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Copyright 2003 by the American Society of Clinical Hypnosis Hypnosis as a Vehicle for Choice and Self-Agency
in the Treatment of Children with Trichotillomania
Alex Iglesias
Three pediatric cases of Trichotillomania were treated with direct hypnoticsuggestion with exclusive emphasis on sensitizing and alerting the patients toimpending scalp hair pulling behaviors. These children had presented with totallack of awareness of their scalp hair pulling behaviors until they had actuallytwisted and pulled off clumps of hair. It was also suggested, under hypnosis, thatupon learning to recognize impending scalp hair pulling behaviors, the patientswould become free to choose to willfully pull their hair or to resist the impulse andnot pull. At no point was the explicit suggestion given that they stop pulling theirhair. A preliminary condition was agreed to by the parents that redefined thepatients’ hair as their own property and affirmed their sole responsibility for itscare and maintenance. An element of secondary gain was identified in each of thesecases. Scalp hair pulling was hypothesized to provide these particular patientswith a vehicle with which to oppose their overbearing and over-involved parents.
The technique of direct suggestion under hypnosis, aimed at alerting the patientsto impending scalp hair pulling behaviors was combined with forming contractswith the parents to relinquish their authority over matters regarding the patients’hair. This combination provided an effective treatment that extinguished the scalphair pulling in 7 visits or less. These cases received follow-up at intervals up to 6months and no evidence of relapse was found.
Keywords: Children, ego-strengthening, family, hypnosis, non-adversarial,
obsessive compulsive spectrum, self-efficacy, Trichotillomania
Introduction
Trichotillomania is defined as the recurrent failure to resist pulling one’s own hair. It is carried out as the culmination of a tension that mounts before the moment ofplucking and is then released during or after the act (Maxmen & Ward, 1995). Themajority of the reported cases focus on hair pulling in the area of the scalp but othersites include eyelashes, eyebrows and pubic hair. Hair loss to Trichotillomania variesfrom barely noticeable thinning to total loss (Maxmen & Ward, 1995). Christenson,MacKenzie, Mitchell & Callies (1991) found that most Trichotillomania patients had The author expresses gratitude to Dr. Claire Frederick for her editorial support. Request reprints from: Alex Iglesias, Ph.D.
11211 Prosperity Farms Rd.
Oak Park, Suite 110CPalm Beach Gardens, FL 33410 Hypnosis in the Treatment of Trichotillomania started the behavior within five years before or after puberty and had the problem fortwo years before seeking treatment. Co-morbidity is reported for most of the cases andparenthetically, it has been reported that only 18% of the cases that come in for treatmentdo not have another Axis I disorder (Maxmen & Ward, 1995). Mood disorders havebeen implicated as co-morbid conditions with Trichotillomania in about 65% of thecases, anxiety disorders in 57% of the cases, eating disorders in 20%, and/or substanceuse disorders in 22% of the cases (Christensen et al., 1991).
Although included under the classification of Impulse Control Disorders, Not Otherwise Specified in DSM IV (American Psychiatric Association, 1994),Trichotillomania has been hypothesized to share a relationship with OCD and has beenincluded into what is conceptualized as an obsessive-compulsive spectrum (McElroy,Phillips & Keck, 1994; Rapoport, 1994; Stein, 2000). Tukel, Keser, Karali, Olgun andCalikusu (2001) reported on a comparison of clinical characteristics in Trichotillomaniaand obsessive-compulsive disorder. The findings indicated that their Trichotillomaniagroup had a greater percentage of women and showed earlier age at onset. Their OCDgroup demonstrated a higher incidence of depressive disorders and Axis II personalitydisorders. Pryor, Martin and Roach (1995) reported on the efficacy of treating bothTrichotillomania and OCD with the serotonin selective reuptake inhibitor fluoxetine,suggesting that such syndromes could share a common serotonin neurotransmitterdisturbance, which suggests possible psychophysiologic similarities between thesetwo syndromes. The literature indicates that Trichotillomania in children is more likelyto present in pure form, or that the symptom of hair pulling comes without any additionalobservable psychopathology (Zalman, Hermesh & Sever, 2001; Rowen, 1981; Kohen,1996; Watson & Allen, 1993).
