Pharmacological and behavioral treatment for trichotillomania: an updated systematic review with meta-analysis
Open accessAbstract
BACKGROUND: Trichotillomania (TTM) is a difficult-to-treat psychiatric condition with no first-line medications approved by the Food and Drug Administration. Individuals with TTM often feel that clinicians know little about this disorder. Here, we present an updated meta-analysis of randomized controlled trials (RCTs) examining treatments for TTM. METHODS: Pubmed, PsychINFO, Embase, and CENTRAL were searched with the terms "Trichotillomania OR Hair Pulling Disorder" to identify randomized controlled clinical trials evaluating treatments for TTM. RESULTS: Twenty-four trials involving 26 comparisons and 857 participants were included in this meta-analysis. Behavioral therapy with habit-reversal training components (BT-HRT) demonstrated a large benefit compared to control conditions (standardized mean difference [SMD] [95% CI] = -1.22 [-1.71, -0.73], p < .0001) for improving TTM symptoms. Clomipramine (SMD [95% CI] = -0.71 [-1.38, -0.05], p = .036), N-acetylcysteine (SMD [95% CI] = -0.75 [-1.36, -0.13], p = .017) and olanzapine (SMD [95% CI] = -0.94 [-1.77, -0.12], p = .025) demonstrated significant benefits compared to placebo in RCTs. CONCLUSIONS: BT-HRT has demonstrated the largest treatment effects and has the strongest evidence base for reducing TTM symptoms. In contrast, several pharmacological agents have demonstrated efficacy in single randomized clinical trials that would benefit from replication. Additional trials are needed to identify other effective medications for TTM and determine the relative efficacy of available agents.
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Behavior therapy (BT) is an effective treatment for trichotillomania (TTM) and skin-picking disorder (SPD), with moderate to large effect sizes compared to passive and active control groups.
“Behavior therapy (BT) has been shown to be an effective treatment for TTM and SPD with moderate to large effect sizes compared to both passive and active control groups (Farhat et al., 2020; Selles et al., 2016).”
From Internet-delivered acceptance-based behavior therapy for trichotillomania and skin-picking disorder in a psychiatric setting: A feasibility trial (2022) · cites this paper as Farhat et al., 2020
Section 3.2.1 (page not provided) reports a large, significant benefit of BT-HRT for TTM compared with control conditions. The paper examines TTM, not skin-picking disorder, and its pooled effect does not establish moderate-to-large benefits separately against both passive and active controls; most listed controls were passive. (LLM, conf=0.88)
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BackgroundResultPsychosocial Treatment of Trichotillomania: A Review
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“For example, grooming may include other body‐focused repetitive behaviors such as pathological nail biting (Maraz et al., 2017) and compulsivity may include other OC conditions such as illness anxiety disorder and olfactory reference syndrome (Greenberg et al., 2016).”
Long-term follow-up of acceptance-enhanced behavior therapy for trichotillomania
Barber, K. E., Woods, D. W., Ely, L. J., Saunders, S. M., Compton, S. N., Neal-Barnett, A. M., Franklin, M. E., Capriotti, M. R., Conelea, C. A., & Twohig, M. P. (2024) · Psychiatry Research · doi:10.1016/j.psychres.2024.115767 · Cited by 6 · see citing works
Wiese, A. D., Stiede, J. T., Greenberg, R. L., Riddle, D. B., Pinciotti, C. M., Guzick, A. G., Goodman, W. K., & Storch, E. A. (2023) · Cognitive Therapy and Research · doi:10.1007/s10608-023-10423-3 · Cited by 5 · see citing works
“HRT is an effective psychotherapeutic for BFRBs, including TTM and excoriation disorder, in both pediatric and adult patients (Bloch et al., 2007; Farhat et al., 2020; Schumer et al., 2016).”
Shamsudeen, S., & Kannekanti, P. (2023) · Clinical Case Studies · doi:10.1177/15346501231189552 · Cited by 5 · see citing works
“There is also limited awareness regarding the availability of effective treatment options except for BT-HRT, as seen in a recent meta-analysis of RCTs examining treatments for TTM (Farhat et al., 2020).”
