This technique includes using a tight scarf on the head and a comb plus or minus different pharmacological interventions. The tight scarf serves as a barrier for the first attempt to pull hair. If hair pulling is repeated, then head combing would be the second mechanism followed by putting the head scarf again. The hair combing is the meaningful competing response when feeling an urge to pull out hair, replacing knee squeezing and other meaningless competing responses. The overall impression by the patients and their families was that, this technique helped reducing hair pulling out and improvement was in average of 50% as per patients’ self-rated improvement and families’ observations to areas of hair loss. The fifty percent improvement included reduction in hair pulling frequency, allowing hair regrowth and reduced areas of baldness. The idea of Al Ain technique (ABT) - Al Ain is a city in UAE - stems from tailoring the behavioral intervention plan around the individualized patient’s behaviors and daily habits also tailoring the behavioral plan around the patients’ whereabouts to suit different patients with different circumstances and preferences in a meaningful way. This technique requires to be repeated in different parts of the world to hopefully replicate the results by other colleagues to have better evidence based status above case series.
This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Trichotillomania, Behavioral Management of Trichotillomania, Meaningful Competing Response,
Al Ain Behavioral Technique (ABT)
1. Trichotillomania: The Historical Background
Trichotillomania (TTM) was first described by French dermatologist Hallopeau in 1889. The word trichotillomania is derived from the Greek word thrix meaning hair, tillein meaning pulling out, and mania meaning madness. It is a form of traumatic alopecia in which there is repetitive, deliberate, and irresistible pulling of one’s own hair resulting in hair loss
[1]
Soundarya S, Jayakar T. Trichotillomania: A case report and review of the literature. Our Dermatol Online. 2024; 15(3): 261-264.
The first documented account was by Aristotle in the fourth-century bc, in his renowned work ‘Nicomachean Ethic’, which had references to plucking hair and gnawing nails
[2]
S. Gupta, V. Loniker, S. Mazzon and A. De.‘Keep your hair on!’ A historical narration of trichotillomania. British Journal of Dermatology Volume 185, Issue S1 p. 166. 06 July 2021
In a study included sixty-two female hair pullers, self-esteem did not appear to be directly related to age at onset of hair pulling or severity of hair loss. However, self-esteem was related to level of depression, frequency of hair pulling, level of anxiety, and body dissatisfaction unrelated to hair pulling
[3]
Diefenbach GJ, Mouton-Odum S, Stanley MA (November 2002). "Affective correlates of trichotillomania". BehaviourResearchandTherapy. 40(11): 1305–1315.
DSM-5 notes that there is some evidence that genetic vulnerability plays a role; trichotillomania occurs more frequently in people with obsessive-compulsive disorder (OCD) and their first-degree relatives. Some twin studies have demonstrated genetic anomalies associated with Trichotillomania and other OCD-related disorders
[4]
American Psychiatric Association. (2013). Diagnosticandstatisticalmanualofmentaldisorders (5th ed.).
. A compared Trichotillomania concordance rates in 24 monozygotic and 10 dizygotic twin pairs using DSM-IV-TR criteria, Trichotillomania concordance rates were significantly higher in monozygotic pairs (38%) than in dizygotic pairs (0%, p = 0.047).
[5]
Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med. 1989 Aug 24; 321(8): 497-501.
Several psychological theories have attempted to explain trichotillomania. It is speculated that hair pulling may function to provide short-term relief from stress and other unwanted emotional states, thus serving as a method of emotional regulation. Trichotillomania is often associated with significant distress and functional impairment with many individuals with trichotillomania report that, pulling worsens during periods of increased anxiety. Pulling hair is related to feeling stressed in some patients and feeling stressed and ashamed follows hair pulling which makes a closed loop. Trichotillomania also could possibly be a benign habit that develops from a sensory event such as itchiness in the scalp or lashes.
[6]
Soriano JL, O'Sullivan RL, Baer L, Phillips KA, McNally RJ, Jenike MA. Trichotillomania and self-esteem: a survey of 62 female hai r pullers. J Clin Psychiatry. 1996 Feb; 57(2): 77-82.
[6]
.
3.3. Role of the Environment
Environment is a large factor which affects hair pulling. Sedentary activities such as being in a relaxed environment are conducive to hair pulling. A common example of a sedentary activity promoting hair pulling is lying in a bed while trying to rest or fall asleep. While trichotillomania may be triggered by stress, the habit itself also causes significant distress, low self-esteem, guilt, and shame. Most people report that pulling is painless, if not pleasurable. It has been proposed that hair pulling creates “counter irritation” to reduce the stress perception by the brain
[3]
Diefenbach GJ, Mouton-Odum S, Stanley MA (November 2002). "Affective correlates of trichotillomania". BehaviourResearchandTherapy. 40(11): 1305–1315.
