J. Behov. Ther. & Exp. Psychior. Vol. II. pp. 127-130.

k:Pergamon Press Ltd., 1980. Printed in Great Britain.

ooO5-7916/80/0604127 $02 W/O
THE USE OF OPERANT SELF-CONTROL PROCEDURES IN THE
TREATMENT OF COMPULSIVE HAIR-PULLING
CHRISTINE J. CORDLE and CLIVE G. LONG
Leicester General Hospital and Walsgrave Hospital, Coventry, England
Summary-Two young female patients with a lo- and 5-year history of compulsive hair pulling
were individually treated by the same operant self-control procedure. Zero pulling was
achieved at weeks 6 and 13, and maintained at follow-up 15 months later. These findings are
discussed in the light of previous behavioural treatments, and the importance of eliciting an
appropriate aversive consequence for habit control is stressed.
The incidence of trichotillomania is extremely
difficult to ascertain, partly because reported
cases are divided between the dermatological and
psychotherapeutic literature; and partly because
many authors have made unverified estimates
on the frequency of the symptoms ranging from
rare (Philippopoulos, 1961) to commonly seen
(Monroe and Abse, 1963).
Although fiddling with hair may be considered
a normal activity among social primates (Horne,
1977), no normative data exists on the incidence
of hair pulling among the non-institutionalized
adult population. What is clear, however, is that
the phenomenon of hair pulling, of a severity
requiring treatment, is uncommon. For this
reason, perhaps, there has never been a con-
trolled trial of any form of therapy for
trichotillomania.
The benefits of psychoanalytically based
psychotherapy have been generally extolled, yet
most of these studies remark on the malignant
and chronic nature of trichotillomania with
frequent exacerbations and remissions (Green-
berg and Sarner, 1965). Generally psychoanalytic
procedures have met with little success, and in
some cases the process involving introspection
may accelerate the rate of self-destructive
symptoms.
Studies using behavioural intervention are
mostly case histories, but in terms of quantitative
data and attempts at specifying the relationship
between symptom change and treatment the
behaviour literature is undoubtedly superior.
Taylor (1963) eliminated the habit by interrupt-
ing the behavioural sequence through the
practice of an antagonistic response. Bayer
(1972) employed a technique of self-monitoring
and a mild form of aversive control (saving hairs
pulled) to treat a case of two years duration.
Unfortunately no follow-up data were presented.
Over the period 1974-1978 at least five
English language reports on the behavioural
treatment of trichotillomania in adults have
appeared with encouraging results. Techniques
used have included contingency contracting
(Stabler and Warren, 1974), positive coverants
and response cost (McLaughlin and Nay, 1975),
covert sensitization (Levine, 1976), suggestive
hypnosis (Horne, 1977), aversive conditioning
(Horne, 1977), and cognitive desensitization
(Bornstein and Rychtarik, 1978).
The six patients treated were mostly young
females with an age range of 14 to 42 years
and with a 2 to 35 year history of hair pulling.
In three cases the extent of the habit had resulted
in the wearing of a wig or headscarf and the
baseline rate of hair pulling ranged from 22.6
Requests for reprints should be sent to Miss C. J. Cordle, Senior Psychologist, Psychology Department, Leicester
General Has+* -h Road, Leicester LES 4PW, England.
127
128
CHRISTINE J. CORDLE and CLIVE G. LONG
to 220 hairs per week. Except in the cases cited
by Horne (1977), where concurrent therapy for
sexual and family problems makes evaluation
difficult, treatment has usually been brief and
effective with no remission at up to six months
follow-up.
Unfortunately, the nature of many of these
studies precludes the possibility of isolating
active agents of therapeutic change, and con-
clusions are based on anecdotal reports by the
patients themselves. Most treatment procedures
include positive and negative reinforcement,
anxiety reduction and feedback.
While self-monitoring and hair collection
may account for initial decline in target be-
haviour, long term maintenance has been attri-
buted to the use of a cognitive desensitization
procedure (Bornstein and Rychtarik, 1978);
while Horne (1977) suggests that more effective
treatment techniques may be developed by
investigating the relationship between anxiety
and habit strength. In Levines (1976) rapid
treatment, an anxiety management technique
(relaxation) was only incidentally used as a
part of covert sensitization (imagined self-
mutilation and nausea following hair pulling).