BackgroundTrichotillomania and its treatment: an updated review and recommendations
DuBois, M. C., Feler, B., Flessner, C., & Franklin, M. E. (2025) · Expert Review of Neurotherapeutics · doi:10.1080/14737175.2025.2557395 · Cited by 5 · see citing works
“To date, the available evidence supports classic behavior therapy (BT; e.g. Habit Reversal Training; HRT) and augmented BT (e.g. acceptance and commitment therapy-enhanced behavior therapy; AEBT) as the first-line treatments for adults with TTM, though other therapies will be discussed below [7,54].”
InfluentialFlannery, M. K., Falkenstein, M. J., & Haaga, D. (2023) · Cognitive Therapy and Research · doi:10.1007/s10608-023-10424-2 · Cited by 4 · see citing works
“Behavioral treatments of TTM (Farhat et al., 2020) and SPD (Schumer et al., 2016) show sizable effects in reducing symptom severity, but access to therapists with expertise in them is limited.”
From tugs to treatments: a systematic review on pharmacological interventions for trichotillomania
Ghani, H., Podwójniak, A., Tan, I. J., Fliorent, R., & Jafferany, M. (2024) · Clinical and Experimental Dermatology · doi:10.1093/ced/llae052 · Cited by 4 · see citing works
Trichotillomania: Therapist Guide
Twohig, M. P., & Woods, D. W. (2023) · doi:10.1093/med-psych/9780197670309.001.0001 · Cited by 4 · see citing works
Body-focused repetitive disorders
Hossain, R., Leung-Yee, J., & Sinyor, M. (2022) · Canadian Medical Association Journal · doi:10.1503/cmaj.220228 · Cited by 3 · see citing works
Coyne, A. F., Carlson, E. J., Malloy, E. J., & Haaga, D. A. F. (2024) · Bulletin of the Menninger Clinic · doi:10.1521/bumc.2024.88.1.81 · Cited by 3 · see citing works
Barber, K. E., Woods, D. W., Deckersbach, T., Bauer, C. C., Compton, S. N., Twohig, M., Ricketts, E., Robinson, J., Saunders, S. M., & Franklin, M. E. (2024) · Behaviour Research and Therapy · doi:10.1016/j.brat.2024.104556 · Cited by 3 · see citing works
StopPulling.com: Real-World Effectiveness of a Self-Guided Online Intervention for Trichotillomania
Barber, K. E., Woolley, M. G., Rogers, K., Hadlock, S., Woods, D. W., & Mouton-Odum, S. (2025) · Cognitive Therapy and Research · doi:10.1007/s10608-025-10584-3 · Cited by 3 · see citing works
Comprehensive Behavioral Treatment of an Older Adult Man with Trichotillomania
Coyne, A. F., Carlson, E., Flannery, M. K., de Oliveira, F. B. R., & Haaga, D. (2022) · Clinical Case Studies · doi:10.1177/15346501221130500 · Cited by 1 · see citing works
“Behavioral treatments incorporating habit reversal therapy (HRT; Azrin & Nunn, 1973) have the most extensive empirical support among therapies for TTM (Farhat et al., 2020), but outcomes are not fully satisfactory.”
BackgroundWoolley, M. G., Sahdra, B. K., Bowers, E. M., Capel, L. K., Twohig, M. P., & Levin, M. E. (2025) · Behavior Therapy · doi:10.1016/j.beth.2025.01.006 · Cited by 3 · see citing works
Usmani, A., Szkutak, A., & Keuthen, N. J. (2023) · Current clinical psychiatry · doi:10.1007/978-3-031-29368-9_12 · Cited by 2 · see citing works
Leibinger, K., Murray, E., Aschenbrenner, S., & Randerath, J. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.1071532 · Cited by 2 · see citing works
“Thus far Habit-Reversal Training (HRT) has the strongest evidence for treating Trichotillomania effectively (Farhat et al., 2020).”