Treatment of Trichotillomania
Pharmacologic Treatment
Pharmacological treatments for Trichotillomania have included the use of the selective serotonin reuptake inhibitor fluoxetine (Pryor, Martin & Roach, 1995). Theauthors reported favorable results from fluoxetine in their case study of an 18-year-old female with Trichotillomania. Khouzam, Battista and Byers (2002) reported onTrichotillomania and its response to treatment with quetiapine (Seroquel). Their casestudy of a 33-year-old female veteran with Trichotillomania demonstrated a favorableclinical response to the atypical anti-psychotic quetiapine. Another pharmacologicapproach to the treatment of Trichotillomania involved the use of a commercialtopical cream that enhances pain sensitivity (Ristvedt & Christenson, 1996). Thesubject, a 38-year-old female, applied the cream daily to two affected areas on herscalp. The increased pain sensitization, in conjunction with the use of a habitreversal technique, resulted in decreased hair pulling.
Psychotherapy
Treatment approaches for this condition have emphasized behavior modification techniques (Stabler & Warren, 1974; Mannino & Delgado, 1969; Schachter, 1961). Theliterature also reports treatment with psychodynamic methods (Hynes, 1982; Masserman,1955).
Hypnosis and Treatment
Hypnotic approaches to the treatment of Trichotillomania can be subsumed into two major categories. Both of these approaches reflect the same objective: makingthe patient stop the hair pulling. These approaches, however, pursue this common goalthrough different means. One approach states its therapeutic objective only implicitly.
The second approach states the therapeutic objective overtly or explicitly.
The first approach includes Ericksonian-based indirect methods (Zeig, 1980) in which suggestions that the patient will stop the hair pulling are implicitly present butexpertly couched and hidden by layers of disguising metaphorical language (Zalsmanet al., 2001). Olness and Gardner (1988) reported on the use of an indirect Ericksonian-based approach for treating pediatric Trichotillomania, that included guiding the childto stroke herself as an alternative to pulling her hair. Zalsman et al. (2001) employed anindirect Ericksonian-based approach to treating Trichotillomania in adolescents, thatthey titled imaginative hypnotherapy (Hilgard, 1974). This approach focused ontransforming the patients’ self-aggression into self-care. The aim of the implicit approach,hidden suggestions notwithstanding, is to control the hair pulling and to eventuallyextinguish it. The position of the therapist, no matter how permissive the metaphoricallanguage being employed may sound, can be interpreted as adversarial to the symptomand his/her role can be perceived by the child as one of passive executioner of the hairpulling habit.
The second hypnotically based approach for the treatment of Trichotillomania states its objective explicitly: to make the patient stop pulling his hair. Included in thisgroup are approaches that employ aversive hypnotic conditioning involving the couplingof hair pulling behaviors with an intense feeling of nausea (Rowen, 1981). Galski (1981)associated hair pulling to the kinesthetic sensation of the pain one feels when sunburnedskin is touched. The aim of the explicit approach is also to extinguish the hair pullingbehaviors. There is no doubt that the position of the therapist employing this explicitapproach is adversarial to the symptom and his/her role is of active executioner of thehair pulling habit.
Barabasz (1987) used a non-adversarial hypnotic method to successfully treat three adults with extended and complicated histories of Trichotillomania. Her approachavoided any direct suggestions under hypnosis that the patient stop the hair pulling.
(Barabasz [1987] used extreme environmental restriction with her adult patients in orderto attempt to increase their hypnotizability.) Her treatment results were maintained inlong-term follow-up.
The use of hypnosis in pediatric cases has an extensive and well-established history. Documentation is ample in the use of pediatric hypnosis for the management ofdisorders of impulse control, habit disorders and dermatological conditions (Wester &O’Grady, 1981; Olness & Gardner, 1988; Crasilneck & Hall, 1985).
Clinical Cases
Population and Formulation
Repressed anger was hypothesized as the driving force behind the three pediatric cases of Trichotillomania reported herein. All three of the children came fromauthoritarian homes where at least one parent demonstrated over-involvement with the Hypnosis in the Treatment of Trichotillomania patient and consistently limited and restricted the child’s freedoms of expression andchoice. Expressing anger openly was not an option in these households.