França K, Kumar A, Castillo D, Jafferany M, Hyczy da Costa Neto M, Damevska K, et al. Trichotillomania (hair-pulling disorder): clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations. Dermatol Ther. 2019; Jul; 32((4)): e12622.
3.4.1. Serotonin Deficiency: Serotonin Is a Monoamine Neurotransmitter
It is also suspected as a potential contributor in Trichotillomania etiology as a link may exist between a deficiency of serotonin and trichotillomania; the hypothesized connection between the two is based on the success of selective serotonin reuptake inhibitors (SSRIs) in treating some patients with trichotillomania.
[8]
França K, Kumar A, Castillo D, Jafferany M, Hyczy da Costa Neto M, Damevska K, et al. Trichotillomania (hair-pulling disorder): clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations. Dermatol Ther. 2019; Jul; 32((4)): e12622.
Sarah Anwar and Mohammad Jafferany. Trichotillomania: a psychopathological perspective and the psychiatric comorbidity of hair pulling Alpina, Acta Dermatovenerologica. 2019; 28: 33-36
Glutamate is an excitatory neurotransmitter it is non-essential amino acid and the most abundant neurotransmitter in the central nervous system (CNS). It accounts for over 90% of synaptic connections in the human brain and it is the main excitatory neurotransmitter in the brain.
[10]
Mackay, Clare. (2023). Trichotillomania: a perspective synthesized from neuroscience and lived experience. BMJ Ment Health. 26.
Some patients with Trichotillomania were found with lower levels of Glutathione mounted to one third of patients in one study which correlates to higher motor impulsivity. Glutathione is the primary antioxidant in the CNS. Glutathione and Glutamate have a close reciprocal relationship. Glutamate is a key substrate for synthesizing the antioxidant Glutathione, while Glutathione serves as a crucial physiological reservoir that regulate neuronal glutamate levels. This cycle balances brain excitation and protects against oxidative stress. Emerging research data suggest that oxidative stress might be involved in the pathophysiology of body focused repetitive disorders such as trichotillomania. As Reduced glutathione is a biological marker of increased oxidative stress, Glutathione or its precursor N -acetyl cysteine (NAC) supplementation manages oxidative stress by restoring Glutathione levels and modulate glutamate.
[10]
Mackay, Clare. (2023). Trichotillomania: a perspective synthesized from neuroscience and lived experience. BMJ Ment Health. 26.
Magnetic resonance imaging (MRI) studies have demonstrated that some individuals with trichotillomania have abnormalities of subcortical regions involved in habit generation, inhibitory control, and regulation of affect.
[12]
Walther MR, Ricketts EJ, Conelea CA, Woods DW. Recent Advances in the Understanding and Treatment of Trichotillomania. J Cogn Psychother. 2010 Feb 1; 24(1): 46-64.
In Female patients (n = 10) with DMS-IV diagnostic criteria for trichotillomania were subjected to single photon emission computed tomography (SPECT) before and after 12 weeks of pharmacotherapy with the selective serotonin reuptake inhibitor (SSRI), citalopram. Pharmacotherapy led to significantly reduced activity in inferior – posterior and other frontal regions. Correlates of hair-pulling symptoms with regional brain activity differed before and after pharmacotherapy. These data are to some extent consistent with work suggesting that trichotillomania, like OCD, is mediated by corticostriatal circuits.
[14]
Grant JE, Odlaug BL, Kim SW. N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Archives of General Psychiatry. 2009; 66: 756–763.
Dan J, Ben van Heerden, Charmaine H, Jeanine van Kradenburg, James W, Nompumelelo Z, and Soraya S. Functional brain imaging and pharmacotherapy in trichotillomania Single photon emission computed tomography before and after treatment with the selective serotonin reuptake inhibitor citalopram. Progress in Neuro-Psychopharmacology & Biological Psychiatry 26 (2002) 885 – 890.
[16]
Grant JE, Peris TS, Ricketts EJ, Bethlehem RAI, Chamberlain SR, O'Neill J, Scharf JM, Dougherty DD, Deckersbach T, Woods DW, Piacentini J, Keuthen NJ. Reward processing in trichotillomania and skin picking disorder. Brain Imaging Behav. 2022 Apr; 16(2): 547-556.
Preliminary data suggest that trichotillomania may represent a disorder of altered reward processing within the central nervous system as there is an evidence of altered nucleus accumbens activations and decreased functional connection between the dorsal anterior cingulate and nucleus accumbens and basolateral amygdala and reward network whose input is mediated through glutamatergic projections.
