Trichotillomania and Skin Picking

By Ira S. Halper, M.D.

The new edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, DSM-5, includes a section on obsessive-compulsive and related disorders. Two of these disorders are trichotillomania and excoriation (compulsive skin picking). Both of these disorders are characterized by repetitive self-grooming behavior that results in damage to the body. These are not rare conditions. The prevalence varies according to the study, but on the order of 1 or 2% of the adult population pulls their hair or picks their skin severely enough to cause significant distress or impairment in social, occupational, or other important areas of functioning.

Individuals suffering from trichotillomania repeatedly pull out their own hair. The most common sites for pulling are the scalp, eyebrows, and eyelashes, but hair can be pulled from any region of the body where hair grows. Pulling sites may vary over time. Episodes of pulling may be brief or can continue for hours. Pulling leads to hair loss, but in mild cases the loss may not be obvious. Pulling continues in spite of repeated efforts to reduce or stop the behavior. Feelings of loss of control and shame are common. Episodes of pulling are commonly triggered by anxiety or other emotions. They may be preceded by an increasing sense of tension, which is relieved when the hair is pulled out. Hair-pulling behavior is associated with varying degrees of conscious awareness. Some individuals exhibit focused attention on hair-pulling; others exhibit more automatic behavior in which pulling occurs without full awareness. Many individuals experience both focused and automatic pulling. Hair loss may vary from areas of thinning to a large area of baldness requiring a wig.

Hair-pulling usually does not occur in the presence of others, except perhaps immediate family members.  Some individuals suffering from trichotillomania pull hairs from other individuals or from pets or dolls. The majority of individuals with trichotillomania also have one or more other body-focused repetitive behaviors, such as skin picking, nail biting, and lip chewing.

The onset of compulsive hair-pulling commonly occurs around the time of puberty, but symptoms can begin later or earlier, even in infancy. The disorder tends to be chronic with waxing and waning over time. Irreversible damage to hair growth and hair quality can occur. The psychological distress associated with compulsive hair-pulling can be significant. Interference with intimate relationships, social isolation, and avoidance of activities that might bring the hair loss to the attention of others is common. Trichotillomania is commonly associated with depression.

Compulsive skin picking (excoriation disorder in DSM-5) is characterized by repeated picking at one’s own skin, resulting in skin lesions. The most common sites of picking are the face, arms, and hands, but many individuals pick from multiple sites. Individuals suffering from this disorder may pick at healthy skin, at minor skin irregularities, at pimples, or at scabs from previous picking. Most individuals pick with their fingernails; others use tweezers or other objects. In addition to picking, sufferers may rub their skin, squeeze it, or bite it. Several hours a day can be devoted to this behavior in spite of repeated attempts to reduce or stop the picking. Feelings of a loss of control and shame are common.

The distress caused by this disorder can be significant and impairment can occur in social, occupational, and academic functioning because of the avoidance of social situations. Episodes of picking may be triggered by anxiety or boredom and may be preceded by an increasing sense of tension, which is relieved when the skin or scab has been picked. Picking may be focused or occur in an automatic way without full awareness, and many individuals with this disorder exhibit a mixture of both behavioral styles. Skin picking ordinarily does not occur in the presence of others, except perhaps immediate family members. Individuals with this disorder may pick the skin of others.

Skin picking commonly has its onset around the time of puberty, and frequently begins with a dermatological condition such as acne. Sites of picking may vary over time. The course tends to be chronic with waxing and waning over time. Skin picking is often accompanied by other psychiatric disorders, including obsessive-compulsive disorder and depression.

Research has not yet given us a clear picture of the cause of body-focused repetitive behaviors. There is evidence for a genetic factor. Trichotillomania and skin picking are more common in individuals who have close relatives with obsessive-compulsive disorder than in the general population. It is of interest that other species engage in similar behavior. Great apes and certain monkeys pull hair and pick insects on their own fur and the fur of others of their species. Birds pull out their feathers, and dogs suffer from a disorder in which they lick their forepaws, removing fur until there are bald spots.

Trichotillomania and compulsive skin picking are treated with medication, with cognitive-behavioral therapy, and with the combination of these two treatment modalities. Medications that have been successful in treating these disorders include SSRIs (selective serotonin reuptake inhibitors), clomipramine, a tricyclic antidepressant which acts on the serotonin neurotransmitter system, naltrexone, an opiate antagonist, inositol, a precursor of a chemical messenger system in the brain, and N-acetylcysteine, a modulator of glutamate, an excitatory neurotransmitter.

Habit reversal training is a cognitive-behavioral protocol that has been used successfully since the 1970s in the treatment of individuals suffering from body-focused repetitive behaviors. Its core components are awareness training, competing response training, and social support. Awareness training helps the individual focus on the circumstances in which pulling or picking is likely to occur. Competing response training teaches the individual to substitute a behavior that is incompatible with the undesired compulsive behavior. Social support involves including family members or others in the treatment to give positive feedback and to cue the individual to employ competing responses.

Because short-term improvement is easier to achieve with habit reversal training than long-term improvement, there has been interest in recent years in a cognitive-behavioral protocol called the Comprehensive Behavioral (ComB) Model. This protocol uses some of the techniques employed by habit reversal training and adds other cognitive-behavioral techniques. The use of this model seems to produce better maintenance of improvement. The ComB model addresses both internal and external factors that contribute to the problematic behavior and includes attention to the thoughts, feelings, and behaviors prior to pulling or picking, during pulling or picking, and after pulling or picking. Depending on the pattern exhibited by a particular individual, the protocol targets sensory, cognitive, emotional, motor, and environmental factors.

If you or a loved one suffer from trichotillomania or skin picking, it is important for you to know that these sometimes puzzling behaviors are not a sign of a weak will but rather symptoms of a neuropsychiatric disorder.  The psychobiology of these behaviors is incompletely understood, but effective treatments are already available. Additional information about body-focused repetitive behaviors can be obtained from the Trichotillomania Learning Center, an excellent resource for information about these disorders. The Trichotillomania Learning Center also maintains a directory of professionals who are experienced in treating body-focused repetitive behaviors. The organization is located in Santa Cruz, California and can be reached at 831-457-1004. Its website is www.trich.org.

Dr. Halper is the Director of the Cognitive Therapy Center in the Department of Psychiatry at Rush University Medical Center in Chicago.  His website is www.irahalpermd.com. 

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