Trichotillomania was hypothesized as a conduit used by these patients to resolve theanger it was presumed had been repressed. The families of these children wereprofessional, successful, and high achievers in numerous pursuits. An interestingdynamic that was observed in each of these families was the failure to recognize andrespect autonomy in their children. It appeared that decisions involving mattersconcerning the children were usually made without regard for the children’s opinions.
At first glance, the choices that these parents made on behalf of their children were,ostensibly, logical and appropriate. However, when choosing and deciding, theyroutinely failed to consider the child’s point of view. Trichotillomania was furtherhypothesized to represent a manifestation of the child’s basic need for autonomy.
Hypnotic and Non-Hypnotic Elements
Barabasz’ non-adversarial method was emulated and adapted to children in this study. (Environmental restriction, however, was not employed as part of thetreatment approach with the children in this study). In light of the developmental strugglebetween these parents and their children, an approach that placed the therapist in anadversarial position to the hair-pulling symptom would have created the same kind ofoppositional stance towards the therapeutic situation that these children were exhibitingtowards their parents. Instead, the role of the therapist and the goals of therapy weredefined non-adversarially, in a way that emphasized boundaries, choice, and autonomy.
The goal of therapy was consequently limited to the following definition: to successfullyheighten the child’s awareness of impending hair pulling behaviors. Moreover, it wasfurther defined that to the degree that this mechanism operated successfully, the childwould never pull his hair without knowing, ahead of time, that he/she was about to doso. Once the child had awareness of imminent hair pulling behavior, he/she was in aposition to exercise free will: to pull or not to pull.
All three families agreed to, prior to start of therapy, to recognize their children’s hair as their property and agreed that they could choose to do with it as they desired.
A verbal contract was agreed to by each family, with the child present, which stipulatedthat no references to the child’s hair would ever again take place. They also agreed towithhold punishment or recriminations for any instances of hair pulling.
The hypnotic sessions were 30 minutes long and included only the child. The accompanying parent was included during the last 15 minutes of each visit in order toprovide a general overview of the child’s progress and to reinforce the contract. An eyefixation with progressive relaxation hypnotic induction was utilized in each of the cases.
Moreover, imagery of the child playing his/her favorite sport, non-competitively andfor fun was employed for deepening. The following non-adversarial, direct suggestionsunder hypnosis were given.
Hypnosis Script
You will hear a bell ringing and will be acutely aware whenever your hand makes theslightest effort to move up to your head. Knowing, ahead of time, that your hand isintending to move up to your head gives you the power and the control to decide ifyou want to pull your hair or if you choose not to. Never again will your hair get pulled without your awareness and your permission. Your hair is your property and itis your choice how to care for it. Case Reports
An 8-year-old boy presented with pure Trichotillomania of about 6 month’s onset that coincided with his dad’s recent remarriage. The stepmother was an overbearingwoman who had taken over the day-to-day management of her husband’s three children,including the patient. Her parenting style was authoritarian, and in keeping with thisstyle she had ordered the child to stop his hair pulling. The patient was unaware of thepulling behaviors until he had a clump of hair in his hand. It was speculated that the hairpulling became the patient’s manifestation for self-determination and autonomy andalso served as a vehicle to torment the stepmother. Direct suggestions under hypnosiswere made for the child to become immediately aware at the earliest movement of thehand towards his head. Suggestions were further provided that since he was a “bigkid,” he could decide like a “big kid” whether to pull or not. Ego strengtheningsuggestions (Hartland, 1971; Frederick & McNeal, 1999; Gorman, 1974; Hammond, 1990)were also provided at each visit. They were aimed at enhancing the child’s self-confidence, autonomy and empowering the child with suggestions that he was in controlof his life. After 5 visits the Trichotillomania behavior stopped. Follow-up visits at 3and 6 months demonstrated no relapse.
This 10-year-old boy already had a 2-½ year history of “seasonal” hair pulling.
