Many people pick at imperfections on their skin or become preoccupied with removing some unwanted hair from time to time. People with trichotillomania and dermatillomania, or hair-pulling disorder and skin-pulling disorder, experience these behaviors to such extremes that it disrupts their lives, causes them distress and shame, and sometimes alters their appearance.
Symptoms of Trichotillomania and Dermatillomania
Trichotillomania and dermatillomania are both body-focused repetitive behaviors (BFRBs) categorized under Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5). “Though there are similar patterns, what people are aiming for with these disorders is a little different than disorders like OCD,” says Kerrie Armstrong, PhD, a clinical psychologist at The Anxiety Treatment Center of Greater Chicago. “While both have repetitive behaviors, there is not always a thought or obsession with BFRBs.”
Hair-Pulling Disorder Symptoms
Diagnostic criteria for trichotillomania include:
- Hair pulling that causes significant distress or impairment in at least one important area of functioning
- Repeated hair removal from any area on the body for cosmetic or non-cosmetic purposes
- Noticeable hair pulling in one or multiple sites (some people concentrate on one area causing bald spots while others pull over larger areas, resulting in hair thinning)
- Unsuccessful attempts to decrease or stop hair pulling
- Hair pulling and loss that can’t be attributed to another medical condition or mental health disorder
People with hair-pulling disorder pull hair from their scalp, eyebrows, eyelashes and other areas. They may have rituals around hair-pulling like biting, chewing, hiding or eating it.
Skin-Pulling Disorder Symptoms
Diagnostic criteria for dermatillomania include:
- Skin picking that causes significant distress or impairment in one important area of functioning
- Recurring skin picking that results in lesions
- Repeated attempts to decrease or quit skin picking
- Skin picking and sores that can’t be attributed to a substance, medical condition or another mental health disorder
People with skin-pulling disorder may see skin imperfections that others don’t consider flaws. They may pick at their skin in an attempt to make the perceived imperfection look better. They may touch, rub, scratch or pinch skin until it bleeds and scabs.
5 Misconceptions About Trichotillomania and Dermatillomania
There are many misconceptions about skin-picking disorder and hair-pulling disorder. Some of these include:
#1 It’s a bad habit – People with skin-picking disorder or hair-pulling disorder feel urges well beyond the desire for everyday cosmetic fixes that many people feel. “They see things as imperfections that others don’t, and have difficulty stopping,” says Dr. Armstrong. “They know they’ve done damage and can’t leave it alone. There’s lots of embarrassment and shame.”
#2 They can “just stop” – Simply deciding to stop pulling their hair or picking their skin isn’t an option for people with these conditions. “Most of us could walk away if we started picking and drew blood or pull one hair, and it’s done,” says Dr. Armstrong. “[People with these disorders] go above and beyond what’s just a typical act for appearance’s sake.” They may have bald spots on their head or scabs and scars on their body. Discontinuing the behavior is complicated by the fact that in some cases, people don’t realize they’re engaging in the behavior until they’re in the middle of it.
#3 It’s a self-harming behavior – There’s often a misconception that people are picking or pulling for attention or as a self-harming activity like cutting. “Many of the parents of adolescents I see are very concerned they’re self-harming like someone who would self-injure, and it’s not the same thing,” says Dr. Armstrong. “Both acts can cause damage and scars, but the motivations are different.” In some cases, they’re aware of the behavior, like trying to fix a blemish. Other times, they’re not necessarily aware of what’s happening and really want to stop.
#4 It’s a form of OCD – Though trichotillomania and dermatillomania are classified under the umbrella of Obsessive-Compulsive and Related Disorders, they’re different than OCD. Unlike people with OCD, those with skin-picking disorder and hair-pulling disorder don’t always experience obsessive thoughts around the behavior. “They’re not necessarily aware of the skin picking or hair pulling, at least immediately,” says Dr. Armstrong. “It can happen automatically, and they don’t recognize it right away.” Also, unlike people with OCD who feel a sense of relief once they’ve engaged in the compulsive behavior, people with trichotillomania and dermatillomania typically feel shame and embarrassment.