Use of covert sensititation in altering symbolic
representations of undesired performance, how-
ever, may require determination of the natural-
istic occurrence and functional role of such
representations (Mahoney, 1974). Application
of operant self-conlrol proccdurcs lo the prob-
lems of obesity, for example, found that verbal
descriptions of aversive comcquences their
subject5 had actually experienced (social rejection,
sarcastic treatment, demeaning infcrenccs) were
more potent variables in treatment than statis-
tically probable consequences such as diabetes
(Fcrstcr, Nurnbcrgcr and Levitt, 1962).
Following the analysis of Fcrstcr e/ (I/. (1962)
an individual will manipula(c the factor\ which
dctcrminc the frequency and amount of an
undesired behaviour if this control is reinforcing
to him-if it cnablcs him to ejcapc from the
ultimate avcrsivc con\equcnces (U.A.C..). In
scvcrc cases of tricllotillornania, whcrc basc-
lint rates of hair-pulling are very high and where
the aversive results of the habit are covered by a
wig or headscarf, it would seem that the
pa!ient is protected from the social con-
sequences of the habit (e.g. embarrassment,
anxiety) as well as from social reinforcement
for habit reduction. It seems likely that penetra-
tion of this disguise is for many extremely
aversive and it is surprising that no treatment
procedure has dealt with manipulation of this
variable.
In accordance with these considerations, the
present study reports the results of two cases ot
severe trichotillomania treated (one by each
author) within an operant self-control regime.
METHOD
Subj ects
Client A was a 25year-old married woman who described
a IO-year history of hair pulling which she had never been
able completely to inhibit. She reported that she had
started pulling her hair out when she was bullied at school.
Eyelash pulling occurred for a short period but spon-
taneously remitted. The usual pattern was for the hair to be
played with, pulled out, examined for root removal,
chewed, and finally discarded. Hair was pulled from the
top of her head and above the right and left ear. In all 3
areas the hair was thin and patchy. Diary recordings
revealed that hair was usually pulled in the evenings, last
thing at night and first thing in the morning. The habit
occurred most typically when she was alone and the fre-
quency increased when she was angry, depressed or worried.
Over the years she disguised her problem with a variety of
hair styles, a scarf and eventually for the last 3 years a wig.
Embarrassment and shame led to constant worry that her
problem, which she hid from everyone except her husband
and mother, would be discovered. The client reported that
her husband was very supportive and willing to help her in
any way possible.
Client B was an attractive 19-year-old girl with a 5.year
history of trichotillomania which started soon after the
death of her mother. Prior to this she had been in the habit
of fiddling with her hair a great deal. The hair pulling had
persisted with only a 2-week period of abstinence which
followed a hurtful comment made about her hair. Hairs
were singly pulled from the top of her scalp, back of her
head and above both ears, where the hair was very patchy.
She would chew the hair before discarding it. The habit was
most likely to occur when working at her desk or at home
when she was reading or watching T.V. The frequency
increased when she was anxious. Her state of mind when
she performed the hair pulling seemed to vary from absent-
mindedness when she would suddenly discover that she had
been pulling her hair without thinking about it, to a state
in which she felt the urge to pull her hair and did so in
spite of some sense of resistance. She was self-conscious
and embarrassed by her problem and had attempted to
THE TREATMENT OF COMPULSIVE HAIR-PULLING 129
disguise it with various hairstyles and a headscarf. Nail
biting apart she showed no other neurotic features.
Procedure
Baseline. After the initial assessment interview each
client was asked to record daily the number of hairs pulled
out over a 2-week period.
Treafmenl. The clients were then seen once a week for
% hourly treatment sessions. Client A was treated by one
of the authors and Client B by the other, using the same
treatment techniques:
(I) Feedback to increase awareness of behaviour including
self-monitoring by weekly collection of hairs in an envelope
(following Bayer, 1972) and visual display of progress via a
graph in the therapists office.
(2) Self-targeting: Client and therapist agreed on the
maximum number of hairs to be pulled each week. This was
to decrease each time the target was achieved.