He was an avid swimmer and swam competitively for a community swim club. Since hecut his hair off during the swimming season, there was no hair pulling during thesemonths. He pulled his hair the rest of the year. He was from a highly achieving familywhere he was expected to excel in multiple pursuits. His mother was highly demandingand over-involved in the child’s life. The child denied knowing or being aware of thehair pulling behaviors until he had twisted and pulled off a clump of hair. The patientwas treated with direct suggestions under hypnosis to sensitize him and make himimmediately aware, at the earliest movement of the hand towards his head. He was alsotreated with guided imagery of swimming and given suggestions that swimming did notalways have to involve competition; that one could also swim for fun. He was also told,under hypnosis, that once he became aware of impending hair pulling behaviors that itwas his choice to proceed and pull his hair or stop and not pull it. He was also remindedthat his hair belonged to him and he was responsible for its care and management. Egostrengthening suggestions (Hartland, 1971; Frederick & McNeal, 1999; Gorman, 1974;Hammond, 1990) were also provided at each visit. They were aimed at enhancing thechild’s self-confidence, autonomy and empowering the child with suggestions that hewas in control of his life. After 7 visits, the hair pulling behaviors stopped. A follow-upvisit 6 months later, after the swimming season and after he again let his hair grow,demonstrated no evidence of relapse.
Hypnosis in the Treatment of Trichotillomania This eleven-year-old girl presented with a well-established case of Trichotillomania. She had been pulling her hair for about a year. The patient was a highacademic achiever who also excelled in several sports. The hair pulling was only evidentduring the course of each athletic season or, said differently, during the period of timethat the patient was participating in a sport. The patient’s father was observed to be anunreasonably demanding man who was over-involved with his daughter. She wasunaware of the hair pulling behaviors and expressed dismay whenever a clump of hair“appeared” in her hand. The father accepted the premise that he was possibly addingtoo much pressure to his daughter with regards to her performance in sports and agreedto limit his comments about this subject. She was treated with direct hypnotic suggestionwith an emphasis on making her aware of impending efforts to bring her hand towardsher head. It was suggested, under hypnosis, that it was entirely her choice to pull herhair or stop. It was also suggested, under hypnosis, that there was going to be lessstress associated with her performance in sports and that they would become moreenjoyable. After six visits the hair pulling stopped. Ego strengthening suggestions(Hartland, 1971; Frederick, & McNeal, 1999; Gorman, 1974; Hammond, 1990) were alsoprovided at each visit. They were aimed at enhancing the child’s self-confidence,autonomy and empowering the child with suggestions that she was in control of herlife. Follow-up one month, two months, and six months later demonstrated no evidenceof relapse.
Discussion
The successful use of direct hypnotic suggestion, with an exclusive emphasis on sensitizing and enhancing immediate awareness of impending hair pulling behaviors,was employed in three cases of pure pediatric Trichotillomania. Additional therapeuticcomponents included successfully persuading the parents to relinquish their authorityover matters concerning their children’s hair, and conveying to each child patientimportant messages about his/her boundaries and rights. These elements of the treatmentprovided the therapist with a milieu in which he could confidently make the hypnoticsuggestion that the patient had the choice to pull his/her hair or not pull it.
The technique of direct suggestion under hypnosis has been effectively used with children (Olness and Gardner, 1988), but, as these authors aptly point out, it has tobe accompanied by attention to and resolution of the underlying dynamics of thebehaviors in question. The core dynamic in each of these cases was hypothesized to berebelliousness and a protest against overbearing parents. The resolution of this dynamicwas achieved by negotiating for the patients the acquisition of control and autonomyover their hair. Additionally, these patients were products of highly demanding andcompetitive households, and it was hypothesized that internalization of demands andcompetitive attitudes could be contributory to the overall significant stress and pressurewith which the patients were struggling (and which probably contributed to symptomproduction). To help reduce these internal pressures, hypnotic suggestions thatredefined competitive sports into activities that could also be engaged in for simplepleasure and enjoyment were given. Ego strengthening suggestions (Hartland, 1971;Frederick & McNeal, 1999; Gorman, 1974; Hammond, 1990) were also provided at eachvisit.
At no point were direct hypnotic suggestions made that indicated to the patients that they should stop pulling their hair. Instead, direct suggestions underhypnosis indicated that as they became cognizant, ahead of time, of hair pullingbehaviors, they were becoming increasingly “in control” of their lives. This controlcould be experienced as a freedom to decide and then carry out either choice: to pull ornot to pull.