[15]
Dan J, Ben van Heerden, Charmaine H, Jeanine van Kradenburg, James W, Nompumelelo Z, and Soraya S. Functional brain imaging and pharmacotherapy in trichotillomania Single photon emission computed tomography before and after treatment with the selective serotonin reuptake inhibitor citalopram. Progress in Neuro-Psychopharmacology & Biological Psychiatry 26 (2002) 885 – 890.
[16]
Grant JE, Peris TS, Ricketts EJ, Bethlehem RAI, Chamberlain SR, O'Neill J, Scharf JM, Dougherty DD, Deckersbach T, Woods DW, Piacentini J, Keuthen NJ. Reward processing in trichotillomania and skin picking disorder. Brain Imaging Behav. 2022 Apr; 16(2): 547-556.
Reports also suggest a possible association between neurodegenerating diseases, such advanced stages dementias particularly affecting frontal lobe. It often manifests as grooming-related, or compulsive behavior associated with frontostriatal dysfunction.
Trichotillomania might be a compulsive-related symptom in dementias of different etiologies as they involve frontal areas and release primitive grooming behavior from frontostriatal dysfunction. Dopamine blockade, rather than SSRIs, may be effective in managing trichotillomania in dementia.
[16]
Grant JE, Peris TS, Ricketts EJ, Bethlehem RAI, Chamberlain SR, O'Neill J, Scharf JM, Dougherty DD, Deckersbach T, Woods DW, Piacentini J, Keuthen NJ. Reward processing in trichotillomania and skin picking disorder. Brain Imaging Behav. 2022 Apr; 16(2): 547-556.
Rege S and Vicki A. An open label flexible dose study of olanzapine in treatment of Trichotillomania. J clinical psychiatry 2003; 64: 49-52.
[16-18]
.
4. Management
4.1. Pharmacological Management
4.1.1. Clomipramine
Clomipramine, is a tricyclic antidepressant (TCA) that blocks the reuptake of noradrenaline and serotonin in the synaptic cleft; Clomipramine has a particular tricyclic profile that makes it much more similar to SSRIs, due to its potent inhibition of serotonin reuptake. Treatment of women with severe Trichotillomania with clomipramine or Desipramine in double blind crossover trial resulted in significantly greater improvement in symptoms clomipramine group than Desipramine, by scores on a trichotillomania-impairment scale, the severity of symptoms was reduced more by clomipramine than by Desipramine. The patients reported that the compulsion decreased in intensity and that they were abler to resist the urge to pull out their hair during treatment with clomipramine.
[5]
Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med. 1989 Aug 24; 321(8): 497-501.
França K, Kumar A, Castillo D, Jafferany M, Hyczy da Costa Neto M, Damevska K, et al. Trichotillomania (hair-pulling disorder): clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations. Dermatol Ther. 2019; Jul; 32((4)): e12622.
Walther MR, Ricketts EJ, Conelea CA, Woods DW. Recent Advances in the Understanding and Treatment of Trichotillomania. J Cogn Psychother. 2010 Feb 1; 24(1): 46-64.
Grant JE, Odlaug BL, Kim SW. N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Archives of General Psychiatry. 2009; 66: 756–763.
Dan J, Ben van Heerden, Charmaine H, Jeanine van Kradenburg, James W, Nompumelelo Z, and Soraya S. Functional brain imaging and pharmacotherapy in trichotillomania Single photon emission computed tomography before and after treatment with the selective serotonin reuptake inhibitor citalopram. Progress in Neuro-Psychopharmacology & Biological Psychiatry 26 (2002) 885 – 890.
[5, 8, 12, 14, 15]
.
4.1.2. Fluoxetine
Beneficial in a small number of adults’ trial. Potentially beneficial to patients with Trichotillomania with depression and / or OCD. Smaller less controlled studies showed limited benefits or no benefits from Fluoxetine. Selective serotonin reuptake inhibitors SSRIs in general are a potential choice.
[5]
Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med. 1989 Aug 24; 321(8): 497-501.
França K, Kumar A, Castillo D, Jafferany M, Hyczy da Costa Neto M, Damevska K, et al. Trichotillomania (hair-pulling disorder): clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations. Dermatol Ther. 2019; Jul; 32((4)): e12622.
Walther MR, Ricketts EJ, Conelea CA, Woods DW. Recent Advances in the Understanding and Treatment of Trichotillomania. J Cogn Psychother. 2010 Feb 1; 24(1): 46-64.
Grant JE, Odlaug BL, Kim SW. N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Archives of General Psychiatry. 2009; 66: 756–763.
Dan J, Ben van Heerden, Charmaine H, Jeanine van Kradenburg, James W, Nompumelelo Z, and Soraya S. Functional brain imaging and pharmacotherapy in trichotillomania Single photon emission computed tomography before and after treatment with the selective serotonin reuptake inhibitor citalopram. Progress in Neuro-Psychopharmacology & Biological Psychiatry 26 (2002) 885 – 890.
