People with Trichotillomania and Excoriation Disorder compulsively pull their hair and pick their skin, respectively, to the extent that the effects change their appearance and disrupt their daily lives. Although these are separate disorders in the Diagnostic and Statistical Manual of Mental Disorders, they are often discussed and studied together as “body-focused repetitive behaviors”. Additionally, the behaviors and emotional states surrounding skin picking and hair pulling are very similar, so we will address them together here.
People are often ashamed of these behaviors and go to great lengths to conceal them. They usually only perform the behaviors in private or occasionally in the presence of family members. They wear hats to cover bald spots, style their hair, apply excessive makeup, or wear clothes to cover sores from picking skin. They avoid situations where their disorders would be revealed, such as swimming areas, intimacy with a partner, or hot places where wearing covering clothes would be uncomfortable. In severe cases, people will seclude themselves and are at risk for depressive disorders.
As a result of these avoidance behaviors, it is difficult to spot patients with these disorders. Even if skin sores and bald spots are visible, there is no way to tell that they are the result of these disorders and not other medical conditions.
Permanent damage to hair and skin can occur. The skin becomes scarred and wounds can get infected, requiring antibiotics. Hair pulling can irritate the skin and decrease the density of hair follicles so it does not grow back to its original state. People also sometimes chew or eat picked skin or pulled hair. While eating skin causes no issues, eating hair can damage teeth and cause digestive problems. People also play with the skin and hair, rubbing it between their fingers or touching it to the lips or face.
Causes and Risk Factors
Both disorders start in puberty, during the preteen and early teen years. Excoriation Disorder begins with a skin condition, which is acne for a large number of patients in this age group, but then continues after the skin issue is resolved. The beginning of Trichotillomania coincides with new hair growth in multiple body areas that can be the starting focus of the disorder.
Both Trichotillomania and Excoriation Disorder occur in about 1% of all people. However, they are 7-to-10 times more common in women than in men.
These disorders are frequently shared by first degree family members (a parent, sibling, or child). In fact, almost 8% of patients with Excoriation Disorder had a first degree family member with Trichotillomania.
Different body-focused repetitive behaviors frequently co-occur in the same people. The overlap between Trichotillomania and Excoriation Disorder is almost 50%. Eighty-three percent of Excoriation Disorder patients have at least one other body-focused behavior, which includes not only Trichotillomania but also nose picking, nail biting, and cheek biting.
Increased stress is definitely a factor for a number of people with body-focused repetitive behaviors. The behaviors can be calming for people in stressful situations. This phenomenon is not unique to humans, either. Monkeys, birds, rodents, dogs, and cats can all groom themselves excessively to the point where they pull out their significant amounts of hair or cause wounds.
Diagnosing Trichotillomania and Excoriation Disorder
Making the diagnosis
The hallmark symptom in Trichotillomania is that patients repeatedly pull out their hair and this leads to noticeable hair loss. In Excoriation Disorder, people compulsively pick at their skin, leaving skin lesions and scars.
In both disorders, patients have tried to stop pulling their hair or picking their skin but continue to struggle with the compulsions. The hair pulling and skin picking lead to negative consequences in work, social, or home life.
People most often pull hair from the scalp, eyebrows, and eyelids, but any part of the body where hair grows can be affected. Similarly, people usually pick skin on their faces, arms, and hands. It can occur during a short, concentrated period or be spread out over the day. Both activities can consume several hours each day.
Active or passive
Skin picking and hair pulling can be active or passive. Active implies the behavior consumes the person’s attention. They are focused on it, often looking in the mirror or using tools like pins or tweezers. Passive means the behavior is done almost without thinking, out of boredom or while doing something else like reading or watching television.
Mounting tension and anxiety can lead up to skin picking and hair pulling or can occur when people try to resist picking and pulling. People experience an emotional release and feelings of satisfaction or pleasure immediately after.
People will run their hands over their skin and hair feeling for the right place to pick or pull. People frequently play will the extracted skin and hair, rubbing it, feeling it, and even eating it.
Treating Trichotillomania and Excoriation Disorder
Cognitive Behavioral Therapy forms the basis of the two primary specialized treatments for body-focused repetitive behaviors: Habit Reversal Training and Comprehensive Behavioral Treatment.
Habit Reversal Training
This is the oldest, most studied treatment for body-focused repetitive behaviors. It’s three central pillars are awareness training, competing response training, and social support. First, in awareness training, patients learn to observe their environment and emotional state during the time leading up to the behaviors. People learn to replace the behaviors with non-destructive ones, like clenching the fists or crossing arms. These are the competing responses. Lastly, social support brings in family members and friends to help the patients recognize the behaviors and replace them.
Comprehensive Behavioral Treatment
Patients using this treatment work with therapists to identify the triggers for their body-focused behaviors. The therapy views the behaviors as serving as a calming or satisfying act for the patient, such as the build up and release of tension that many patients describe. The patients then swap the picking and pulling behaviors for other acts that satisfy the same needs. This therapy also involves practical interventions, such as limiting time in front of a mirror for people who use one to pick or wearing a hat to remind people not to pull hair.
Acceptance and Commitment Therapy
This is an additional therapy that guides patients to understand the urges that drive their body-focused repetitive behaviors. It helps the patients to find their own motivations for deciding to try to change their behaviors. Patients use mindfulness to monitor their emotions around the behaviors and simply observe and experience them, rather than try to avoid them or fix them.
There are no medications approved by the Food and Drug Administration to try body-focused repetitive behaviors. An older antidepressant called Anafranil (clomipramine) has been promising, but it has a number of undesirable side effects. Selective serotonin reuptake inhibitors like Prozac (fluoxetine) are no better than placebo.
Managing Trichotillomania and Excoriation Disorder
Body-focused repetitive behaviors often become points of contention for families. Family members often see them as bad habits that the patient can break. This leads to arguments between spouses, and parents may discipline their affected children for something that actually needs treatment. In fact, when parents aren’t familiar with the disorder, they sometimes see it as a phase that will go away, which also precludes treatment.
Every patient with either of these disorders has a unique set of circumstances that triggers their behaviors, and there are ways to combat these in everyday life. Do you pick skin or pull hair because your hands need something to do? Get a small toy to occupy your fingers. Is it because you enjoy the sensation on your hands? A swatch of fabric with a pleasing texture may do the trick. Is it done out of boredom or anxiety? Replace it with something else calming, like stretching or meditative breathing. Do your hands seem to have a mind of their own? Wear gloves or put a small piece of tape on your fingertips to serve as a reminder. Understand the triggers and have responses ready to go when you need them.
Since these disorders usually crop up in childhood, they often cause problems with patients’ school performance. First, it is important to rule out a learning disorder with academic testing. Children who are picking their skin or pulling their hair can easily lose focus in class. They may seem disinterested in the subjects and appear like their mind is elsewhere. An official diagnosis of one of these disorders can qualify children for special education provisions, like extra testing time or permission to use some of the practical remedies in school (like wearing gloves or a hat).
Trichobezoar: the human hairball
People who pull their hair and eat it are at risk for a trichobezoar, a tangled ball of hair that gets trapped in the stomach or small intestine because it is not digestible. These can be quite large and cause a sensation of fullness, decreased appetite, and intestinal blockage. As a result, they can cause medical emergencies and may require surgery to remove.