 Good evening everybody and welcome to tonight's MHPM webinar on Psychological Treatments for Trichotillomania. We have about 400 people logged in from all over Australia. Welcome everybody and also there'll be a number of people who will watch this later on the podcast as well. Our conference support people read back will post numbers into the general chat tab. Actually I think that's for me so every now and again I'm going to give you an update on how many people are in the webinar but so far it's around 400. Welcome to you all and I'd like to acknowledge the traditional custodians of the land, seas and waterways across Australia upon which our webinar presenters and participants are located. We wish to pay our respect to the elder's past, present and future for the memories, the traditions, the cultures and hopes of Aboriginal and Torres Strait Islander Australia. My name is Mary Emily and I am a GP by background and a psychotherapist and now I'm a second year psychiatry trainee based in Cairns. I've been in North Queensland for 20 years so my pretty much my whole working career and I have had the privilege of facilitating quite a number of MHPM webinars and really enjoy meeting interesting panelists and also it's very interesting to see the discussions between the participants as well and I know that you teach each other a lot during the sessions as well. The purpose of the webinar is to give health professionals the skills they need so that they can help people more effectively in the future. Personal stories of illness are very important and the MHPN does often include consumers and carers on our panels. The chat box however is not a forum for personal stories it is designed to complement the panel discussion by allowing professionals to share resources and their experiences of practice. Thank you for respecting that and remember that if any of the content in tonight's webinar does cause you personal distress please seek care if you require it, be on blues on 1300 224 636 or you can contact your GP or local mental health service. Now the panelists bios were disseminated beforehand and hopefully you'll have a chance to read them but I'd like to just introduce each person briefly so in no particular order. Johanna welcome. Now you are a GP yourself you do have a particular interest in complex trauma and I know that you're doing a THD at the moment. I just wondered if you put in about two sentences or less just give us a little idea about your PhD topic. Yes I'm in my third year of researching primary care approaches to distress using a framework of sense of safety and it's been a process of inquiring of stakeholders and international academics to form a new way for GPs to think about the whole person including their their life story their life story and their experiences. So I'll be showing a little bit of that in our time talking today. Now Scott you are I believe in Melbourne and you're a psychiatrist. I was just wondering if you'd like to just tell us a little bit about what Melbourne's like today and also about your practice. Melbourne's very hot today we're expecting I think 40 degrees again tomorrow so it'll be a good day to stay inside and not be doing too much out. I'm a psychiatrist I've been practicing for a while but I've I've always had my main interest in anxiety disorders excessive compulsive disorder and tracheotillomania sort of in relation to that so and I do I treat people with both pills and with CBT stuff so um there's yeah look there's a huge demand for combination treatments and uh and so I'm not under basically. Well it's fantastic for us to have you on our panel tonight with your expertise thank you so much for joining us. Thank you. And Imogen you're a clinical psychology registrar I understand you're just about to get your letters um and I and you have done a PhD specifically around trichotillomania is that right? Yeah that's right so I did my PhD in clinical psychology at Swinburne um finished that off mid 2016 and I focused on trichotillomania specifically in that research so um trying to understand if there are particular thoughts or thinking styles that contribute to hair pulling episodes in these people so yeah I've got a soft spot for learning about trichotillomania and I really enjoy working with people who have trick and related problems. Thank you and I must admit I hadn't heard just the abbreviation trick until we had our panel preparation so we're already learning something. Thank you very much Imogen and welcome. Just a few housekeeping things remembering that this is similar to a live audience it is a live audience so anything that you type into the chat box um to our participants don't say things that you wouldn't say in a public setting so um and also please try and keep your comments on the topic and remember that if you post you a technical if you have a technical issue pop it into the technical support FAQ tab and then there's a technical support um you can phone the hotline if you don't find your answer there but don't type your technical questions into the general chat because I may not see it and if there is a significant technical issue that affects everybody you will be alerted via an announcement and um you'll be advised what to do so that very rarely happens a couple of times it has and we've been able to sort things out and get it going and if you're watching it later on you probably won't even notice things like that um so you also had a chance to read the case study beforehand and through our exploration of the case study and our topic we're going to hopefully by the end of it be able to describe the common symptoms and causes of trichotillomania identify suitable medications and psychological therapies to reduce symptoms of trichotillomania and identify best practice for referrals and psychological care for people living with trichotillomania and this is in the context of our multidisciplinary team discussion just a note there on that slide to point out the supporting resources in the library tab at the bottom right of your screen you'll see a little folder icon down there now I would like first of all so that the way that tonight will be is that each of our presenters is going to respond to Hannah he's the young woman who has presented to her GP in the way that they would think about it from their professional chair just to let you know that there are 550 people logged in now and I would like to now invite Johanna so read back if you could just unmute Joe and she's going to talk to us about her response to Hannah who comes to see her as a patient with this probably tricky problem thank and that wasn't meant to be a pun I just realized welcome Joe thank you so I'm speaking as a GP um focusing on the patient and less on her behavior and the long name we have for that behavior um as a Scotland image and who have more specific knowledge will address those areas my talk was focused mostly on the task of holding the whole attending to the relationships that Hannah has with herself with other people and with her world and attending to the breadth as well as depth of information that might be relevant when I was preparing this I thought you know there's sort of four main tasks and one slide I'm going to present of my hopes for Hannah my tasks are what broad areas of knowledge do I need in order to make a diagnosis what parts of the story am I currently missing what processes are being enacted as part of this consultation and what kind of responses am I having to Hannah and the way this story is being told so I thought the holding the whole in mind um you know what do I need in order to make a diagnosis the word die I mean thorough or complete and no this is knowledge and so those that word is really important for the generalists are holding that whole and so I put there the areas of the whole that are important for the generalist to consider and I thought I'd focus a little bit in Hannah's case on relationships all of those areas affect health and well-being and her relationships I'm really interested in the availability of people in her life their attunement to her is there anybody in her life that can help her calm herself down their responsiveness over her