It is believed that the significant therapeutic alliance that was achieved with these children came as a result of a non-adversarial treatment posture adopted by theauthor. This posture communicated an unconditional positive regard to the childrenthat was devoid of the parents’ condition that they had to stop pulling their hair.
Unconditional positive regard is a relationship variable that has been posited as anecessary condition for positive change to occur in psychotherapeutic relationships(Rogers, 1951, 1957, 1961). To the degree that the children were regarded unconditionally,and to the degree that the treatment became non-adversarial, the children, in turn,accepted the hypnotic suggestions free of obligations and/or expectations. This allowedfor the success of the treatment to be attributed to the children’s renewed sense ofempowerment and self-efficacy (Bandura, 1977). The success of the treatment and thechanges effectuated in the lives of the children embraced more than the management ofTrichotillomania. The therapy allowed the children to literally achieve identity andpsychosexual advances and growth (Erikson, 1968) that resulted in ego-strengtheningand increased sense of autonomy and personal worth.
It is hypothesized that the crucial psychodynamic issues addressed by the family interventions and hypnotically facilitated psychotherapy of these children were: = Allowing the children to experience a new, healing model of unconditional acceptance, cooperation, and respect in the therapeuticalliance.
= Allowing the children to experience new, healing models of unconditional acceptance, cooperation, and respect in the changedbehavior of their parents.
= Strengthening boundary formation in both children and parents.
= Facilitating the normal developmental emergence of autonomy (Erickson, 1968) and self-efficacy (Bandura, 1977) and consequently“strengthening the egos” of the children (Frederick & McNeal, 1999;Hartland, 1971).
As Hartland (1971) reminded us, it is when patients’ egos are strengthened that they are able to relinquish their symptoms.
As distinguished from Barabasz’s (1987) adult patients, the patients described herein entered trance easily. The relatively easy hypnotizability of these children washypothesized to be a result of innate predisposition for trance states in the young. Thispoint is eloquently elaborated by Gardner and Olness (1988). These authors furtherasserted the need to select an age appropriate induction technique when working withchildren. The eye fixation technique employed for induction of hypnosis in the threecases presented in this study was selected based on the guidelines offered in Gardnerand Olness (1988).
Possible contraindications to this approach would be its use in children with Trichotillomania that is not pure, but rather is complicated by Obsessive Compulsive Hypnosis in the Treatment of Trichotillomania Disorder (OCD) that could cloud the ability of the child to actually make a choice; thepresence of the symptoms of hypomania, mania, or psychosis; or other seriouslycompromising co-morbidities that could compromise the childrens’ decision-makingabilities.
There are always limitations inherent in case studies. Generalizability is not possible because of small sample size, and issues of validity and reliability are a majorsource of statistical weakness. However, the case studies described suggest that thereis merit in considering further investigation of the efficacy of the treatment approachused with these patients.
References
American Psychiatric Association (1994). Diagnostic and Statistical; Manual, Fourth Edition. Washington, D. C.: American Psychiatric Press.
Bandura, A. (1977). Self efficacy: Toward a unifying theory of behavior change.
Psychological Review. 84, 191-215. Barabasz, M. (1987). Trichotillomania: A new treatment. International Journal of Clinical and Experimental Hypnosis, 3, 146-154.
Christenson, G.A., MacKenzie, T.B., Mitchell, J.E., & Callies, A.L. (1991). A placebo- controlled, double-blind crossover study of Fluoxetine in Trichotillomania.
American Journal of Psychiatry, 148, 1566-1571.
Crasilneck, H. & Hall, J. (1985). Clinical hypnosis: Principles and applications. Erikson, E. (1968). Identity youth and crisis. New York: Norton.
Frederick, C., & McNeal, S. (1999). Inner strength: Contemporary psychotherapy and hypnosis for ego strengthening. Mahwah, NJ: Lawrence Erlbaum andAssociates.
Galski, T.J. (1981). The adjunctive use of hypnosis in the treatment of Trichotillomania: A case report. American Journal of Clinical Hypnosis, 23, 198-201.
