Suzanne Mouton-Odum, PhD, has built a practice in Houston around trichotillomania. Lots of psychologists serve niche markets. But deriving 98 percent of an approximately 20-hour per week practice just from people with the disorder--characterized by hair pulling to the point of baldness--is certainly unique.

"I happened upon a niche where there are so many people out there, and so few providers who know how to treat this disorder," she says.

About five to 10 million people in the United States, roughly 3.5 percent of the population, meet the clinical criteria for trichotillomania--they must have noticeable bald spots from pulling their hair. Though, according to Mouton-Odum, there are many people who suffer from a milder form of the disorder.

A bit about "trich"

People typically develop "trich" around age 12, and 75 percent of those who have it are female, according to research findings. Their compulsive hair pulling often results in a "thin" appearance on the scalp, says Mouton-Odum. Some people also pluck other hairy areas, such as their eyebrows, eyelashes or body hair. In more severe cases, some might eat the hair they pull out, and that can lead to physical problems such as trichobezoar--hairballs that get stuck in the stomach.

Though most people tend to deny their hair-pulling habit and face adverse effects on their social and family lives, each person experiences trich differently, Mouton-Odum says. She elaborates: "Some people pull to relax themselves. Some do it when they are bored. Some pull when they are tired and want to energize themselves. Across the board, they all say it feels good. It seems to have a soothing or calming effect."

For that reason, experts say, the disorder seems to be closely related to Tourette's Syndrome or, Mouton-Odum says, even nail-biting or skin-picking. Though trich is categorized as an impulse control disorder, some people who have it show symptoms of obsessive-compulsive behavior. For example, says Mouton-Odum, "These folks often pull hairs that are 'out of place' or they pull certain kinds of hairs like coarse or curly ones in an attempt to have more 'smooth' hair.'"

Breaking into the niche

For Mouton-Odum, an interest in obsessive-compulsive behavior led her to trichotillomania. While in graduate school, she got a job at the University of Texas Medical School at Houston with a grant project on obsessive-compulsive disorders. On the first flier sent out to attract participants, "We put in a line about hair pulling, and we got swamped," she says. "We were stunned." She ended up doing her residency there, working closely with Melinda Stanley, PhD, a recognized expert in trichotillomania.

"I got a lot of exposure working with these people and lots of good training," she says. "So when I got into private practice, I thought about what I liked doing and what I knew how to do," she says. Her training and interest fueled her current practice. And her practice is booming. Once she participated in a local talk show about trich.

"I got 80 calls in 24 hours," she says. "The main thing I love about working with this disorder is that people don't know there's anyone else out there who does this. When they find out they can get treatment and there are others who do it, it's a huge eye-opener."

Treatment begins with individual therapy, "basically cognitive behavioral therapy," she notes. "We analyze the behavior in the person. Once you figure out how it works for them, you find ways to help them achieve the same sensation without pulling. If they use it to go to sleep, for example, I teach them other ways to do that."

After about four to six weeks of self-monitoring--keeping a journal about triggers, how they felt and how many hairs they pulled each day, and then charting progress--Mouton-Odum's patients begin to learn ways to cope with their urges through competing responses or more adaptive behaviors. Patients have the option to participate in group therapy, in addition to individual therapy. She has two groups--one for adults and one for children with trich.

"I think it's helpful to be with others who do this," she says. "Some people do get better and just need a monthly touch-base sort of thing. Others need ongoing support."

Mouton-Odum has also developed www.stoppulling.com, an interactive Web site devoted to helping people with trichotillomania. There, people can get information, learn behavioral strategies online and track their progress. The site gets about 70 hits a day, she says. Next, Mouton-Odum plans to develop a Web site aimed at children with trich.

Mouton-Odum also reaches out to potential patients through hairdressers. "They see this a lot," she notes. She recently wrote an article for Modern Salon magazine to educate hair stylists--who, she says, often chide their hair-pulling clients without realizing that it isn't helpful. Hairdressers aren't the only ones who may come in contact with people with trich. "I recently read that one-third of the wigs sold in the United States are sold to hairpullers. It's really a lot more common than people realize," she says.

And she also devotes some of her time to serving on the Trichotillomania Learning Center's scientific advisory board. The group, founded in 1991 by Christina Pearson in Santa Cruz, Calif., has about 2,500 patient and provider members nationally. "I felt so alone treating this disorder it was nice to meet other providers," she explains.

Though Mouton-Odum says she's content with a half-time practice right now--she's the mother of two small children--at some point she may expand her practice to work with patients with Tourette's. For now, there's plenty of demand for her expertise, and people are willing to pay for it. Almost 99 percent of her practice is out-of-pocket, she says.

"It's more narrow a niche than I've typically seen," says Russ Newman, PhD, JD, APA's executive director for practice. But he adds, "No niche is too narrow if in fact it can support a satisfying niche practice."

Certainly, a narrow niche has worked for Mouton-Odum. "A long time ago, someone said figure out what your perfect client is and make that 98 percent of your practice," Mouton-Odum says. Looks like she was successful.