lifetime how has she been responded to is there anyone who really got her and knows how to calm her who can she trust and you know can she tell her friends about her worries or disclose her deepest distress to anyone and then boundaries is there anyone who invades her space emotionally or physically or distances from her and then the other sort of focus on is her sense of self I'm really interested in what her attitude towards herself is when she makes a mistake does she have compassionate relationship with herself can she tolerate strong emotions and calm herself down and what sort of things improve her sense of self and I see in there that sometimes I'd go across to some of the questioning that we use from the positive psychology thinking about perma the positive relationships and engagement emotions and meaning and and accomplishment that she might have in her life for looking for her strengths as well and then she may have spiritual distress any or have some sense of purpose and meaning those things sometimes help us to focus on what really matters to her other second question I ask is what parts of her story am I currently missing and in her case I really noticed that you know I'm not really sure what's going on in her family I'm not really sure where dad is or what happened in her relationship with her boyfriend I'm not sure what's going on in her mind or her heart just before she feels like pulling her hair what sort of trigger thoughts that she might be having and I'm not really sure what she feels towards herself what she loves doing what she's good at what what her how connected she feels to herself so those are areas I think I'm missing in the story so far and then if I look at the process of what processes are going on in this story I see that Hannah's ambivalence her mom's the one bringing her for help she seems reluctant to visit the GP and reluctant to do what suggested and she seems a little disconnected from people in the story I noticed she's not paying much attention to herself she's minimizing consequences and really not engaged in her own self-care and she's using behavior to manage her stress and I noticed the patches of knowledge that are missing what key elements of the history that are missing and her the incoherence of her story of is something that has bothered me so if I look at my responses to this situation I see that I'm struck by the incoherence of her self-harming behavior when what talked about is that loss of relationship with her boyfriend as being no apparent reason it just doesn't make sense to me so my responses are not convinced something's missing I'm noticing this absence of connection with her self with her body with others with a GP and I'm getting a sense of helplessness as her symptoms worsen I feel that in her mother and in Hannah and then I'm struck by the passive role she's playing in her own healing and the active role she's playing in her hair pulling and I'm wondering if we could engage that active energy to help her rather than hinder her so my last slide is my hopes for Hannah I feel I want her to be safe in her own environment increase her connection to past supportive relationships find ways to increase her play and interactive reaction with people help her to use her body to calm herself through mindful grounding awareness of her sensations beauty music creativity all those things to help her to tolerate uncomfortable feelings and understand things that get distorted and her need to sometimes escape inter-repetitive behaviors to numb or dissociate and I'd love for her to increase her self-compassion and the sense of inner unity so she can befriend herself in this story and look after herself and to help her make sense of what happened to her 14 and in her recent relationship to find a sense of purpose and hope and connect her to any resources she may have so that's my hopes for Hannah and I look forward to hearing the rest of the story from the others thanks Joe that's really comprehensive and I I know that particularly the first slide there about the end the idea of gnosis and whole knowing was really helpful and I think it made me think about the kinds of things that as a GP you are actually thinking about all those areas but I've never seen them so well defined so I'll be using that slide as a resource that's my PhD so be careful that's that's bits of my PhD that I'm sharing there so so I would say that a lot of our participants are going to find that really useful too so just once again a reminder about the resource library in the bottom corner there so the slides will be available afterwards um now the other thing is that there's now over 600 people nearly 700 blogs in so in the case of Hannah what happened was she went to her GP and then um she the GP knew that psychological therapy would be helpful and encouraged her to see a psychologist she didn't want to because she felt it hadn't been helpful at 16 but the GP supported her to try it again um and so oh I'm absolutely sorry what we did in this case because um we have such an expert psychologist in this case Hannah is going to go and see the psychiatrist first um because in actual fact having a psychologist as expert as images is uh unusual so in this case Scott knows images through his professional network and interest in trichotillomania so first of all we're going to go and see the psychiatrist and see how he might think about Hannah thanks very much Scott okay thanks Mary um yeah look Joann is focused on a range of the broad psychological issues and I should say before we get on to the the specific stuff about trick is that there's a lot there and I think many people could end up getting treatment for those issues the anxiety and depression issues there um and before doing any work on trichotillomania but anyway we're going to be specific on trick for a little while now uh at least for the next few minutes so these are the characteristics that we see um so some of this is is just basic sort of diagnostic stuff repetitive hair pulling to the point that noticeable loss or functional impairment um a number of people get a get a feeling of tension which they need to relieve um many don't um the it's much more common in females and males um it's got this chronic waxing and waning course which is pretty characteristic of most um OCD anxiety impulse control disorders um starts around 13 or a little earlier in a lot of cases um it probably needs to be noted that there are a lot of um really young kids who develop some hair pulling you know much younger than this where it appears fairly briefly and then tends to disappear so um I have a lot of people who come in and say my kids just started pulling hair um and I say well we need to be aware of that but that isn't necessarily a long-term issue at this stage um the impairment relates to damage to the hair and the skin and also to ingestion a lot of people will play with the hair after they they pull it they'll often eat it as well and that can lead to hair balls and related issues there um the big issue um really though is psychosocial impairment um and like if it wouldn't come a little bit in particular um but as you can imagine it has effects in a whole range of other areas as well so let me go on so this is this is a simple model for understanding it um in essence there are people who do what we call focus pulling where the event is preceded by some sort of private internal event so they get an urge they might get a bodily sensation sometimes a tingle in their hair um but some people have an oiliness in their hair um for some it's just a physical awareness emotions are important autumn is a classic one and stress of course and cognition you know I need to pull I can't cope without pulling um so that's the focus side of things but it's also another group of people and often people do a bit of both so people will um be uh do the focus pulling but they'll also do automatic pulling and this is almost where they're not entirely aware of it and people will say you know I found out I was pulling because I looked on the floor and I noticed that there was a whole pile of hairs on the floor which I don't even fully remember pulling out um so one of the things