[5, 8, 12, 14, 15]
.
4.1.3. Others Antidepressants
Case reports describe possible benefits from a range of antidepressants such as Amitriptyline, imipramine, venlafaxine and Doxepin. These medications have shown benefits in the treatment of depression and anxiety, but given its limited data in its use in Trichotillomania, they should not be used as first line.
[5]
Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med. 1989 Aug 24; 321(8): 497-501.
França K, Kumar A, Castillo D, Jafferany M, Hyczy da Costa Neto M, Damevska K, et al. Trichotillomania (hair-pulling disorder): clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations. Dermatol Ther. 2019; Jul; 32((4)): e12622.
Walther MR, Ricketts EJ, Conelea CA, Woods DW. Recent Advances in the Understanding and Treatment of Trichotillomania. J Cogn Psychother. 2010 Feb 1; 24(1): 46-64.
Grant JE, Odlaug BL, Kim SW. N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Archives of General Psychiatry. 2009; 66: 756–763.
Dan J, Ben van Heerden, Charmaine H, Jeanine van Kradenburg, James W, Nompumelelo Z, and Soraya S. Functional brain imaging and pharmacotherapy in trichotillomania Single photon emission computed tomography before and after treatment with the selective serotonin reuptake inhibitor citalopram. Progress in Neuro-Psychopharmacology & Biological Psychiatry 26 (2002) 885 – 890.
[5, 8, 12, 14, 15]
.
4.1.4. Neuroleptics
Failures of some patients to respond to an SSRI led to several augmentation strategies including lithium, anxiolytics and neuroleptics. Marked improvement of trichotillomania was noted by several researchers with the addition of a neuroleptic to an SSRI.
[12]
Walther MR, Ricketts EJ, Conelea CA, Woods DW. Recent Advances in the Understanding and Treatment of Trichotillomania. J Cogn Psychother. 2010 Feb 1; 24(1): 46-64.
Selective serotonin reuptake inhibitors (SSRIs) in a case report were ineffective in controlling her hair-pulling behavior in a dementia case, which subsequently responded to quetiapine 150 mg/day. The literature suggest that trichotillomania may be a compulsive-related symptom in dementias of different etiologies as they involve frontal areas and release primitive grooming behavior from frontostriatal dysfunction. Dopamine blockade, rather than SSRIs, may be effective in managing trichotillomania in dementia.
[5]
Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med. 1989 Aug 24; 321(8): 497-501.
França K, Kumar A, Castillo D, Jafferany M, Hyczy da Costa Neto M, Damevska K, et al. Trichotillomania (hair-pulling disorder): clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations. Dermatol Ther. 2019; Jul; 32((4)): e12622.
Walther MR, Ricketts EJ, Conelea CA, Woods DW. Recent Advances in the Understanding and Treatment of Trichotillomania. J Cogn Psychother. 2010 Feb 1; 24(1): 46-64.
Grant JE, Odlaug BL, Kim SW. N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Archives of General Psychiatry. 2009; 66: 756–763.
Dan J, Ben van Heerden, Charmaine H, Jeanine van Kradenburg, James W, Nompumelelo Z, and Soraya S. Functional brain imaging and pharmacotherapy in trichotillomania Single photon emission computed tomography before and after treatment with the selective serotonin reuptake inhibitor citalopram. Progress in Neuro-Psychopharmacology & Biological Psychiatry 26 (2002) 885 – 890.
[17]
Pongsatorn P and Mario N. Trichotillomania as a Manifestation of Dementia. Case reports in Psychiatry. October 2016(6): 1-5.
Rege S and Vicki A. An open label flexible dose study of olanzapine in treatment of Trichotillomania. J clinical psychiatry 2003; 64: 49-52.
[5, 8, 12, 14, 15, 17, 18]
.
4.1.5. Naltrexone
Opioid antagonist FDA approved for management of Alcohol and opiate dependence. Was examined in two controlled trials, one trial showed no benefits and another trial showed limited benefits in management of Trichotillomania. Some clinicians consider Naltrexone if there is family history of Alcoholism in the patient’s family.
[5]
Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med. 1989 Aug 24; 321(8): 497-501.
França K, Kumar A, Castillo D, Jafferany M, Hyczy da Costa Neto M, Damevska K, et al. Trichotillomania (hair-pulling disorder): clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations. Dermatol Ther. 2019; Jul; 32((4)): e12622.
Walther MR, Ricketts EJ, Conelea CA, Woods DW. Recent Advances in the Understanding and Treatment of Trichotillomania. J Cogn Psychother. 2010 Feb 1; 24(1): 46-64.