#5 It’s a rare condition – Some data estimates that up to 4% of the population experience trichotillomania at some point in their lives. That translates into millions of people. Skin-picking disorder is also common, affecting about 1 in 20 people, according to the OCD Foundation. However, researchers believe that these statistics underestimate the prevalence of the disorder. They presume many people suffering from these disorders don’t seek treatment because of embarrassment or lack of available resources. “It’s only in the last eight or nine years things really started picking up with more advocacy,” says Dr. Armstrong. “Even though there’s all that info out there, patients still struggle to find people who know what it is and are willing to treat it.”
Possible Causes of Trichotillomania and Dermatillomania
Research on hair-pulling disorder and skin-pulling disorder is still in its infancy, but so far, studies have shown contributing factors that include:
Brain abnormalities – Some research has found neurological abnormalities in people with skin-picking disorder. Research has also shown changes in areas of the brain associated with cognition, affect regulation and habit learning in animals and people with hair-pulling disorder.
Genetics – Some studies have found genetic indicators in people with these disorders such as the same gene mutation in first-degree family members diagnosed with trichotillomania.
Co-occurring disorders – People with trichotillomania and/or dermatillomania are often diagnosed with one or more co-occurring mental health disorders. Some of these include body dysmorphic disorder, anxiety, mood disorders, OCD and eating disorders. “The biggest thing I see is anxiety in general and anything that falls within it,” says Dr. Armstrong. “I have several patients with mood disorders. When you have a patient with skin-picking disorder you also have to be aware of the possible presence of body dysmorphic disorder.”
Emotional regulation issues – Some data indicates people with body-focused repetitive behaviors have less tolerance for strong emotions and stress than those without these disorders.
Treatment for Trichotillomania and Dermatillomania
Treatment for skin-pulling disorder and hair-pulling disorder aims to increase the individual’s awareness of the behavior and target strategies to decrease it. “We could probably come up with the root cause, but a lot of times that doesn’t do enough,” says Dr. Armstrong. “Generally they need a very focused behavioral piece.” She compares it to people in addiction recovery. Effective drug and alcohol rehab addresses the underlying issues. Another critical component is making environmental changes that lessen exposure to triggers as well as developing tactics for dealing with those triggers when the individual encounters them.
Most hair-pulling disorder and skin-picking disorder approaches have a cognitive behavioral therapy component and include:
Functional assessment – Therapist and client dissect the experience before, during and after skin picking or hair pulling to try to “slow down” the behavior. For instance, Dr. Armstrong will ask clients to think about a specific hair-pulling or skin-picking incident – where they were, what they were feeling, what they were thinking, what they did prior to and following, and if they did anything with the skin or hair after they picked or pulled. This process can help her determine what therapeutic tools to use.
Habit-reversal training (HRT) – HRT helps clients become aware of destructive behaviors before they take place and then counter them with a “competing response.” For example, people with skin-picking disorder might make a fist or play with a fidget toy when they feel the urge to pick their skin coming on.
Stimulus control – In this technique, people try to change the environmental components of their behaviors. For instance, if they always pull their hair or pick their skin in bright lights with a mirror, they’d cover the mirror and keep lights low. Dr. Armstrong says this approach can be useful with clients that don’t necessarily feel the urge coming on but rather become aware of their behavior while in the midst of it.
Dialectical behavior therapy (DBT) – The mindfulness and distress tolerance aspects of DBT can be especially helpful with hair-pulling disorder and skin-picking disorder. These skills help people better tolerate their emotions and remain present in the moment so they’re aware of urges before it’s too late. “Having pieces of mindfulness so they are better able to be in the present moment and aware of urges that happen can help them ride those [urges] out without having to do anything about it,” says Dr. Armstrong.
Medication – Pharmacology outcomes are mixed for these disorders and large, double-blind studies are needed. One study showed N-acetylcisteine, a glutamate modulator often used for asthma, rashes and other skin conditions, has been effective in treating trichotillomania. Treatment with fluoxetine (Prozac) has shown some positive results for people with skin-picking disorder. However, the general consensus of researchers is that any pharmacology should be used in combination with behavioral therapy.
Usually treatment involves a combination of techniques; what works is different for each individual. “Very rarely is it one thing that is going to work,” says Dr. Armstrong. “What we’re working toward is not necessarily a cure but ways to manage and decrease the behavior so the individual can feel that they are the one in control.”