Trichotillomania and Skin Picking
by Suzanne Feinstein, Ph.D. and Ori Shinar, Psy.D.
It is common for people to express frustration, anxiety or even boredom by muttering phrases such as “I feel like ripping my hair out” or ‘I’m jumping out of my skin”. Most often, these expressions are used figuratively and people find other outlets to alleviate physical tension like punching a wall, yelling into a pillow, venting to a friend, taking a walk, etc. However, there are people who literally rip their hair out and attack their skin in an attempt to alleviate tension. Hair pulling and skin picking can involve any area of the body and frequently are accompanied by like-behaviors such as pulling apart split ends, nail biting, and cuticle picking.
Hair pulling, known as trichotillomania, and skin picking are behaviors which are not well understood by most clinicians. Diagnosticians currently struggle to decide on the most appropriate category in which to group these disorders. Some argue that trichotillomania and skin picking most closely resemble obsessive compulsive disorder (OCD) and should be categorized as an OC Spectrum Disorder. OCD is an anxiety disorder in which people perform repetitive behaviors or compulsions to alleviate distress brought on by recurrent thoughts, feelings, fears or preoccupations known as obsessions. Common examples of compulsions include frequent hand washing to alleviate a constant feeling of being unclean, checking the stove to assuage one’s doubt of leaving on the gas, and excessive arranging of items in an attempt to satisfy the need for perfect order. Many people engage in hair pulling and skin picking compulsions to satisfy their need for symmetry (“I have a lesion on my left cheek so I need to even it out by making a mark on my right cheek), their need for exactness (“This hair feels more wiry than the others so I need to pull it out”) or magical thinking (If I don’t pull my eyelash out by the root, something bad will happen”).
However, not all people who pull or pick report obsessive thoughts or physical tension to be the reason behind their behaviors. Some people claim that these behaviors are not triggered by stress; rather they occur most frequently when they are involved in sedentary (low stress) behaviors such as watching television, surfing the web, reading, talking on the phone, etc. People frequently report being in a trance-like state when they pull their hair or pick their skin. Thus, clinicians recognize that trichotillomania and skin picking cannot be categorized exclusively under an anxiety disorder such as OCD. Diagnosticians have stated that hair pulling and skin picking can be defined as “impulsions” instead of compulsions since these behaviors are not always triggered by thoughts or fears, but rather by an inability to control simple urges or impulses. Thus, certain clinicians argue that it is more appropriate to classify trichotillomania and skin picking as impulse control disorders, and feel that they should be grouped with other impulsive disorders, such as compulsive gambling, binge eating and substance abuse.
Needless to say, the ongoing controversy about how to properly classify hair pulling and skin picking and the scarcity of literature about the disorders leave most clinicians stumped about the most effective way to treat these problems. Many therapists make the mistake of implementing a cookie cutter approach in treating hair pulling and skin picking and see little or no improvement in the people they treat. It is important for clinicians to understand that each person has a different motivation behind the pulling or picking and treatment needs to be tailored specifically to the needs of the individual.
At Advanced Behavioral Health, LLP, we pay close attention to the triggers (thoughts, feelings, impulses, urges, images) that precede the behavior. We are extremely thorough in collecting every detail about the behaviors through questionnaires, tracking diaries, and special monitoring devices, and formulate treatment plans accordingly. And most importantly, we recognize the sensitivity of these disorders and provide the utmost sympathy and professionalism in treating our patients. It is truly rewarding for our clinicians to witness new hair growth, clearer skin, and an improved self-image in our patients. We hope that this message speaks out to anyone who has been struggling with hair pulling or skin picking, and that you can acquire a newfound confidence that treatment works.
Please contact us to learn more about how we use short-term Cognitive Behavior Therapy to effectively treat Trichotillomania, understand how to navigate your insurance policy, and inquire about available appointment times.