Grant JE, Odlaug BL, Kim SW. N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Archives of General Psychiatry. 2009; 66: 756–763.
Dan J, Ben van Heerden, Charmaine H, Jeanine van Kradenburg, James W, Nompumelelo Z, and Soraya S. Functional brain imaging and pharmacotherapy in trichotillomania Single photon emission computed tomography before and after treatment with the selective serotonin reuptake inhibitor citalopram. Progress in Neuro-Psychopharmacology & Biological Psychiatry 26 (2002) 885 – 890.
[5, 8, 12, 14, 15]
.
4.1.6. Memantine
A single placebo controlled RCT of repurposed agents examined placebo and (memantine) in 100 adults with either trichotillomania or skin- picking disorder yielded promising results, with 60.5% of the memantine group reporting much improved symptoms after 8 weeks of treatment, relative to only 8.3% of the placebo group.
[5]
Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL. A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med. 1989 Aug 24; 321(8): 497-501.
França K, Kumar A, Castillo D, Jafferany M, Hyczy da Costa Neto M, Damevska K, et al. Trichotillomania (hair-pulling disorder): clinical characteristics, psychosocial aspects, treatment approaches, and ethical considerations. Dermatol Ther. 2019; Jul; 32((4)): e12622.
Walther MR, Ricketts EJ, Conelea CA, Woods DW. Recent Advances in the Understanding and Treatment of Trichotillomania. J Cogn Psychother. 2010 Feb 1; 24(1): 46-64.
Grant JE, Odlaug BL, Kim SW. N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Archives of General Psychiatry. 2009; 66: 756–763.
Dan J, Ben van Heerden, Charmaine H, Jeanine van Kradenburg, James W, Nompumelelo Z, and Soraya S. Functional brain imaging and pharmacotherapy in trichotillomania Single photon emission computed tomography before and after treatment with the selective serotonin reuptake inhibitor citalopram. Progress in Neuro-Psychopharmacology & Biological Psychiatry 26 (2002) 885 – 890.
[5, 8, 12, 14, 15]
.
4.1.7. Glutathione
A comparative study of placebo versus N-Acytlcysteine (NAC) which is a direct precursor to glutathione and, a glutamate modulator in 50 adults with TTM. Using a double-blind randomized trial design, results clearly showed that following 12 weeks of treatment, N-Acytlcysteine yielded significantly greater reduction in pulling severity than placebo.
[14]
Grant JE, Odlaug BL, Kim SW. N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Archives of General Psychiatry. 2009; 66: 756–763.
Habit reversal training (HRT): is the trichotillomania treatment with the most empirical support. HRT begins with developing an in-depth understanding of the client's unique pulling behaviors. The major components of HRT can then be carried out in a way that targets the client's specific needs and this includes competing response procedures. It is technique in behavior therapy that involves two sequential stages: (a) identification of habit occurrence, including antecedents and warning signs; and (b) creation and practice, in session and through homework, of a competing (i.e., alternative) response to the problem behavior. The competing response should be physically incompatible with the behavioral habit, inconspicuous, and easy to practice. This technique is typically used with habit disorders and is also used in anger management training.
[14]
Grant JE, Odlaug BL, Kim SW. N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Archives of General Psychiatry. 2009; 66: 756–763.
4.3 Predictors of Psycho-social Impairment in Individuals with Body Focused Repetitive Disorder (BFRBs)
A study conducted in 2022 involved a sample of 98 adults aged 18 to 65, diagnosed with trichotillomania, skin picking disorder, or both, and controls. The study utilized Partial Least Squares Regression to identify variables associated with disability on the Sheehan Disability Scale. The findings suggest that symptom severity, perceived stress, comorbid disorders, trait impulsivity, family history of alcohol use disorder, atypical pulling/picking sites, and older age are significant predictors of psychosocial impairment in BFRBs.
[14]
Grant JE, Odlaug BL, Kim SW. N-Acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Archives of General Psychiatry. 2009; 66: 756–763.
Jon E. Grant, Ibrahim H. Aslan, Samuel R. Chamberlain. Statistical Predictors of Psychosocial Impairment in BodyFocused Repetitive Behaviors. CNS Spectr. 2022 October; 27(5): 621–625.
This technique includes using a tight scarf on the scalp plus and a comb plus or minus different pharmacological interventions. The tight scarf serves as a barrier for the first attempt to pull hair. If hair pulling is repeated, then head combing would be the second mechanism followed by putting the head scarf again. The hair combing is the meaningful competing response when feeling an urge to pull out hair replacing knee squeezing and other meaningless competing responses. The overall impression by the eight patients in this case series and their families was that, this technique helped reducing hair pulling out and improvement was in average of 50% as per patients’ self-rated improvement and families’ observations. The fifty percent improvement included reduction in hair pulling frequency specially in the time that is known to be maximal hair pulling time, allowing hair regrowth and reduced areas of baldness. Al Ain behavioral technique (Al Ain is a city in UAE) considered tailoring the behavioral intervention plan around the individualized patient’s behaviors, daily habits and patients’ whereabouts to suit different patients with different circumstances and preferences in a meaningful way. This technique requires to be repeated in different parts of the world to hopefully replicate the results by other colleagues to have better evidence based status above case series.