(3) Stimulus control: The use of incompatible responses
when the urge to pull hair occurred (a prepotent repertoire
including knitting, isometric and relaxation exercises) and,
in the case of Client A, removal to a predetermined safe
environment, e.g. the room in which her husband was
working.
(4) Escalating response cost: (a) After each occasion
of hair-pulling the client was instructed to examine a
photograph of herself which showed very clearly the results
of her trichotillomania. (b) Use of the U.A.C. should the
client pull more than the self-targeted number of hairs per
week. In both cases this was found to be removal of their
respective disguises and a scalp examination by a young
male member of the hospital staff.
(5) Positive reinforcement consisting of coffee and
general pratre at each session when the stated target was
achieved.
(6) Phasing out of wig and scarf wearing as control was
achieved and hair grew back.
Follow-up
After 4 weeks of zero hair pulling, each client was
followed up every month for 6 months and at 3-monthly
intervals thereafter for a total of 15 months.
RESULTS
The number of hairs pulled decreased dramatic-
ally in the case of Client A from a baseline mean
of 515/week to zero/week after 5 treatment
sessions. In the case of Client B the number of
hairs pulled decreased more gradually from a
baseline mean of 692/week to zero/week over a
period of 13 weeks (see Table 1). Phasing out
the wig and headscarf in the case of Client A
was gradually achieved over a period of 12
months. Initially, 5 months after zero hair
pulling, she was able to discard the wig at
Table I. Number of hairs pulled out
Week Client A Client B
Baseline mean 515 692
I 17 531
2 16 487
3 10 455
4 7 420
5 1 22
6 0 I90
7 0 86
8 0 58
9 0 52
IO 0 50
II 0 39
12 0 35
13 0 0
16 0 0
home, substituting it for a headscarf. After a
further 2 months she was able to go out in the
evenings and then at weekends with only a
headscarf and after another month she paid her
first visit for 11 years to the hairdressers. By
this time, there had been substantial hair-growth
at the back and sides of her head but the hair on
the top of her scalp remained very thin and
patchy. After 12 months she was able to go to
work without a wig or headscarf, with her hair
styled to cover the bald patches. Since then the
wig has been completely discarded and she
and her husband reported strong negative
feelings towards it.
Client Bs disguise was less total than Client A
and the phasing out process was therefore
quicker. Three months after zero hair pulling,
she only used a headscarf on very windy days
and after a further three months she no longer
used any form of disguise.
At 15 months follow-up there had been no
relapse with either client.
DISCUSSION
The present study provides support for the
use of operant self-control procedures in the
treatment of two severe cases of trichotillo-
mania. The length of follow-up, which greatly
exceeded that of previous studies, was sufficient
to monitor phasing out of habit disguise, which
was particularly difficult for Client A. As a
130 CHRISTINE J. CORDLE and CLIVE G. LONG
result of treatment, both clients were able to
engage in activities previously restricted, such
as swimming and various other outdoor pursuits.
They both reported an increase in self-confidence
and assertiveness, and Client B initiated her first
serious relationship. Her embarrassment con-
cerning her hair had previously led her to
avoid such contact. The differential rate of
reduction in hair pulling between the 2 clients
was thought to reflect the greater support Client
A received from her husband. Further, the
U.C.A (wig removal) was possibly a greater
deterrent than that for Client B whose disguise
was less total.
Observation and the clients own report
showed a number of factors to be of importance
in treatment success. The cases support Hornes
(1977) hypothesis that where a strong habitual
component exists, strong forms of feedback
(hair collection and photograph examination)
are required. As in previous studies (McLaughlin
and Nay, 1975; Levine, 1976) both patients
commented on increased feelings of self-control
made possible by self-targeting; using a margin
of error of I or 2 hairs per week clients felt
safe and more capable of maintaining zero
pulling. Habit-related anxiety was minimal in
both cases. The most important treatment
component identified by the clients was threat
she clearly found the process extremely stressful,
she felt it was the critical factor in continued
abstinence. In the case of Client A, the threat
alone of the U.A.C. was a sufficient deterrent.
This study suggest that a self-control pro-
cedure combining feedback with appropriate
negative reinforcement can be a potent and
lasting form of intervention for trichotillomania.
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237-244.
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of
1.