we're looking at here is those private experiences and that relates a bit to what Johanna said before about trying to understand the the sort of the the process and the thinking that goes through people's heads when they're um when they're pulling or when they're about to pull um now I like the um act enhanced behavior therapy of the tricotillomania um it's a manualised treatment um you can the references are in the in the library at the end if you want to have a look at them they present sort of a nice description both for the therapist and for the patient and there's a it's a workbook approach and you can go through it if you want to and you can go through it as quickly or as slowly as you wish essentially it's a combination of habit reversal training stimulus control and some act ideas for the more focused pulling and um Imogen's going to talk a lot more about the specifics there so we want to teach people to be aware of their pulling and when they do it in what circumstances etc we want to give them self-management strategies to stop that and the act ideas look at things like diffusion and acceptance trying to get people to get better at just handling that feeling and that urge that they feel like they must respond to a certain experiential avoidance is relevant here and that's a real act idea which I think has some a lot of relevance here the next bit I guess is I guess the psychiatry issue and it's quite relevant in this case this woman um has obviously preceding issues with anxiety depression and I think from reading the case or it is already on medications and has received some treatment um in essence most people with trichotillomania have psychiatric comorbidity depression is the probably the most important um OCD is extremely common other anxiety the sort of social anxiety is is always a big issue and I always get people to be aware of the social anxiety it's absolutely relevant for these people it's relates it relates a bit to her and her issues with the wig substance use and eating disorders sometimes but what I've written down the bottom there is probably more important these people have lots of issues with shame guilt discussed and in fact that's really the thing that that causes their depression or is a huge motivating continuing factor in them being depressed and that's really important and so finally medication treatment now most commonly the people I see are already on medications in most cases and I've got to say that the evidence for pills in trichotillomania is actually pretty poor there've been a few randomized controlled trials um the the results are just average at best um this is again controlling for depression obviously when people are depressed you're going to get a better response I think and that may improve things but in essence behavior therapy is the treatment um and if you do it in combination with medications that's fine um but they they if they have significant tricks they must get onto some sort of CBT behavior therapy approach and Imogen's going to discuss this in a bit more detail in a sec um the research says that um some anti-depressant SSRIs and chlamypramine which is an older tricyclic antidepressant can be helpful look a range of other pills have been used and I've listed some down the bottom there none of those would be first choice options or even maybe second or third choices um and they're all you know sort of the evidence for it for all of them is is a bit scanty really so whilst pills are perhaps important it's the specific behavioral stuff that's probably more important and that's all for me thanks very much Scott that's really helpful and I'm one of the things you mentioned was that you sometimes see or not uncommonly can see hair pulling in much much younger children and it was interesting that you said it often goes away so we might come back and talk about that in the um discussion if we have time but I just wanted to acknowledge that because it was one of the questions that quite a few people had put in at registration was about when it occurs in much younger kids so we'll come back for that if we have time thanks very much and um if we go back to thinking about Hannah so she's been to see um Scott and he's recommended that she really does need psychological therapy confirming what the GP recommended um and has referred her off to see Imogen welcome Imogen all right thanks very much it's um yeah lovely place to move on from so essentially from my perspective um I would be starting out again with validating um that this is a really difficult condition to live with there can be a lot of ambivalence around whether you want to work on this um hair pulling problem or um maybe try to avoid it entirely which might be the case for where Hannah might be feeling um and one thing that can sort of help clients to realize that this behavior doesn't sort of come out of nowhere and it's not weird or random is actually conducting a really comprehensive assessment so for us psychologists it's really back to the basic sort of classical and operant conditioning principles this is a common model for how we understand some of the factors that contribute to this hair pulling cycle being quite difficult to break so we've got a basic sort of behavioral model here where there's a conditioned cue maybe um we're really just trying to help Hannah figure out what are these conditioned cues which are constantly sort of eliciting that that trigger to start pulling whether it's maybe she sees or feels a particular hair and that then elicit an urge to pull maybe there's some facilitative or inhibitive factors as well that might contribute to whether she she does go on to pull or maybe stops herself in the moment so these can be things like being um you know alone at home there's no one else around um being quite sort of sedentary um sitting certain postures on the couch so that your hand's already up near your hair um the hair pulling behaviors themselves can be quite reinforcing so things like you know touching the hair with your face um playing with it feeling the texture it can actually be quite nice and enjoyable pulling out hair um a lot of the time is described as um generating quite a lot of pleasure and gratification and actually not too painful so this can be another factor that contributes to white so um ingrained and then we've got these consequences too where it's sort of facilitates a sense of relaxation um facilitating a bit of a sense of being in a trance where you sort of feel a bit dissociated and it's a bit kind of warm and cozy and you're not thinking about everything else that's going on in your life but it can also get to a point too where um because people can sit pulling um in awkward positions with their bodies for several minutes to even um hours maybe sometimes that pain in muscle joints can come in um pain in the fingers that sort of thing and at that moment maybe the hair pulling episode stops or maybe there's an appointment that the person needs to go to and they sort of stop then and there to move on to a different task so during the initial stages um of working with a person with TRIC I like to conduct this really comprehensive functional analysis using a behavioral model to really pinpoint what are the factors that are um kind of leading up to during and after the hair pulling cycle and we can break them down into the sensory cognitive affect or emotional motor or behavioral and place or situational or environmental based factors too so making the acronym SCAMP which is quite nice so as part of doing this I I guess your own sort of functional analysis along with Hannah the next um really important stage of um treatment is to do a lot of self monitoring um and I really try to encourage this from from the get go so you can use your standard sort of self monitoring form and maybe tweak them to sort of capture those elements of the sensory cognitive affect motor and place based factors that might be contributing to this hair pulling cycle some clients can be quite resistant to to self monitoring um and others find it quite enlightening so it can be important to find ways of getting people to engage in this task as it's it's critical to improve that awareness