Trichotillomania 

​​(All identifying details have been changed to protect confidentiality.)

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Client (anonymised): Female, mid-20s

Presenting issue: Trichotillomania (hair pulling) with noticeable bald patches on the scalp

Duration: 10 years

Sessions: 6 sessions + 3-month follow-up

Outcome: Hair pulling stopped by session 6; no pulling reported at 3-month follow-up

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Presenting Difficulties

The client sought support for longstanding trichotillomania that had resulted in bald patches and significant distress. At the start of therapy, she reported

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• Pulling for up to ~5 hours per day

• An estimate of 50+ hairs per day

• A strong sensory drive (seeking hairs that felt “just right,” often longer hairs)

• Pulling with both hands, especially when one hand was “free”

• Emotional impact including anxiety, stress, frustration, and a sense of being out of control

• Reduced confidence and increased self-consciousness due to visible hair loss

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Before starting sessions, her longest period without pulling had been around two weeks.

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Goal

The client’s primary goal was to stop hair pulling and feel more in control of urges, particularly during periods of stress and anxiety.

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Approach

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We used an evidence-based behavioural framework combining:

1) Habit Reversal Training (HRT)

• Awareness training (noticing early cues, positions, contexts)

• Competing responses (physically incompatible actions)

• Stimulus control (reducing opportunity and automaticity)

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2) The COMB Model (Comprehensive Behavioural Model for BFRBs)
Interventions targeted multiple drivers of pulling, including:

• Sensory: tactile input needs

• Cognitive: beliefs/attention patterns around “finding the right hair”

• Affective: stress/anxiety states

• Motor: hand movements and automatic reaching

• Place/environment: contexts that increased likelihood of pulling

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Each session included structured monitoring of what had changed since the previous session, allowing us to refine strategies quickly.​

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Outcomes

By the end of six sessions, the client reported

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• No pulling

• Increased sense of control and confidence

• Reduced distress around urges and triggers

• A clear plan for maintaining change during stressful periods

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Follow-up At 3 months, the client reported no pulling during the entire follow-up period—an improvement from her previous pattern of relapsing within two weeks.

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Note 

Outcomes vary between individuals depending on many factors, including severity, triggers, and context. This is not a guarantee of results.