BackgroundGallinat, C., & Schmidt, J. (2024) · Die Psychotherapie · doi:10.1007/s00278-024-00718-5 · Cited by 2 · see citing works
“…Wahl zur Behandlung der TTM gilt die Kognitive Verhaltensthe-rapie (KVT), wobei insbesondere Kombi-nationen von KVT mit Habit-Reversal-Trai-ning und Elementen der Dialektisch-Beha-vioralenTherapiebzw. derAkzeptanz-und Commitment-Therapieuntersuchtwurden (Farhat et al. 2020; Gallinat et al. 2022).”
InfluentialHoyer, L. N., Schmotz, S., Jelinek, L., & Moritz, S. (2024) · Verhaltenstherapie · doi:10.1159/000540265 · Cited by 2 · see citing works
“In einer Faktorenanalyse zeigten Zwang und BFRBs Ladungen auf unterschiedlichen Dimensionen et al., 2017; Farhat et al., 2020].”
InfluentialHossain, R., Sinyor, M., Nestor, S. M., Richter, M. A., Lipsman, N., Hamani, C., & Giacobbe, P. (2022) · Psychiatry Research · doi:10.1016/j.psychres.2022.115007 · Cited by 2 · see citing works
Psychopharmacotherapy of Obsessive-Compulsive and Related Disorders
Hoffman, J., & Stein, D. J. (2022) · Springer eBooks · doi:10.1007/978-3-030-62059-2_433 · Cited by 2 · see citing works
Sabra, M. A. A., Al‐Kalaldeh, M., Alnaeem, M. M., & Zyoud, A. H. (2023) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-023-09604-8 · Cited by 2 · see citing works
“Recent systematic reviews and meta-analyses regarding psychotherapy and behavior therapy showed superior efficacy when compared to a passive control group, as well as behavior therapy (Abu Sabra et al., 2023; Farhat et al., 2020).”
Harries, M. J., Holmes, S., McMichael, A. J., & Messenger, A. G. (2024) · Wiley eBooks · doi:10.1002/9781119709268.rook087 · Cited by 2 · see citing works
Phillips, K. A., Rodríguez, C. I., Harding, K. J. K., Fallon, B. A., & Stein, D. J. (2023) · Springer eBooks · doi:10.1007/978-3-030-42825-9_24-1 · Cited by 1 · see citing works
N-Acetylcysteine (NAC) for Trichotillomania and Excoriation Disorder: An Overview.
Goldin, D., Salani, D., & Valdes, B. (2025) · Journal of Psychosocial Nursing and Mental Health Services · doi:10.3928/02793695-20250506-04 · Cited by 1 · see citing works
Gulassa, D. C. R., Amaral, R., Angelo, D. L., de Oliveira, E. C., de Abreu, C. N., & Tavares, H. (2025) · International Journal of Group Psychotherapy · doi:10.1080/00207284.2025.2551504 · Cited by 1 · see citing works
“Indeed, for TTM, HRT was found to have the largest estimated effect size (1.22) compared to both non-pharmacological and pharmacological treatment (Farhat et al., 2020).”
InfluentialMayerson, T. F., Mackay, C., & Waite, P. (2025) · JCPP Advances · doi:10.1002/jcv2.70041 · Cited by 2 · see citing works
“…reversal therapy (HRT) is currently considered by experts as the gold - standard treatment for BFRBs, but has rarely been shown to simultaneously eradicate co - occurring symptomology, and its longitudinal efficacy is unclear (Farhat et al., 2020; Grant & Chamberlain, 2021; Usmani et al., 2023).”
Banerjee, D. (2025) · Indian Journal of Psychological Medicine · doi:10.1177/02537176251385212 · Cited by 1 · see citing works
“8 .”
Aldakhil, A. F. (2026) · Research in Developmental Disabilities · doi:10.1016/j.ridd.2026.105229 · Cited by 1 · see citing works
Barber, K. E., Cram, I. C., Smith, E. C., Woods, D. W., & Lee, H. (2026) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2026.02.020 · Cited by 1 · see citing works
Febre-Alemañy, D. A., Bonilla-Robles, J. C., Serpa-Irizarry, M., Cordero, J. C. B., Trinidad-Pineiro, J., & Abdul‐Hadi, A. (2026) · Cureus · doi:10.7759/cureus.111103 · Cited by 1 · see citing works
“HRT has demonstrated superior evidence-based effect sizes (SMD = -1.22) versus controls [7,8].”
