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An Interview with the Scientific Advisory Board

November 2008, Jennifer Raikes conducted an online interview with members of TLC's Scientific Advisory Board about the latest in research and treatment. Answering Jennifer's questions were researchers Joseph Garner, Ph.D., and Dan Stein, M.D., Ph.D., and clinicians Ruth Golomb, M.Ed., L.C.P.C., Suzanne Mouton-Odum, Ph.D., and Fred Penzel, Ph.D.

What do you think are the key ingredients to successful treatment for hair pulling or skin picking?

Ruth Golomb:

I think that the three R's are important: readiness, rapport, and resourcefulness. The person (client) truly has to be READY to commit to treatment and be able to tolerate the bumpy road to feeling better. It's a process, not a single answer. The RAPPORT with the clinician is very important. The person may be the most knowledgeable person in the field, but if there is no connection, it's hard to make a lot of progress (you need to feel comfortable, trust the person you are working with, and be able to talk about things that are not always easy to articulate). Finally, the clinician (who, ideally, would be trained to treat BFRBs) and client together must be RESOURCEFUL. It is important to be creative, think outside of the box, and look for helpful ideas in unique places. Keep up with the recent available information.

Suzanne Mouton-Odum:

First and foremost, a good therapist will complete a thorough analysis of an individual's hair pulling or skin picking behavior. For effective treatment to take place, one must understand where, when, how, why, and under what specific circumstances a behavior may occur. Although the behavior may seem similar across sufferers, each person has a unique pulling/picking "habit," therefore the treatment must be tailored specifically to that person.

In addition to completing a comprehensive behavioral analysis, a trained therapist will assess an individual's progress in the change process. Specifically, a person must possess a level of readiness to change for treatment to be successful. Different from motivation (a desire to change), readiness is a willingness to alter one's habits (which sometimes involves doing things that are inconvenient) in order to result in change. Sometimes altering one's habits (i.e., wearing Band Aids or hats, using Koosh balls or dimming the lights in the bathroom) requires energy, focus, determination, and sacrifice. Entering treatment with the knowledge and acceptance that it will require more than just "wanting to change" can assist you in being not only motivated, but ready for change.

Fred Penzel:

Body-focused repetitive behaviors are complex problems with many inputs, and I believe that for treatment to be successful it must be extremely comprehensive, taking into account all the various inputs and triggers. This would include environmental, biological, cognitive, behavioral, sensory, and affective factors. As a result, it must also be tailored to the specific inputs and circumstances of each individual sufferer. This treatment ought to be done within a cognitive/behavioral framework, including help from the medical/biological side if needed, as I believe BFRBs are biological and genetic in nature. Obviously, for success to occur, the treating clinician must also be well trained in all aspects of the above. In the case of treating children, I think that educating family members and getting their close cooperation is also essential. There may be as many things for them to learn not to do, as to do. Finally, I believe that sufferers need to accept that these are stubborn problems, that success may not be instantaneous, and that they need to be very persistent and hardworking if they are going to succeed.

What do you think are the most promising new areas in treatment?

Ruth Golomb:

There are a number of interesting areas in treatment these days. One interesting area is looking at sensory integration. The sensory needs of individuals with hair pulling and skin picking are important to address. Also, there is very interesting mindfulness work being done with hair pulling and skin picking. These important aspects, added to what we already know and find useful, are enhancing treatment.

Fred Penzel:

I think that the use of the Comprehensive Behavioral Model (ComB model), as originated by Dr. Charles Mansueto, holds much promise for success in therapy and gives therapists a real framework for successfully approaching what has, in the past, appeared to be a confusing group of problems. In addition, I think that the use of off-the-shelf compounds, such as the B-vitamin Inositol and the amino acid N-acetyl cysteine, hold promise for helping a good percentage of sufferers, and I look forward to their being scientifically investigated further. Perhaps there are other helpful remedies sitting on shelves out there still waiting to be discovered.

How would you describe the current state of research in the field of trichotillomania and body-focused repetitive behaviors?

