Trichotillomania and skin picking

Trichotillomania involves recurrent pulling of hair from the scalp, eyebrows, eyelashes or other parts of the body, leading to noticeable hair loss or thinning. People usually try many times to stop or cut down, and the behavior causes distress or interferes with daily life.

Hair pulling can be focused or automatic. Focused pulling is done deliberately, often in response to an urge, tension or a specific sensation. Automatic pulling happens without full awareness, for example while reading, scrolling, driving or watching TV. Many people experience both.

Trichotillomania often begins in childhood or adolescence. It is grouped with obsessive-compulsive and related disorders, but it is different from OCD. It is not self-harm in the usual sense; the aim is not to hurt oneself but to relieve tension, soothe or satisfy a sensory urge.

BFRB is an umbrella term for repetitive self-grooming behaviors that cause physical damage and are hard to control. The most common include:

• Trichotillomania (hair pulling disorder)
• Skin picking disorder, also called excoriation disorder or dermatillomania
• Severe nail biting
• Cheek or lip biting

These behaviors share similar patterns and respond to similar treatments. Many people have more than one. They are far more common than people realize, but shame and secrecy often keep them hidden. Some people go years without telling anyone, including their doctor.

Common signs of trichotillomania and other BFRBs include:

• Bald patches, thinning hair or missing eyelashes or eyebrows
• Skin wounds, scabs or scars from picking
• Rituals, such as examining, playing with or biting the hair after pulling
• Feeling tension before pulling and relief or pleasure afterward
• Pulling or picking more when stressed, bored, tired or alone
• Hiding hair loss with hats, makeup or hairstyles
• Avoiding activities such as swimming, haircuts or intimacy

The emotional impact can be significant. Many people feel embarrassed, frustrated or guilty, and they may avoid social situations. Recognizing the behavior as a condition rather than a personal failing helps reduce shame.

The exact causes are not fully understood, but several factors seem to play a role:

• Genetics, as BFRBs tend to run in families
• Differences in how the brain regulates habits, urges and emotions
• Stress, anxiety or boredom acting as triggers
• Sensory factors, such as the texture of certain hairs or rough skin
• Co-occurring conditions like anxiety, depression, OCD or ADHD

BFRBs are not caused by bad parenting or a lack of willpower. They are often a way the nervous system seeks regulation, which is why simply telling someone to stop rarely works.

The best-supported treatment is a form of cognitive behavioral therapy called habit reversal training (HRT), often combined with additional components in an approach called the comprehensive behavioral model. Treatment typically includes:

• Awareness training to notice when, where and how pulling or picking happens
• Competing responses, such as clenching fists or holding an object, until the urge passes
• Stimulus control, such as wearing gloves, using fidget tools or changing environments
• Managing emotions and triggers that drive the behavior

Acceptance and commitment therapy can be combined with HRT to help people tolerate urges without acting on them. When anxiety, depression or OCD are present, a psychiatrist may consider medication as part of the overall plan. Support groups can reduce isolation.

A psychologist or clinical psychologist with experience in BFRBs or habit reversal is usually the best option. A psychiatrist can help when co-occurring conditions are present, and a dermatologist can treat skin damage or hair loss. In a first appointment, you will talk about the behavior, its triggers and how it affects your life, with no judgment.

Meanwhile, you can:

• Track when and where pulling or picking happens.
• Keep hands busy with fidget items.
• Create barriers, such as bandages, gloves or short nails.
• Practice self-compassion; slips are part of recovery.

Seek help if the behavior causes hair loss, wounds, infections or distress.