InfluentialAccelerated Continuous Theta Burst Stimulation in the Treatment of Trichotillomania
Chaudhary, P., & Kar, S. K. (2024) · Journal of Ect · doi:10.1097/yct.0000000000001010 · Cited by 1 · see citing works
A genomic study of trichotillomania and excoriation disorder in families
Greenspun, S. R., Milanes, I., Farhat, L. C., Abdallah, S. B., Bok, D. D., Chen, D., Liu, W., Teefe, E., Bloch, M. H., Fernandez, T. V., et al. (2026) · Translational Psychiatry · doi:10.1038/s41398-026-04164-6 · Cited by 1 · see citing works
“Currently, these conditions remain dif fi cult to treat, with limited evidence-based treatments available [12 – 15].”
Development of a measure of hair pulling modalities
Ghosh, J., Golomb, R. G., Mouton‐Odum, S., Boyd, M., Froehlich, M., & Haaga, D. A. F. (2022) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2022.100744 · Cited by 1 · see citing works
Developing and Evaluating a Situated Assessment Instrument for Trichotillomania: The SAM² TAIPreprint
Lūka, C. T. B., Hendry, K., Dutriaux, L., Stevenson, J. L., & Barsalou, L. W. (2023) · doi:10.31234/osf.io/v6qna · Cited by 1 · see citing works
Obsessive-Compulsive Spectrum Disorders
Ramsey, K. A., Myers, N., Reagan, S., & McGuire, J. (2021) · Reference Module in Neuroscience and Biobehavioral Psychology · doi:10.1016/b978-0-12-818697-8.00082-0
Psychopharmacotherapy of Obsessive-Compulsive and Related Disorders
Hoffman, J. A., & Stein, D. (2021) · NeuroPsychopharmacotherapy · doi:10.1007/978-3-319-56015-1_433-1 · Cited by 1 · see citing works
Trichotillomania and excoriation disorder
Scrandis, D. A., & Duarte, A. C. (2021) · The Nurse Practitioner · doi:10.1097/01.npr.0000753840.44209.51
Troubles répétitifs centrés sur le corps
Hossain, R., Leung-Yee, J., & Sinyor, M. (2023) · Canadian Medical Association Journal · doi:10.1503/cmaj.220228-f
Session 8: Practicing Acceptance and Commitment Therapy (ACT)
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.003.0008
Client Forms, Graphs, and Worksheets
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.005.0002
Modifications for Working with Adolescents
Petersen, J. M. (2023) · doi:10.1093/med-psych/9780197670309.003.0011
Session 4: Can Pulling-Related Inner Experiences Be Controlled?
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.003.0005
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.003.0002
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.005.0004
Session 2: Habit Reversal Training (HRT) and Trigger Reduction Strategies
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.003.0003
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.005.0001
Session 5: Acceptance of Pulling-Related Inner Experiences
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.003.0006
Sessions 6 and 7: Defusion from Your Inner Experiences: You Are Not Your Urges to Pull
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.003.0007
Session 9: Practicing Acceptance and Commitment Therapy (ACT) and Review of Treatment
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.003.0009
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.005.0003
Session 10: Review and Relapse Prevention
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.003.0010
Session 3: Increasing Motivation for Treatment Through Values
Woods, D. W., & Twohig, M. P. (2023) · doi:10.1093/med-psych/9780197670309.003.0004
A case series of trichotillomania; Impact of therapeutic intervention: Clinical out-turn
Algin, S., Akter, A., Jalil, S., Joti, F. J., Hridi, H. S., Ahmad, R., & Haque, M. (2023) · Advances in Human Biology · doi:10.4103/aihb.aihb_98_23
TRICOTILLLOMANIA SECONDARY TO TRAUMATIC BRAIN INJURY
Şahin, Ş. K., Gonultas, U., & Demir, B. (2023) · Psychiatria Danubina · doi:10.24869/psyd.2023.430
“Better results are obtained when pharmacotherapy and psychotherapy are used in combination (Farhat et al.2020).”