Joe Garner:

Very exciting. TLC is one of the most important new developments. TLC has raised public and governmental awareness, which helps raise money needed for serious research. TLC has brought together a 'critical mass' of researchers, and fostered new collaborative and interdisciplinary research. TLC has worked hard to engage patients in research, and TLC members have been incredibly generous in participating in research studies. All of this means that the published research on trichotillomania has increased exponentially in recent years.

Dan Stein:

Relative to other areas in medicine and psychiatry, things are at an early stage. At the same time, there have been some important advances in recent years, including brain imaging studies, genetics research, and some rigorous clinical trials.

What is on the horizon?

Dan Stein:

With advances in brain imaging and genetics, we can expect that these technologies will be used more. New ideas for treatment are still coming up - some from basic laboratory research, others from clinical experience - and hopefully they will reach the clinical trial stage.

Joe Garner:

In terms of animal research, there is now a mouse model of trichotillomania, and a mouse model of skin picking is on the horizon. At least 8 genes in mice have been identified which affect these behaviors. The mouse models promise to help us understand why trichotillomania and skin picking are female biased, and what role reproductive physiology may play in these disorders. Recent work shows that dietary changes can trigger these behaviors in mice, making the prospect of preventative dietary interventions a possibility.

What would you like to see studied that isn't being studied yet?

Dan Stein:

It's hard to predict what work will have the biggest bang for the buck. I'd like to see a broad array of approaches, both laboratory-based and more clinical, being funded.

Joe Garner:

Many of us are working to identify effective treatments for existing patients, but my goal is to be able to prevent BFRBs in the first place. I hope for a future where we can identify at-risk children, and provide simple interventions that drastically reduce the risk of trichotillomania, skin picking, or any of the BFRBs. This isn't a complete pipe dream - we already do this very effectively for simpler physiological disorders like phenylketoneuria. Because BFRBs are so much more complex, I doubt we'd be able to completely prevent them, but if we could prevent even a small percentage, this would be a huge victory.

I'd like us to use the mouse models to attack issues that are very difficult to study in humans, but which are critical to getting us closer to this goal. For instance, we could identify the environmental factors which trigger trichotillomania (like diet, or stress, for instance), and test whether we can prevent the onset of trichotillomania by controlling these factors. Perhaps most importantly, we could identify the changes that occur in the brain during the onset of trichotillomania, and use this knowledge to design new treatments. At the same time we can help existing patients by quickly testing experimental therapies in mice (like inositol) to identify which ones might work best in humans.

What gives you hope for the future in this field?

Fred Penzel:

Several things. One is that we are seeing more children than adults being brought in for treatment, indicating that there is a growing awareness that BFRBs are real problems, and that they are being correctly recognized at earlier ages. Actually, we are seeing more people going for treatment in general. This would indicate that more people are becoming aware that there is effective help out there. Another thing that makes me hopeful is the ever-increasing body of research in the field of BFRBs, in the areas of treatment, demographics, neurobiology, and genetics. This can only lead to newer and more effective treatment and understanding. Finally, seeing more, younger therapists and physicians getting involved in the field also gives me hope for a better future. It means that more clinicians are starting to see this as a field where they can make a difference in people's lives, and this can only lead to treatment being more available in more locations nationally and internationally.

Ruth Golomb:

Clinicians are becoming more and more interested in learning about treating hair pulling and skin picking. We have been training interested professionals for about five years and found these clinicians to be wonderful individuals who are tremendously committed to the field. They are all an extremely welcome addition to our professional resources across the country. Today there are more than 100 trained professionals who are able to treat hair pulling and skin picking! This gives me great hope for the future. We are also currently making plans to expand our training.

Dan Stein:

We have had major advances in methods of psychiatric and psychological research (e.g., neuroimaging, genetics, trials methods), and these haven't yet been fully applied to this field. So there is huge scope for moving forward.

Joe Garner:

The researchers working on trichotillomania are some of the most generous and dedicated colleagues one could ask for. With so much progress being made in basic descriptive research (like the TIP projects), in brain biology (like the recent imaging studies), in human genetics, in intervention research, and in mouse models, and with so much cross-fertilization between these fields, it's only a matter of time before we make some major breakthroughs.

Related Information

• Information about Treatment »
• More about TLC's Professional Training Institute »
• Learn about TLC's recently funded research studies »

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