Steps of Al Ain Behavioral Technique (ABT)
Firststep is to apply hair oil or hair cream all over the scalp (optional) followed by combing the scalp equally in all directions to create same feeling all over the scalp and to eliminate the possibility of feeling irritations or uneven sensations all over the scalp which might trigger hair pulling out. This step is expected also to reduce roughness in the hair endings that might trigger pulling out hair in some patients who play with the rough ended hair before pulling it.
Secondstep is to cover the scalp tightly with a headscarf preferably a favorite one clearly attempting to boost self-esteem by the choice. This scarf will act as the first barrier that the patient’s fingers will touch before pulling out the hair and at this step the patient can change her/his mind and resume what she is actually doing reducing hair pulling out.
Third step using the hair combing as a meaningful competing response whenever the patients gets an urge to pull hair out and if touching the scarf is not stopping the hair pulling, then removing the scarf followed by hair combing would replace the hair pulling out and even serves as grooming that does not attract much attention compared to hair pulling which again feeds to better self-esteem and reduced feelings of shame. Combing the hair will also help creating an even feeling of sameness all over the scalp that would replace the feeling following hair pulling if this feeling following hair pulling was required by the patient. Combing the hair will also replace scratching the scalp if itching or an abnormal sensation of the scalp is triggering the hair pulling out.
The reason of being meaningful is that, other described competing response such as squeezing the knees or making a fist might not suit every patient with Trichotillomania, and actually it is less competing and less meaningful the same way squeezing a rubber ball might not reduce anxiety in every anxious patient, and it might even worsen anxiety.
Whether there is maximal hair pulling time or no, and depending on the patient’s whereabouts whether at home or at work, the plan will be tailored to suit the location. If the time of maximal hair pulling is at work and the patient does not usually wear a scarf or if the patient cannot wear a head scarf at work, then no need for using a tight scarf. Instead, patients can start by doing the hair combing all over with or without the hair oil/ cream as a competing response whenever there is an urge to pull hair out. It is accepted to see a woman or a man running a comb through hair at work and this is even closer to normal compared to being noted pulling out the hair. Going to a private room like dining room at work, bathroom or any other place could be useful for the technique for a few minutes.
Fourthstep, if the patient is usually at home at the time of having maximal hair pulling, then starting by applying the hair oil/cream (optional) followed by combing the scalp all over and applying tight head-scarf could be used. At the time of having an urge to pull out the hair any time whether at night during watching television or during studying, this urge to pull out the hair to be replace by removing the scarf and doing the hair combing (meaningfulcompeting response) of hair all over again. This is followed by re-putting the scarf tightly. If the patient does not prefer to use the scarf at home, then to use the hair combing as a competing response every time the patient feels the urge to pull out the hair. Mathematically with the reduction of the time consumed in hair pulling, it is expected to reduce the percentage of pulled out hair. In the same time, regrowth of baby hair is expected to increase steadily because patients are giving time to the recently grown hair to continue growing.
6. Conclusion
Al Ain Behavioral Technique (ABT) combined to pharmacological interventions is a technique that entails the following advantages: 1- Allowing time for the urge to pull hair to dissipate as it has two phases one includes the head scarf and the other is the combing. 2- ABT covers those who are in need to feel sameness or a feeling of similarity all over the scalp as the stage of combing the hair provides this feeling which could distract from pulling a hair. 3- ABT is expected to help improve low self-esteem, feelings of guilt and anxiety as the impulse of pulling hair is diverted into meaningful process of combing and the hair pulling is gradually getting less in frequency. 4- The feelings of losing control due to inability to reduce hair pulling are expected to be switched to feelings of being in control of the situation, also and on the contrary doing reasonable grooming instead of the hair pulling feeds to improving self-esteem. 5- The feelings following hair combing could replace the feelings desired by some patients following the hair pulling. 6- This technique included the time of maximal hair pulling which is presented in other research as antecedents to the hair pulling or environmental factors triggering maximal hair pulling. Al Ain Behavioral Technique (ABT) requires replication by other colleagues from different parts of the world and to measure outcome by a structured tool so that it could gain higher place in the hierarchy of evidenced based practice. In future research, coloring behavioral therapies with meaningful actions in the management of disorders that patients seek particular feelings during, after or in the context of these disorders might improve the outcome. Examples of disorders that could benefit from the concept of meaningful behaviors are skin picking and self-harming. We expect the term meaningful in various behavioral therapies to improve outcome and add more to the current evidence based therapies and the future therapies.