and understanding of of what's contributing to this behavior but also helping people to see that it's not coming out of nowhere um there's predictable systematic situations in this person's life that um makes hair pulling more or less likely to occur so we can enhance um situations that are you know more more likely for the person to not engage in pulling um as one for the strategy so Scott touched on this before in terms of some of the I guess habit reversal therapies that are enhanced with these cognitive approaches and the two evidence-based approaches for this augmentation are ACT and DBT and like Scott I take more of an ACT based approach with my clients personally the comment to all of these evidence-based treatments for TRIC we've basically got psychoeducation self monitoring and awareness training as I was saying before which are really important competing response training stimulus control and then you put some of your emotion regulation distress tolerance techniques and values and motivational strategies so I'm going to focus on three key aspects of habit reversal therapy here each of these needs to be collaborative we need to be inviting our clients to um think about what's going to be useful to them what helps them um what sounds like it could be reasonable for them to to work on if they think something won't be helpful or um they've tried it before and it was completely useless then that may not be our best bet to try and and go for it the other thing to note with these strategies is um using them on their own for a couple of days will get you nowhere the more likely um that you kind of engage all of these strategies together and in a very focused and systematic way you'll have more success with that so I've already talked about awareness training competing response um that can be simple things like when you feel that urge um come on to pull your hair maybe clench your fist fold your arms do something that's incompatible physically incompatible with hair pulling for one minute and preferably it should be socially discreet um easy to do and then the stimulus control strategies here as well they're also really crucial um three key principles there stimulus control um they should make pulling more effortful they should be relatively easy to do um simple and um the purpose of stimulus control isn't to prevent or entirely avoid uncomfortable experiences but actually to control the stimuli that contribute to the likelihood of um engaging in hair pulling so you're not trying to control the behavior itself just the factors that contribute to that behavior occurring so monitoring progress that's another thing that um is really important and we do have um a few resources which um I believe I've also kind of pointed out how to find those in the resources library to help you track change over time which isn't quite important for helping um you know someone like Hannah to see that hey things are shifting um if this doesn't have to be forever and any progress know about it how small is is really important but also you know liaising back with your GP your psychiatrist about how things are going um again collaborate with your client about the best way for keeping up that self-monitoring um that progress reporting so whether using smartphone apps or technology could be useful trying to make it as easy and relevant to them as possible and problem solving around barriers, homework, treatment strategies that sort of thing and finally um I really want to impress the importance of of psycho education normalizing empathy validation um hearing Hannah's story um again reinforcing that this behavior it's it's not just this random weird thing um she's not alone it's actually a lot more common than we think um and hair pulling sort of it ranges on a domain a dimension from you know everyone does it to remove an annoying gray hair for example right through to that more severe spectrum so we can think of hair pulling as serving a purpose and for some people it it can become a bit um out of control and harder to manage treatment goals need to be realistic as well um clients may come in expecting that things will change immediately and that may not be um realistic um or that they will be pull free after a few sessions and it's also important as well to be looking after yourself um looking yeah that sort of self-care behaviors and and sort of working on any co-morbid conditions like depression and anxiety as well as Scott was saying um so I think that fits for me and yeah perhaps we move on thank you image and that's really helpful and the audience really um very active in the chat box and really getting a lot out of the panel's contribution so far there's 744 participants which is great um I'll just keep you there image and I just wanted to ask you a couple of questions that have been coming in um so you mentioned that someone might have had this for more than 10 years so one of the there's been a couple of things so so some people have said look I've been practicing for 30 years and I've only ever seen one person with treat I guess it's possible that people may feel so ashamed that they just don't acknowledge it and that would maybe be common I'm wondering and then my other question is about do eyelashes count yeah so yeah I'll um eyelashes count yes um so hair can be pulled from anywhere from the body most commonly um it affects women and most commonly they'll be pulling hair from the scalp the eyelashes and the eyebrows um not necessarily all three um so people can also pull hair from um like the arms and legs and even even their pubic region and you know there might be sort of you know beauty products and and you know cosmetic standards even that sort of say hey just remove that bodily hair no problem but what I found is it's that sort of that urge and that desire which feels really uncontrollable to actually pull hair from areas like the pubic region that some clients can feel quite a lot of shame about that sort of sense of you know why am I so compelled to be pulling hair from those areas that's a bit strange am I the only one who does this and I guess it sort of ties in with that second sorry that first question um around I guess the the rarity of seeing this in practice one thing that I've heard from my clients and research participants is they might sort of go online to find information about this and it's online that they sort of discover that this this problem has a name um and they'll find sort of internet-based peer support communities and information and that sort of thing and for some people that can be enough and that can be quite validating and helpful um and for others it might sort of spur them on to to check in with their GP and then they might hit another barrier where their health professional is just a bit unsure of what this is and doesn't know what to do or who to refer to and at that point that can be another barrier to preventing that person from going on from their GP to seeing the psychiatrist or a psychologist um but it is more prevalent than we think so um there's been a little bit of research um across uh the US and oh yeah I was studying recently in Australia actually so prevalence roughly is about two to four percent which is a lot higher than you might expect but then again of that proportion who were seeing you know their health professionals to work on this um if you know we're not too sure but I imagine it would be a lot lower because of that low awareness and the shame and stigma. Thank you Imogen um I know that George had something else to add um on the comment of the different kinds of behaviours that can be part of this so um did I say Scott then or George? I'm very sorry. You said George my cousin George is a shrink in Brisbane so you probably know him better than me but anyway um look that's no problem uh yeah look I was going to make a couple of quick comments one um the rarity issue is is is important because um I agree with Imogen it actually reflects more the issues relating to shame and and guilt and the wish to avoid things um my main sort of treatment interest is OCD and 40 years ago OCD was seen as an extremely rare condition and it wasn't at all I mean we know that OCD occurs