.
First up is cognitiverestructuring, which
systematically challenges thoseirrational beliefs about
(07:40):
control, perfectionism, orself-amuse that keep the pulling
going.
If I can't stop pulling, I'm afailure, needs to become this is
a disorder, not a characterflaw.
Next is stimulus control, whichinvolves reducing exposure to
triggers.
If pulling happens during screentime, maybe they need to keep
their hands busy with a fidgettoy.
(08:01):
If it's in the bathroom mirror,maybe the lighting needs to
change.
Competing response training isabout developing alternative
behaviors that make pullingphysically impossible.
Can't pull if your hands areclenched into fists, or busy
playing with putty.
Self-managering helps buildawareness through tracking when,
where, what emotion, and howmany hairs.
(08:22):
This data is gold for treatmentplanning.
And finally, mindfulness-basedregulation helps clients sit
with distressing emotionswithout needing to do something
about them.
The urge isn't the enemy, thepulling is what we're working
on.
Let me walk you through how toactually implement treatment
with your clients.
We start with a comprehensiveassessment.
(08:42):
Get the full picture byevaluating focused versus
automatic pulling patterns,identifying specific triggers
and high-risk situations,assessing how much this is
impacting their life, andscreening for other conditions
that need attention.
Then you move intopsychoeducation and engagement.
This is where you normalize theexperience and reduce shame.
Education is powerful.
(09:04):
Help them understand they're notalone, they're not crazy, and
this is a real disorder withreal treatments.
Build that therapeutic allianceand get them invested in
treatment through shareddecision making.
Now you're ready for the coreintervention phase.
You implement habit reversaltraining and competing response
development while introducingself-monitoring tools and
awareness training.
(09:25):
Apply cognitive restructuringfor those maintaining beliefs
and integrate stimulus controlstrategies.
And you're not done yet.
The final piece is consolidationand relapse prevention.
Keep practicing those skills,develop strategies for managing
high-risk situations, addressany lingering symptoms, and
create a maintenance plan.
Regular check-ins are key.
(09:46):
All right, we're finally readyfor the key takeaways,
especially for your licensureexam.
Number one, trichotillomania iscomplex.
It's not just stop pulling yourhair.
They're behavioral, cognitive,and emotional factors all
interacting.
You need a comprehensiveassessment and individualized
treatment planning.
Number two, evidence-basedapproaches work.
(10:07):
CBT and HRT have strong researchbacking.
Combining behavioralinterventions with medication
can boost outcomes for complexcases.
Number three, address shame andstigma like your job depends on
it.
Because honestly, thetherapeutic alliance does.
Psychoeducation reduces shame,enhancing engagement, and
(10:28):
supporting sustained change.
You can't skip this step.
And number four, always monitorfor complications, assess for
comorbid psychiatric conditions,social and occupational
impairment, and physicalcomplications.
Here's the thing abouttrichotillomania.
It's one of the disorders that'sway more common than people
think, but clients often sufferin silence because of shame.
(10:50):
As therapists, you have theprivilege of being the person
who says, this is real, this istreatable, and you deserve
support.
If you have a client strugglingwith trichotillomania, approach
with curiosity and compassion,not judgment.
The shame is already there.
Your job is to be the safe spacewhere healing can actually
(11:10):
happen.
So there you have it.
Everything you need to knowabout trichotillomania.
Thanks for being with me today.
Hopefully, Lytton resurfacesnext week.
Probably with sushi inducedregrets that he missed this one.
Till then, remember, it's inthere.
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