Abbreviations
TTM
Trichotillomania
DSM
5 Diagnostic and Statistical Manual Version 5
OCD
Obsessive Compulsive Disorder
TCA
Tricyclic Antidepressant
SSRIs
Selective Serotonin Reuptake Inhibitors
CNS
Central Nervous System
NAC
N-acetyl Cysteine
MRI
Magnetic Resonance Imaging
PFC
Prefrontal Cortex
FDA
The Food and Drug Administration
RCT
Randomized Clinical Trial
HRT
Habit Reversal Training
UAE
United Arab Emirates
BFRBs
Body Focused Repetitive Disorder
ABT
Al Ain Behavioral Technique
Author Contributions
Mohammed Ahmed Allam: Conceptualization, Resources, Formal Analysis
Conflicts of Interest
The author declares no conflicts of interest.
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Allam, M. A. (2026). Management of Trichotillomania by a Meaningful Competing Response Combined to Various Pharmacological Interventions (Al Ain Technique). American Journal of Psychiatry and Neuroscience, 14(2), 41-46. https://doi.org/10.11648/j.ajpn.20261402.12
Allam, M. A. Management of Trichotillomania by a Meaningful Competing Response Combined to Various Pharmacological Interventions (Al Ain Technique). Am. J. Psychiatry Neurosci.2026, 14(2), 41-46. doi: 10.11648/j.ajpn.20261402.12
Allam MA. Management of Trichotillomania by a Meaningful Competing Response Combined to Various Pharmacological Interventions (Al Ain Technique). Am J Psychiatry Neurosci. 2026;14(2):41-46. doi: 10.11648/j.ajpn.20261402.12
@article{10.11648/j.ajpn.20261402.12,
author = {Mohammed Ahmed Allam},
title = {Management of Trichotillomania by a Meaningful Competing Response Combined to Various Pharmacological Interventions (Al Ain Technique)},
journal = {American Journal of Psychiatry and Neuroscience},
volume = {14},
number = {2},
pages = {41-46},
doi = {10.11648/j.ajpn.20261402.12},
url = {https://doi.org/10.11648/j.ajpn.20261402.12},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajpn.20261402.12},
abstract = {This technique includes using a tight scarf on the head and a comb plus or minus different pharmacological interventions. The tight scarf serves as a barrier for the first attempt to pull hair. If hair pulling is repeated, then head combing would be the second mechanism followed by putting the head scarf again. The hair combing is the meaningful competing response when feeling an urge to pull out hair, replacing knee squeezing and other meaningless competing responses. The overall impression by the patients and their families was that, this technique helped reducing hair pulling out and improvement was in average of 50% as per patients’ self-rated improvement and families’ observations to areas of hair loss. The fifty percent improvement included reduction in hair pulling frequency, allowing hair regrowth and reduced areas of baldness. The idea of Al Ain technique (ABT) - Al Ain is a city in UAE - stems from tailoring the behavioral intervention plan around the individualized patient’s behaviors and daily habits also tailoring the behavioral plan around the patients’ whereabouts to suit different patients with different circumstances and preferences in a meaningful way. This technique requires to be repeated in different parts of the world to hopefully replicate the results by other colleagues to have better evidence based status above case series.},
year = {2026}
}
TY - JOUR
T1 - Management of Trichotillomania by a Meaningful Competing Response Combined to Various Pharmacological Interventions (Al Ain Technique)
AU - Mohammed Ahmed Allam
Y1 - 2026/04/13
PY - 2026
N1 - https://doi.org/10.11648/j.ajpn.20261402.12
DO - 10.11648/j.ajpn.20261402.12
T2 - American Journal of Psychiatry and Neuroscience
JF - American Journal of Psychiatry and Neuroscience
JO - American Journal of Psychiatry and Neuroscience
SP - 41
EP - 46
PB - Science Publishing Group
SN - 2330-426X
UR - https://doi.org/10.11648/j.ajpn.20261402.12
AB - This technique includes using a tight scarf on the head and a comb plus or minus different pharmacological interventions. The tight scarf serves as a barrier for the first attempt to pull hair. If hair pulling is repeated, then head combing would be the second mechanism followed by putting the head scarf again. The hair combing is the meaningful competing response when feeling an urge to pull out hair, replacing knee squeezing and other meaningless competing responses. The overall impression by the patients and their families was that, this technique helped reducing hair pulling out and improvement was in average of 50% as per patients’ self-rated improvement and families’ observations to areas of hair loss. The fifty percent improvement included reduction in hair pulling frequency, allowing hair regrowth and reduced areas of baldness. The idea of Al Ain technique (ABT) - Al Ain is a city in UAE - stems from tailoring the behavioral intervention plan around the individualized patient’s behaviors and daily habits also tailoring the behavioral plan around the patients’ whereabouts to suit different patients with different circumstances and preferences in a meaningful way. This technique requires to be repeated in different parts of the world to hopefully replicate the results by other colleagues to have better evidence based status above case series.