in about two percent of the population and it was rare because people didn't go to see doctors because um they thought well firstly they thought that doctors didn't know what they were doing and they didn't have any treatment for it and secondly they thought that um they'd be seen as crazy and tossed in into um a psych hospital now OCDs come a long way and I think um you know this has happened with a lot of psychiatric conditions in the last sort of 10 20 years and I suspect it'll happen here with with trick as well um the other issue um that I just wanted to pop in is that um there's a whole range of other sort of impulsive conditions that are sometimes associated skin picking is the obvious one um and this can be pretty severe and bad in a lot of cases um but there's also other things nail biting as well again probably more often younger children so these sort of things all tend to go a bit together and I think currently in our latest um classification system DSM-5 they're all related they're all described as OCD related disorders so they're all somewhat linked with OCD. Thanks Scott um yeah I just had a question I'm going to bring we'll come back to you in a minute I just wanted to bring Jo in I there was a question from the audience that I thought was really interesting about um seeing someone who has actually had this for 40 years and has only just told their health practitioner now and I think that that sometimes happens to GPs that people eventually get to know you and feel comfortable enough and safe enough to talk about something really difficult and I wondered how as a GP I mean it's it is a thing that can happen with lots of issues but if Hannah was in her 50s and this had been going on for a long long time and she told you as her GP would your approach be any different and do you think that that you can actually do anything after 40 years? Um that's a tricky one isn't it because I think it's a question we come across with lots of compulsive behaviors where people have habit formed almost grown up maybe with that as their main way of coping with internal distress and learning new ways of doing that is harder um I think after you've been doing it for longer I'd love to know what Scott and Imogen think about that um you know I guess I'd be thinking um if someone finally revealed it um that something had happened to make it safe enough for them to show that part of themselves to me as a clinician um I'd be sort of sensing probably that I'd there'd been a sense of building the space for them um because of the other signs in their life that they've got things things that might be causing shame um and so sort of creating a space where they felt free to to show that particular behavior um and not feel they were going to be judged for it um and you know I think that's part of what we've been talking about today is really normalizing all you know all of our coping mechanisms as as sort of logical rational responses defenses almost or ways to make ourselves feel safer um that that happen across all the different kinds of ways we get compelled um including some of the you know really you know more socially acceptable things like over exercising or um other forms of um ways that we manage our moods in in our community so I guess I'd be thinking I'd want to hold out hope um something's changed she's told us something new um there's always hope when something new gets shifted um but I'd also be a little bit wary of um expecting too much from her and more wanting to see what else in their life can what what else can we do to decrease shame in all the areas of their life um that that will provide a sort of place where they could learn something new as well shame often prevents learning it prevents us feeling safe enough to take in something new um and so I'd be thinking of a very broad way including relationships relationship to their self relationship to their world um that would help shift this situation for them if they want it moved thank you that's really helpful and you know it's um a really the practical kinds of things that um that's the reason we attend these webinars is because we will have to just deal with whatever comes in the door um and I also I didn't acknowledge earlier but we do have lots of clinicians from regional and remote centres as well and it's fantastic to have you here so I guess we also need to be thinking about we don't all have a Scott and an Imogen in the next suburb and so it's fantastic to share their expertise and be able to learn these things as well so I'd like to bring Imogen back in uh Imogen someone in the um participant chat box has asked a question pointed out that these are all part of what's called body focus repetitive behaviors yep um which is terminology I hadn't heard before but the question was actually around does the same kind of treatment approach is it applicable to the the different manifestations of body focus repetitive behaviors yeah absolutely so we're learning a little bit more about these body focus repetitive behaviors um for example skin picking disorder um as of 2013 has been recognised as I guess an official obsessive compulsive related disorder alongside trick in the DSM five so um and the diagnostic criteria are actually identical for both of those conditions they just replace the words hair pulling with skin picking so we are learning more and more that there are a huge um symptom based similarities among these conditions but also we think that the um the emotional regulation mechanisms that might be underlying these disorders are also quite similar to so um Johanna mentioned before um this idea of conceptualizing these problems as ways of coping with stress and and emotion and life much in the same way that you know excessive um eating or exercising or gambling can also be ways of regulating your emotion so so can bfrb like hair pulling and skin picking and so um you know the research that is emerging for skin picking as well um again it's have reversal therapy and you can enhance it with um cognitive therapies like um act for that as well yeah and actually I'll keep you on while we're just talking about the evidence-based therapies there's been a couple of questions about specific kinds of therapy so there was quite a lot of questions at the registration around hypnotherapy and then this evening there's also been some questions about sensory strategies and occupational therapy so I wonder if you could comment on on those two so to my knowledge um I don't believe there is much published in the way of hypnotherapy um as an evidence-based treatment for um hair pulling or or even skin picking um although yeah clients of mine have seen hypnotherapists and and have found varying success with that um in terms of like a sensory-based approaches um this is something that I um incorporate into um treatments as well so using that kind of scam for acronym again if you're finding that for this particular individual that you're working with there's a really strong sensory component that's driving that behavior so um you know they associate that tension or stress or anxiety that might drive the hair pulling with particular physical sensations and they really get strong desire or I guess pleasure or gratification from the sensory experiences like um you know noticing how coarse the hair feels or how smooth it feels or um you know the color that sort of thing then you can find ways you know working collaboratively again finding ways of you know other other textures that might give you a similarly pleasurable sensation um but without relying on the hair to give you that sensation and again that's where an OT might come in as really helpful yeah and I think it's really interesting to me that the the detailed behavioral analysis that you're taking to be able to actually know exactly what it is that's um that's helping this person even down to the texture of the hair so you must get really used to talking about things that people actually um have felt very ashamed about and I'm assuming that that safe place where they can talk about it in detail isn't itself part of the therapy yeah I think it's it's like you know what most practitioners are already doing is just taking