BackgroundCommon pitfalls, and how to avoid them, in child and adolescent psychopharmacology: Part I
Cortese, S., Besag, F., Clark, B., Hollis, C. P., Kilgariff, J., Moreno, C., Nicholls, D., Wilkinson, P. O., Woodbury‐Smith, M., & Sharma, A. (2024) · Journal of Psychopharmacology · doi:10.1177/02698811241239582
“For instance, to date, there is no published evidence supporting the role of low-dose antipsychotic augmentation in body dysmorphic disorder (BDD) nor is any clear evidence that SSRI medications are helpful in the treatment of trichotillomania (Farhat et al., 2020).”
BackgroundSantos, M. P. P. M. S., Santos, R. M. D. S., Montanha, R. S., Assis, R. M. S. D., Jesus, R. S. D., Lima, S. E. A., Silva, N. G. D., Alves Faria, E., Paiva Lins, J., Oliveira, Y. V. S., et al. (2024) · Editora Científica Digital eBooks · doi:10.37885/978-65-5360-574-9
Hauschildt, G. F., & da Cruz, J. X. (2024) · Editora Científica Digital eBooks · doi:10.37885/240215838
Actualización en el tratamiento de la tricotilomanía
Dominguez, L. N., Imbernón‐Moya, A., Saceda‐Corralo, D., & Vano-Galván, S. (2024) · Actas Dermo-Sifiliográficas · doi:10.1016/j.ad.2024.05.003
Tan, C. M. T. H. S., Yenn, L. C., & Dua, J. P. L. (2024) · Dermatological Reviews · doi:10.1002/der2.240
“…a meta ‐ analysis on the pharmacological and behavioral treatment for trichotillomania involving 857 participants, demonstrated that behavioral therapy with habit reversal training components (BT ‐ HRT) has a large benefit compared to control conditions for improving trichotillomania symptoms [7].”
BackgroundUnterdiagnostiziert und unterbehandelt
Schmotz, S., Hoyer, L. N., Augustin, M., Sommer, R., Traxler, J., & Moritz, S. (2024) · Deutsche Dermatologie · doi:10.1007/s15011-024-6615-4
Phillips, K. A., Rodríguez, C. I., Harding, K. J. K., Fallon, B. A., & Stein, D. J. (2024) · Springer eBooks · doi:10.1007/978-3-030-51366-5_24
Can pharmacotherapy help to reduce trichotillomania?
Thomson, M., & Sharma, V. (2024) · Expert Review of Neurotherapeutics · doi:10.1080/14737175.2024.2398471
“Pharmacotherapy should be considered for patients who don’t respond to BT-HRT, cannot access BT-HRT or have a moderately severe TTM either alone or in combination with other psychiatric disorders [20].”
Gabapentin in the treatment of trichotillomania: A case report
Yin, K., Dayal, A., Rush, A. J., DeMoss, D. S., & Davis, S. (2024) · Personalized Medicine in Psychiatry · doi:10.1016/j.pmip.2024.100136
- Authors
- Farhat, L. C., Olfson, E., Nasir, M., Levine, J. L. S., Li, F., Miguel, E. C., & Bloch, M. H.
- Affiliations
- Departamento de Psiquiatria da Faculdade de Medicina FMUSPUniversidade de São Paulo São Paulo São Paulo Brazil
- Yale University (US)
- Corresponding author
- Bloch, Michael H.
- Venue
- Depression and Anxiety
- Publisher
- Wiley
- Published
- 2020-05-10
- Volume
- 37
- Issue
- 8
- Pages
- 715-727
- ISSN
- 1091-4269 (ISSN-L)
- 1520-6394
- OpenAlex
- W3023888988
- Cited by
- 133
- References
- 54
- Citations by year
- 2026: 16 · 2025: 23 · 2024: 26 · 2023: 39 · 2022: 13 · 2021: 15 · 2020: 1
- FWCI
- 1.33
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Depression and Anxiety (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Body Image and Dysmorphia Studies
- Keywords
- trichotillomania, habit reversal training, behavior therapy, clomipramine, N-acetylcysteine, olanzapine, pharmacotherapy, treatment efficacy
- MeSH terms
- Acetylcysteine, Behavior Therapy, Clomipramine, Humans, Trichotillomania, Selective Serotonin Reuptake Inhibitors
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