A wide variety of treatments are attempted clinically to alleviate TTM symptoms in adults, adolescents and children, including cognitive and behavioral therapies, supportive counseling, support groups, hypnosis, medications and combined approaches [14
]. However, the scientific literature supporting the efficacy of these approaches is not well developed, with fewer than 20 randomized controlled trials available to guide treatment choice and implementation. Most of the available randomized treatment outcome studies have examined behavioral therapies or medications, and their collective findings have been somewhat mixed, especially with respect to the efficacy of medication. Furthermore, only one of these randomized trials was conducted with a pediatric sample [26
], despite clear evidence that onset during childhood or adolescence is the norm. A comprehensive review of the entire extant treatment literature is beyond the scope of the current article, but recent reviews (e.g., [14
]) and a quantitative meta-analysis [46
], as well as our own article, have highlighted several key points: first, CBTs are associated with relatively large effect sizes in adults following acute treatment, although relapse appears to be a problem; second, selective serotonin-reuptake inhibitors (SSRIs) generally do not appear to be efficacious in reducing hair pulling symptoms per se
; third, several compounds that appear to affect other neurotransmitter systems hold some promise for the treatment of TTM; fourth, combined treatments of behavioral therapy plus medication may also prove useful; and fifth, the absence of evidence from randomized controlled trials conducted with pediatric samples hinders treatment development and treatment planning for perhaps the most vulnerable population of TTM sufferers.
Behavioral interventions for TTM (e.g., [44
]) have generally included three core elements: first, awareness training, wherein techniques (e.g., self-monitoring) are implemented to improve the patient’s awareness of pulling and, better yet, the patient’s awareness of the urge that precedes pulling; second, stimulus control, which includes a variety of methods that serve as ‘speed bumps’ to reduce the likelihood that pulling behavior begins; and third, competing response training, where patients are taught at the earliest sign of pulling, or of the urge to pull, to engage in a behavior that is physically incompatible with pulling for a brief period of time until the urge subsides. These core methods were initially developed and tested by Azrin and Nunn [47
], and comprise the main elements of contemporary behavioral treatment, although some habit reversal training protocols have also included other techniques (e.g., relaxation training and cognitive strategies to address dysfunctional thoughts that precipitate pulling).
Expert opinion [32
] is convergent with the treatment outcome literature in supporting the use of CBTs that include habit reversal training as the first-line option in TTM. It is also now generally accepted that SSRIs, although potentially useful to address comorbid symptoms of anxiety and depression, are not considered first-line treatments for pulling per se
. One recent study did support the efficacy of an SSRI in combination with behavioral therapy over behavioral therapy or medication alone [48
]; replication of these findings is needed. New developments in pharmacotherapy discussed in the next section open up the possibility of examining the relative and combined efficacy of these novel approaches in concert with behavior therapy too. Whether these treatments should be started simultaneously or delivered sequentially – for example, premedication with an agent of established efficacy followed by behavioral intervention when pulling urges are lowered by medication effects – also needs to be examined using randomized designs.
Behavioral therapy, although efficacious, is not without its limitations, the most pressing of which is the observation that relapse following treatment is common (e.g., [36
]). Treatment development work is already underway in several laboratories to examine whether behavioral therapy involving habit reversal training can be augmented by methods designed specifically to address negative emotions. There is also hope that the research tools developed to more specifically examine pulling styles will aid clinical researchers in providing more targeted behavioral interventions that can be tailored to individual pulling profiles.
Recent developments in pharmacotherapy offer encouragement that therapies that modulate neurotransmitter systems other than serotonin will prove helpful in reducing pulling behavior and pulling urges. Bloch and colleagues’ thorough review of the treatment outcome literature highlights the fact that SSRIs offer very little in the way of clinical benefit above and beyond what can be expected from a placebo pill [46
]. Clomipramine, a tricyclic antidepressant with serotonergic and other properties, appears to be more efficacious than placebo, but its unfavorable side-effect profile renders it a second-line treatment. Instead, new data have emerged to support, at least preliminarily, the efficacy of an opioid antagonist (naltrexone), a glutamate modulator (N
-acetylcysteine [NAC]) and an atypical neuroleptic (olanzapine) for TTM. A summary of each is provided in the following section.
Two studies have examined the effects of naltrexone on pulling behavior; the logic of its use is that TTM appears to be appetitive, and some investigators have emphasized the phenomenological and underlying neurobiological overlap with other forms of addictive behavior (e.g., [49
]). Accordingly, medications that block opi-oid binding may well prove useful in decreasing the positive reinforcement derived from pulling, hence decreasing urge strength and affecting the behavior. A recent open-label study on 14 children with TTM found that naltrexone reduced hair pulling urges and behavior, and was not associated with any significant side effects [50
]. Similarly, a randomized double-blind trial on adults with TTM found some improvement in hair pulling behaviors in adults taking naltrexone [51
]. This trial, however, was never peer reviewed. To date, there has yet to be a positive peer-reviewed, double-blind study of naltrexone in individuals with TTM that compromises assessment of its potential usefulness in clinical practice. Further study of the efficacy and safety of this intervention is needed, as is more basic research on its mechanism of action.
Formal, if not functional, similarity between the repetitive behaviors seen in tic disorders and those seen in TTM led other neurobiologically oriented investigators to examine the potential utility of atypical neuroleptics to treat hair pulling, either alone or in combination with SSRIs. Initial open trials attested to their use as an augmentative agent [53
], as well as a monotherapy [55
]. In the first randomized controlled study of this intervention, monotherapy with the atypical neuroleptic olanzapine was found to be superior to pill placebo in adults [57
], although the potentially significant side-effect profile for this class of medications, which includes significant weight gain, metabolic dysfunction and extra-pyramidal symptoms [58
], continues to render them a second-line option when other treatments are available or have not yet been attempted in a given patient.
Perhaps the most important recent development in pharmacotherapy for TTM involves the use of the glutamate modulator NAC, which was found to be superior to pill placebo in a randomized controlled trial for adults with TTM [60
]. Treatment response rates for the NAC condition were not only clearly superior to the control condition, but they also yielded rates that were comparable to those observed in CBT trials with adults. In addition, the side-effect profile was quite favorable, which may well make this compound the most promising recent development in the field. Notably, NAC is not a US FDA-regulated product, so it is readily available in health food stores. However, comparability of products containing NAC between different manufacturers is unknown.