a curious non-judgmental approach to understanding um the way that people feel and behave and and hair pulling is just yet another behavior um yet another coping strategy and so just sort of you know I think I want to impress upon um you know people attending tonight that you've probably already got the skills to work with people with hair pulling and even skin picking problems um it's just focused on a different behavior thanks Imogen I'd like to invite George back in George um we've had a couple of questions when we were speaking before I've just called you George again they're going to sack me Scott I'm very sorry about this I'll get into ring you up I have to concentrate more on what I'm doing I'm trying to read questions at the same time um so Scott the question I we spoke earlier about um young people and even children who might develop this and for some of them it's just something that pops up for a while and then goes away and it's not really a problem um and then someone's raised a question about are there any sometimes things like ADHD meds this clinician has seen them make something like this worse so wonder if if you if you come across that and also whether whether you have any particular different approaches if you're working with younger children um I know there've been some case reports of stimulants um increasing these sort of behaviors um but I don't think it's been looking too much more than that um look I probably should declare here that I don't actually treat kids I usually um see their parents who are telling me about their children and and again in in in people with anxiety and OCD and you know trichotillomania parents are very aware usually because they the diagnosis was missed in their own situation um and you know we used to see people presenting you know 10 sometimes 20 years after they the condition had started and you know those parents obviously are you know very you know they're very focused in their if anything maybe a little too sensitive to their kids developing these symptoms so they're right onto it when when it happens and I I do have a number of child psychiatrist and clinical psychologists who work with kids who who I've got some links with and we share referrals and so that's normally what happens in those situations but as I said usually we're waiting a little bit early on just to see whether this becomes an issue or whether it becomes you know combined with something else um and you know usually I mean the things that I worry about mainly in kids with social anxiety because this is something that that precedes you know a lot of OCD and all of these things to a large extent and often doesn't improve um so if you've got a kid who's very very very anxious and socially anxious in you know kindergarten or early primary school you know that's something that we really need to get on to quick smart and in that case if you're working with the parents if it's the parents coming to see you are you able to use the similar kind of approaches with the parents as the therapist almost giving and treating their kids or yeah look usually in those situations I'd be focusing on the psychoish side of things and and I'd be giving them stuff to read I'd be asking them to you know perhaps to or look into a little bit of that first the first part of Imogen's approach which is really trying to work out when it happens where it happens what's the circumstance that sort of stuff and you look you can on occasion you know give them some suggestions you know just simple things like presenting a barrier you know one of the things that we try to do sometimes is get people you know to increase their awareness of their pulling particularly with that automatic version and one of the ideas might be just to put a band-aid around around the the kids or the person pulling fingers so that they become aware of when they're doing it so that they they pick it up a bit more quickly um so but I don't think I I don't actually get into specific therapy really it's that needs to be done um by someone focusing on the kids specifically and and you've got all sorts of issues with um you know not so much confidentiality but to some extent that sort of stuff is you're treating people in the same family and you know there are circumstances where that has to happen and I guess we're thinking particularly of regional circumstances where there might only be one psychiatrist or psychologist around who has to think about what they're going to do in that circumstance um for me I'm happily able to thank you but it's really practical and helpful um someone else had asked about um family systems therapy and I I guess that there are situations where um addressing the issues in the dynamics of the family is going to help the child as well but I'm imagining that there isn't specific evidence for um family systems therapy and tricks I don't think there is Imogen will know more about this because she's obviously done all the research recently um my guess is I mean think about systems therapy and family therapy is that they they almost certainly wouldn't be focusing specifically on the hair pulling they'd be focusing on the issues with communication the issues with um you know the kids sort of relationships and you know more uh sort of you know system oriented stuff so while they would probably talk about the hair pulling I doubt they would be delving into the sort of the specifics that we're talking about here yeah okay thank you for that now I'd like to invite um Joe back in and I know that we were talking um before about about shame and about how if someone came to you you know especially if they've held on to something like this for years and then they um feel safe to talk to you I know you have an interest in something called self compassion and I wonder how you might if we go back to Hannah um as a 26 year old how you might actually talk about that with her um yeah I was I was interested I was interested if there was I already only documented um uh information on that you know with specifically to Fort Cotillomania but from my perspective as a generalist I guess I'm sensing with Hannah there's some forms of sort of self rejection ignoring maybe and it could even be worse than that where she's maybe having some self loathing that's mixed in with shame and so um I found the kind of framework of self-compassion a helpful way to think about how we relate to ourselves um there are other more you know more sophisticated families um therapy based systems like internal family systems that do similar work where we sort of think about how we what sort of relationship we have to ourselves and um whether that relationship is one where when we're distressed we can be of use to you we can be helpful to ourselves or whether we actually increase the distress um so some of what we've been talking a little bit about today where we normalize it and they're not the only one in the world who does this that's part of the self-compassion framework is to sort of think of yourself as part of the common humanity and that your experience your internal experiences that are leading to Cotillomania are part of that as it's and it decreases that sense of shame and isolation that you sort of belong to a group of people that you know other human beings feel like this too and then there's the aspects of can you be towards yourself as compassionate as you sometimes are to others and um and so this this process is um in in this way of seeing that about helping the person to have affection towards themselves I love the work from Russell Mears of the conversational model where he talked about tender reflective attention towards ourselves and you know I sometimes use that word and word tenderness is so um so you know beautiful in terms of us thinking about how we relate to ourselves and doing something that we later regret is not tender doing something that hurts us or makes us ashamed is not tender and so you know and it's a reflective pay way of paying attention to ourselves um so that's probably enough said for me on that but just just thinking that the way that Hannah's relating to herself maybe is being enacted in her body um and that instead of getting tied up