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Hair Pulling/Skin Picking (Trichotillomania/Excoriation Disorder)

Trichotillomania is a disorder in which people pull out hair from various parts of their body (e.g., their scalp, face, arms, legs, pubic area), or sometimes from their pets. In many instances the hair pulling results in bald patches. The strength of the urge varies. For some, the urge is incredibly strong and some people dissociate or “zone out” while they are pulling and lose track of time.

Compulsive skin picking is diagnosed as an impulse control disorder not otherwise specified. It is a disorder in which people compulsively pick pimples, scabs, and other imperfections on their skin. Depending on severity, skin picking results in red marks, scab, scars, and disfigurement.

Hair pulling and skin picking are usually preceded by an emotional feeling of tension or anxiety. During episodes of pulling and skin picking, feelings of relief, relaxation, or even dissociation (i.e., zoning out) usually occur. After episodes of pulling and skin picking, feelings of guilt, shame, and depression are common. Hair pulling and skin picking frequently result in disruptions to one’s life such as lateness or avoidance of social interactions. There are many different triggers of pulling and skin picking and the specific triggers vary from person to person. Common triggers include:

  • being in a location in which pulling or skin picking commonly occurs (e.g., the bathroom, bedroom, or car)
  • being around utensils used to pull or pick (e.g., tweezers, mirrors)
  • noticing an imperfection in the appearance of one’s hair or skin (e.g., the shape of the hairline is not perfect; noticing pimples or scabs on one’s skin)
  • feeling an imperfection in one’s hair or skin (e.g., the hair does not feel smooth; a pimple can be felt)
  • feeling anxious, depressed, angry, excited, or bored
  • desiring to fidget with ones hair or skin
  • desiring to feel a certain physical feeling from pulling or skin picking (e.g., a tingling feeling when the hair is being pulled from the scalp; a pop when the root of their hair is bitten; a pop when a pimple is popped)
  • finding oneself pulling or skin picking after a significant amount of time (minutes to hours) during which the person was not aware of the pulling or picking.

Although trichotillomania and compulsive skin picking are defined as impulse control disorders, they frequently occur with obsessive compulsive disorder (OCD), and are informally considered OC spectrum disorders. While they are not addictions, they function very much like addictions. The more one pulls or picks the greater the urge to do so; pulling and picking feel pleasurable despite the fact that the behavior later causes depression, shame, guilt, scarring, bald patches, and other negative consequences.

Treatment of trichotillomania and compulsive skin picking

AATC offers a specialized form of cognitive behavioral treatment called Habit-Reversal Training and Stimulus Control—the first-line treatment for trichotillomania and compulsive skin picking. Treatment must be designed to treat the specific triggers and emotional responses of the individual and includes education about these disorders, the development of awareness of the triggers of pulling and picking, and the development of strategies to reduce their occurrence. Once the occurrence of pulling or picking is reduced, the urge to pull or pick is reduced accordingly. Antidepressant medications can reduce these urges in some individuals so that clients can better use the strategies they are learning in treatment.