Gorman, B.J. (1974). An abstract technique for ego-strengthening. American Journal of Clinical Hypnosis, 16, 209-212. Hammond, C. (1990) Ego-strengthening: Enhancing esteem, self-efficacy and confidence.
Chapter in: C. Hammond (Ed.) Handbook of hypnotic suggestions andmetaphors. (pp. 109-151). New York: W.W. Norton.
Hilgard, J.R. (1974). Imaginative involvement: Some characteristics of the highly hypnotizable and the non-hypnotizable. International Journal of Clinicaland Experimental Hypnosis, 22, 281-286. Hartland, J. (1971). Further observations on the use of “ego-strengthening” techniques.
American Journal of Clinical Hypnosis, 14, 1-8.
Hynes, J. V. (1982). Hypnotic treatment of five adult cases of Trichotillomania. Australian Journal of Clinical and Experimental Hypnosis, 10,109-116.
Khouzam, H.R., Battista, M. A., & Byers, P.E. (2002). An overview of Trichotillomania and its response to treatment with quetiapine. Psychiatry 3, 261-270.
Kohen, D.P. (1996). Hypnotherapeutic management of pediatric and adolescent Trichotillomania. Journal of Developmental and Behavioral Pediatrics, 17,328-334.
Mannino, F. U., & Delgado, R.A. (1969). Trichotillomania in children: A review. American Journal of Psychiatry, 126, 505-511.
Masserman, J. (1955). Dynamic psychiatry. Philadelphia: W.B. Saunders.
Maxmen, S.J., & Ward, G.N. (1995). Essential psychopathology and its treatment. (2nd edition). New York: W.W. Norton and Company.
McElroy, S.L., Phillips, K.A., & Keck, P.E. Jr. (1994). Obsessive-compulsive spectrum disorder. Journal of Clinical Psychiatry, 55 (Suppl 33-51), 52-53.
Olness, K., & Gardner, G. (1988) Hypnosis and hypnotherapy with children. (2nd edition) (pp. 148-150). New York: Grune & Stratton.
Pryor, T.L., Martin, R.L., & Roach, N. (1995). Obsessive-compulsive disorder, Trichotillomania, and anorexia nervosa: a case report. International Journalof Eating Disorders, 18, 375-379.
Rapoport, J.L. (1990). The “obsessive-compulsive spectrum”: A useful concept.
Ristvedt, S.L., & Christenson, G.A. (1996) The use of pharmacologic pain sensitization in the treatment of repetitive hair pulling. Behavior Research Therapy 8, 647-648.
Rogers, C.R. (1951). Client-centered therapy. Boston: Houghton Mifflin.
Rogers, C.R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103. Rogers, C.R. (1961). On becoming a person. Boston: Houghton Mifflin.
Rowen, R. (1981). Hypnotic age-regression in the treatment of a self-destructive habit: Trichotillomania. American Journal of Clinical Hypnosis, 23, 195-197.
Schacter, M. (1961). Trichotillomania in children. Praxis der Kinderpsychologie und Kinderpsychiatrie (Practice of Child Psychology and Child Psychiatry), 10,120-124.
Stabler, B., & Warren, A.B. (1974). Behavioral contracting in treating Trichotillomania: Case note. Psychological Reports, 34, 401-402.
Stein, D.J. (2000). Neurobiology of the obsessive-compulsive spectrum disorders.
Biological Psychiatry 47, 296-304.
Tukel, R., Keser V., Karali, N.T., Olgun T.O., & Calikusu C. (2001) Comparison of clinical characteristics in Trichotillomania and obsessive-compulsive disorder. Journalof Anxiety Disorders 5, 433-441.
Watson, T.S., & Allen, K.D. (1993). Elimination of thumb sucking as a treatment for severe Trichotillomania. Journal of the Academy of Child and AdolescentPsychiatry, 32, 830-834.
Wester, W. C., & O’Grady, D. J. (1981). Clinical hypnosis with children. (pp 91-95).
Zalsman, G., Hermesh, H., & Sever, D. Hypnotherapy in adolescents with Trichotillomania: Three cases. (2001). American Journal of Clinical Hypnosis, 44, 63-68.
Zeig, J. (Ed.) (1980). A teaching seminar with Milton Erickson, M.D. New York:

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