completely in what she's doing with her hands or her hair I'm I want to focus on the relational aspect of what's going on as well. Thanks though and I'd like to bring Imogen back in just to comment a little further on a the question about children and young people and also whether there's any other kind of emerging therapies that we haven't really addressed yet that you think would be helpful for people to know about. I think it's really interesting that we're getting a lot of questions and comments around um yeah things like family therapies and self-compassion-focused therapies so in the research literature to my knowledge this hasn't been investigated as you know say evidence-based treatments but I really agree with Johanna that we should be taking quite a holistic approach to to working with our clients with Trichotillomania as you would with you know working holistically and you know person focused with all of our clients irrespective of what sort of conditions or concerns they bring to us so I think it's you know when we're working with children it is important to understand what's happening within the family and we know that hair pulling and skin picking in BFRBs they run in families it's you know like everything with the biopsychosocial models to how we understand psychological conditions there's a genetic component yes but then there's also like a learned component so you know we want to know how else do people in the family hold their anxiety or manage stress or respond to difficult emotions or express or inhibit anger and what do they do with frustration and boredom that sort of thing so you know for children and adolescents could they be picking up on some of these experiences within you know their families and likewise with the self-compassion therapy again no research evidence but I think it's it's not too far removed really from some of the the notions that come through in act-based treatments anyway this idea of you know focusing on your values and and meaning in life and you know what makes life worth living and fulfilling which can actually be quite nice for helping people with tricks to reframe themselves as not just their appearance or not just their hair or not just their lack of control over their hair pulling behaviors but they're actually you know that their whole being is composed of so much more than that so I think it's you know it's certainly something that I think more research should focus on in terms of these self-compassion folks focus therapies and reflect some of the themes that were coming through in my research as well with that sense of self you know the the shame and the low self-esteem and the belief that they're abnormal or abhorrent or strange in some way I found was not just in relation to the co-morbid depression so this isn't just the influence of depression occurring here this is you know these are themes and beliefs that are specific to trichotillomania as well so we need to be addressing them more in our treatments I think and do you know somebody was asking about you know you're talking about emotion regulation and running in families and things like that sometimes you know shame's often associated with people who've had traumatic experience as well do you know if there's any evidence about the use of EMDR therapy for this kind of thing yeah so again none that I've come across in the research literature but yeah it could be an interesting one for future studies to explore yeah quite commonly there can be a trauma history for people with trichotillomania but it's no higher than in other disorders like you know anxiety depression eating disorders that sort of thing so trauma can be a factor but it's not the only explaining variable yeah and before I let you go this is a very practical question I'm somebody's asking about if there a particular issue about the root of the hair I'm I'm guessing that there might be different things for different people but this person has just noticed that often children seem to like the root of the hair even if it's mum's hair yeah yeah so yes this is something that I've noticed with my clients as well in some ways I like to think of hair pulling as mindfulness gone wrong so what my clients are very skilled at doing is paying attention to very very minute details of their hair like sensations that you and I just you know don't even notice people with trick often you know really pay attention to every aspect of detail of the hair follicle the hair root the hair shaft like just all of it the oil smell the taste the texture yeah it's really really detailed and so this can be one way of I guess leveraging a skill that they already have they already know how to engage in some of these mindfulness and and attention based skills in regulating emotion that we use but we can flip that and reframe this skill to be used for more adaptive emotion regulation purposes which can be helpful for some people who you know they hear the word mindfulness and they go oh it's just I'm not doing it no I've tried it before it's ridiculous or or don't want to engage in that kind of yeah experiencing your emotions they've got the skill just need to learn how to apply it in a different context and for a different purpose thank you now I had another question for Scott a couple actually um just back to the small children and you mentioned in your presentation that it sometimes appears in kids and then they grow out of it so there was a question from someone about how long would you leave that before you um considered whether before you thought help so if you had like a toddler or a young child who was pulling their hair at what point would you consider that you might need to get some professional help for that I think probably when it starts I mean this is going to sound a bit basic but when it becomes a problem really so it becomes sort of if the kid is spending a lot of time doing it um if it's um becoming an issue sort of within the family or at school um I don't think there's there's no sort of definitive answer to that question so I think uh it's really when it becomes sort of a problem I mean one of the things that a lot of people with tricks become quite skilled at hiding their hair pulling now kids it might not be quite as devious but I'd imagine that some could be particularly sort of young teens and the like and they'll pull from areas that are not immediately visible and so it might sort of remain hidden for quite some time so you know kids can sometimes or people can sometimes pull from behind their ear which isn't sort of immediately visible um and you know occasionally you know some pulling of of eyebrows and lashes obviously is is sort of acceptable um so yeah as I said no no definitive answer to that that question really and look it probably was a bit of a um main question to this is job on you with no warning um I do have a question which I think does have more researched answers so there's a a substance called N-acetyl cysteine or NAC which I understand has some perhaps preliminary evidence has been effective and probably doesn't have a lot of side effects so I wondered if you wanted to comment on that yeah look um NAC um has been around for a while I mean there there was a there was a study um done in the US uh almost 10 years ago actually um and that showed benefit in about half the people who used it and but on a fairly substantial dose um I think it was 2,400 milligrams um per day um that I don't I don't think that's been replicated um although there have been a number of case histories um subsequently that showed to be helpful um we've been doing uh in Melbourne we've been doing some work with OCD patients with NAC um and we've done a preliminary report that is suggest it's somewhat helpful we're doing a much larger study now with studies in Brisbane and and Sydney as well um I don't know what whether this is going to prove to be particularly helpful or not um in OCD we're doing it uh we're only doing it in addition to an SSRI uh so an antidepressant as well um and I'd have to look up that study done in the US with with Trigatillamani the circle was the same um it has an advantage in that it is um essentially without side effects the disadvantage