VL - 14
IS - 2
ER -
Allam, M. A. (2026). Management of Trichotillomania by a Meaningful Competing Response Combined to Various Pharmacological Interventions (Al Ain Technique). American Journal of Psychiatry and Neuroscience, 14(2), 41-46. https://doi.org/10.11648/j.ajpn.20261402.12
Allam, M. A. Management of Trichotillomania by a Meaningful Competing Response Combined to Various Pharmacological Interventions (Al Ain Technique). Am. J. Psychiatry Neurosci.2026, 14(2), 41-46. doi: 10.11648/j.ajpn.20261402.12
Allam MA. Management of Trichotillomania by a Meaningful Competing Response Combined to Various Pharmacological Interventions (Al Ain Technique). Am J Psychiatry Neurosci. 2026;14(2):41-46. doi: 10.11648/j.ajpn.20261402.12
@article{10.11648/j.ajpn.20261402.12,
author = {Mohammed Ahmed Allam},
title = {Management of Trichotillomania by a Meaningful Competing Response Combined to Various Pharmacological Interventions (Al Ain Technique)},
journal = {American Journal of Psychiatry and Neuroscience},
volume = {14},
number = {2},
pages = {41-46},
doi = {10.11648/j.ajpn.20261402.12},
url = {https://doi.org/10.11648/j.ajpn.20261402.12},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajpn.20261402.12},
abstract = {This technique includes using a tight scarf on the head and a comb plus or minus different pharmacological interventions. The tight scarf serves as a barrier for the first attempt to pull hair. If hair pulling is repeated, then head combing would be the second mechanism followed by putting the head scarf again. The hair combing is the meaningful competing response when feeling an urge to pull out hair, replacing knee squeezing and other meaningless competing responses. The overall impression by the patients and their families was that, this technique helped reducing hair pulling out and improvement was in average of 50% as per patients’ self-rated improvement and families’ observations to areas of hair loss. The fifty percent improvement included reduction in hair pulling frequency, allowing hair regrowth and reduced areas of baldness. The idea of Al Ain technique (ABT) - Al Ain is a city in UAE - stems from tailoring the behavioral intervention plan around the individualized patient’s behaviors and daily habits also tailoring the behavioral plan around the patients’ whereabouts to suit different patients with different circumstances and preferences in a meaningful way. This technique requires to be repeated in different parts of the world to hopefully replicate the results by other colleagues to have better evidence based status above case series.},
year = {2026}
}
TY - JOUR
T1 - Management of Trichotillomania by a Meaningful Competing Response Combined to Various Pharmacological Interventions (Al Ain Technique)
AU - Mohammed Ahmed Allam
Y1 - 2026/04/13
PY - 2026
N1 - https://doi.org/10.11648/j.ajpn.20261402.12
DO - 10.11648/j.ajpn.20261402.12
T2 - American Journal of Psychiatry and Neuroscience
JF - American Journal of Psychiatry and Neuroscience
JO - American Journal of Psychiatry and Neuroscience
SP - 41
EP - 46
PB - Science Publishing Group
SN - 2330-426X
UR - https://doi.org/10.11648/j.ajpn.20261402.12
AB - This technique includes using a tight scarf on the head and a comb plus or minus different pharmacological interventions. The tight scarf serves as a barrier for the first attempt to pull hair. If hair pulling is repeated, then head combing would be the second mechanism followed by putting the head scarf again. The hair combing is the meaningful competing response when feeling an urge to pull out hair, replacing knee squeezing and other meaningless competing responses. The overall impression by the patients and their families was that, this technique helped reducing hair pulling out and improvement was in average of 50% as per patients’ self-rated improvement and families’ observations to areas of hair loss. The fifty percent improvement included reduction in hair pulling frequency, allowing hair regrowth and reduced areas of baldness. The idea of Al Ain technique (ABT) - Al Ain is a city in UAE - stems from tailoring the behavioral intervention plan around the individualized patient’s behaviors and daily habits also tailoring the behavioral plan around the patients’ whereabouts to suit different patients with different circumstances and preferences in a meaningful way. This technique requires to be repeated in different parts of the world to hopefully replicate the results by other colleagues to have better evidence based status above case series.
VL - 14
IS - 2
ER -
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