The name of the game in CBT, at least right now, is Habit Reversal. This includes: (1) building up the client’s awareness of the behavior so it’s not done on “autopilot;” (2) teaching the client to use a competing response such as playing with a fidget toy or squeezing a fist when they have an urge to pull, and (3) stimulus control, which involves using cues (e.g., signs in high-risk locations) and barriers (e.g., wearing band-aids on the fingertips) to help the client get better control over the behavior.

No one really knows why hair-pulling begins around that age range. But some research suggests that trichotillomania can start in response to stressors that often occur in childhood, such as alienation from friends, entrance into a new school, academic difficulties, onset of menarche, parental divorce, and the birth of a sibling.

Many people with trichotillomania pull when they’re bored, although some pull when they are overstimulated. It’s thought that hair pulling serves an emotion regulation function, by relieving boredom or by helping the person to feel soothed. In either case, however, it’s good to know what the trigger is so you can attack trich early. For example, when boredom is the trigger, then we’d want to teach the person to start using their strategies whenever they notice themselves feeling bored, before the urges even come on.

You’ve got me there. I think it’s an impulse control disorder. But there was a long debate about this issue, and some scholars have suggested that trich and OCD have common heritability and shared abnormalities in brain function.

Early childhood-onset trichotillomania can sometimes go away on its own or with a simple intervention. However, in many cases, and especially with adults, the disorder tends to be chronic, with fluctuations in severity often related to environmental stressors.

Yes, there are high rates of ADHD in people with trichotillomania. As a side note, sometimes, the medications that we prescribe for ADHD can actually make hair pulling get worse.

Hair pulling and skin picking can be related to anxiety and depression, but generally require a focused, specialized treatment. The most well-validated treatment for these problems is called Habit Reversal, which includes building awareness of the behavior, training a competing behavioral response (for example, squeezing a fist or playing with a fidget toy), and using cues and barriers in the person’s environment to discourage pulling and picking.

For further reference see https://www.amazon.com/Treating-Trichotillomania-Cognitive-Behavioral-Hairpulling-Disorders/dp/1441924256

Sounds like a very tricky case. Here, the hair pulling seems to be less of a true trichotillomania, and more related to gender identity. Before starting in on the hair pulling, it might be helpful to work with this client to process their feelings about gender and the transition.

Unfortunately, there are very few well-controlled studies of medications for trichotillomania, and some studies (for example, a trial of fluoxetine) showed minimal impact. There is some preliminary evidence that clomipramine, olanzapine, and N-acetylcysteine might be effective for trichotillomania, but this comes largely from smaller studies.