is that it's not pbs and therefore it has to be bought essentially over the counter and it's not so widely available and so therefore it can be uh in some cases relatively expensive um there is a capsule form I think 600 milligrams but you have to take uh four or five or even more of those per day uh we think the effective dose for OCD is about 3 000 milligrams so that's five of those captions um there are some watch this space sorry watch this space yeah there are some chemists that have that will set you a powder which is a lot cheaper um although you have to be a little bit careful I had a patient who who wanted to take his powder overseas and I said look perhaps not to Malaysia that probably wouldn't be a great idea to go into the country with a with a big bag of white powder so he he decided to to to cease his meds uh for that period of time that's wise and I just had one general question for you about the success of treatment of Trigatillamania so we do know what some of the evidence based treatments are how successful are they as a board look question this is always um and I'm sure Imogen will will sort of um back me up here I mean this is always one of the dilemmas that we have is that the the studies end to focus on a group of people who are barely sort of limits that they have they have say the specific condition but they don't have too many comorbidities and so perhaps this group responds a bit better to the treatment in comparison to real life and real practice and it is a big issue one of the people we were talking before about people rarely seeing this part of the issue is that again people don't have a lot of confidence that we have a treatment for it yet and the other thing is the treatment is excuse me very bloody difficult it's really hard to do this work and that you know people drop out a lot so if you can get people to stay with you and do the work they nearly all make improvements without necessarily getting rid of the problem um but uh you know it is one of the big issues people who come along for a few sessions and then they realize what they're going to need to do and you know this may be partly me not explaining it properly but I don't think it's all that I think part of it is that you know the idea for some of them that they're going to have to resist this urge um is you know they they don't think they can do it okay thank you very much for that Scott it we'll come back to you shortly we're just approaching the end of the webinar and so I'm going to invite everyone to come back in with their take home messages and I'd first of all like to start with Joe yes thank you Mary um I guess my take home message as a generalist is that complexity is our friend in the case of Hannah um that there's so many things I can see in her story that where little small changes might make a difference to her life experience um and that might decrease the kind of dominance of her pair pulling as a coping style um so I I see in a case like this that as a GP I might get tempted to get really focused on her behavior um to the exclusion of some of the other things that matter for her um and so I think there's lots of ways we can help her in her day-to-day life in her relationships in her relationship to herself um in her having more fun more play more interest more sense of purpose and where she's going and she may I really sense that she needs somebody to help her talk through the relational things that might have happened when she was 14 and when she just in her recent relationship breakdown there's a sense of something of a very private pain for her and loneliness I guess I sense in her um and so my my goal really is what what can we do to comfort her in all the different areas of her life um so that she doesn't need that pulling as much um all of her matters and um I'm I'm I've got a real sense of affection towards Hannah and a little a sense of hope of what might come if she was able to face the things that make her want to hide thank you and I'm going to invite Imogen back in before I do I just want to acknowledge that we've had many many questions tonight and I haven't been able to get through them all so I really apologize to those in the audience who haven't had their questions answered but I think we've covered an enormous amount of material Imogen I wondered if there were any things that you would like to say and leave as we finish up oh yes um I suppose uh just emphasizing that um conducting a really comprehensive functional analysis of this behavior is quite important um the more you understand the factors at every stage of the hair pulling cycle that contributes to the urges and the actual behavior the more you and your client can work together to figure out what particular strategies can we try at this time to help me cope with those urges or to help me distract myself or to help me um yeah do something else um useful um and it's a bit of a trial and an error approach really so um psycho education preparing our clients as Scott was saying to expect that um a problem that last that's lasted for 10 years won't be treated in 10 sessions um so scaling back those expectations for um you know progress and you know cure um that's not to say that the treatments that we might use with people won't be effective but that change is hard it's really hard work but it is possible um you know helping clients to see that they're more than their trichotillomania they're more than their hair loss might be one way of I guess uh preventing some of the um the challenges to motivation when it feels like nothing's improving um and um yeah and I guess realizing that um you probably already have the skills necessary to work with people with trichotillomania um curiosity non-judgment compassion um understanding classical and operant conditioning principles your CBT your ACT you already know these things and you can work with people with trichotillomania so yeah certainly not a shy away thanks very much Imogen and last but not least I would definitely like to invite Scott back in and once again with an apology for the wrong name earlier um Scott is there anything that you would like to um finish up with yeah look one point really and that is that there is there is as Imogen said there is lots of hope here I mean the most people with this condition and a whole range of other important anxiety and OCD conditions other time actually the vast majority of them actually make progress and get a lot better now they may not get 100 well but they certainly get better and you know we need to think about this I mean part of the problem with with my practice and with a lot of practices is that the people who get better they they disappear because they're good and they don't want to come back instead of shrink um the people who who and so we tend to get a somewhat pessimistic view about things but in fact you know the vast majority of people um get benefit even if it isn't um even if it isn't cure that's it yeah that's great thank you look it's just been such an interesting discussion tonight I've learned so much myself and I know that the participants have as well judging by the chat box just before we go I'd like to remind everyone to complete the survey feedback um it really helps MHPN um think about webinar topics for the future so the survey feedback tab is at the top of your screen uh that will open a survey your certificates of attendance will be emailed to you within four weeks and you will also be emailed a link to the online resources associated with the webinar within two weeks and you'll get a notice when it's um up online for people to be watching it on the podcast if they'd like to um remembering also that MHPN have a system of local networks you might find it really helpful to join with other interdisciplinary practitioners in your location and then there are more national webinars coming up and um there are also some online networks around specific topics so if you're new to MHPN I encourage you to have a really good look around the website and once again remember to give us feedback and thank you all so much for contributing in the chat box and for our panelists tonight for your contribution good evening thank you