Trichotillomania is characterized by chronic hair pulling. The scalp is the
most common pulling site for adults, with eyelashes and eyebrows being second.
However, hair may be pulled anywhere on the body including; arms, legs,
eyebrows, eyelashes, chest, beard, and pubic areas. More than one third of the
people with trichotillomania pull from more than one place.
Hair pulling and skin picking disorders are part of a category of disorders call Body Focused Repetitive Behaviors (BFRB). While these behaviors are not OCD, they are now considered part of the OCD
spectrum in the Diagnostic Statistical Manual V (DSM-V) published by the
American Psychiatric Association. However, the reasons for repetitive behaviors
for persons with body focused repetitive behaviors, are different from OCD. While
stress can aggravate trichotillomania, hair pulling usually occurs during
solitary activities (i.e.; watching TV, talking on the phone, being on the
computer, reading, driving, lying in bed, etc.). The emotion is commonly
associated with pulling his boredom. People with trichotillomania frequently
report being unaware of when or how much they have pulled.
Other repetitive behaviors, that are functionally similar to
trichotillomania are; fingernail biting, skin picking, and thumbsucking.
Fingernail biting and skin picking, like trichotillomania generally occur when
one is bored and engaged in solitary activities. Fingernail biters and skin
pickers are also frequently unaware of how much damage they have done, which is similar to trichotillomania. However,
nailbiting is more socially accepted and does not have the emotional
consequences of skin picking or hair pulling.
With hair pulling, hairs are pulled one at a time, using the thumb and index
or middle finger. Hair pulling is often preceded by playing with the hair and
looking for a hair with a certain texture. Some people, however use tweezers and
pull multiple hairs at a time. Pulling usually occurs during solitary activities
and in specific situations. Sometimes stress aggravates pulling. The consequence
of repetitive pulling is bald spots. When hair begins to grow back it causes
itching, which leads to more pulling. With chronic pulling, hair follicles may
become so damaged individual hairs do not grow back. Some people with
trichotillomania eat their hair, which can cause trichobezoars. Hair is not
digestible and eating it can cause intestinal bleeding, pancreatitis,
obstructive jaundice, and sometimes death. When trichobezoars occur surgery is
indicated.
Similarly, persons with skin picking look for imperfections in their skin.
This leads to skin picking, and can cause minor sores, permanent scars, skin
infections and craters on the skin.
Both skin pickers and hair pullers experience feelings of shame and guilt
as a consequence of these behaviors. This may lead to increased picking or
pulling and can contribute to other emotional problems. Skin picking and hair
pulling can lead to avoidance of activities (e.g.; swimming) where bald spots or scars might be
exposed. It may have an impact on romantic relationships,
participation in sports and can lead to social isolation. Sufferers are afraid
that other people may notice the physical consequences of their pulling or picking.
Cognitive behavior therapy for skin picking and trichotillomania centers
around a technique called habit reversal. The technique focuses on developing
awareness for situations, thoughts and emotions which are associated with hair
pulling or skin picking. Developing awareness for situations that precede hair pulling and skin picking is important. It is frequently easier to
take action and prevent pulling or picking before it happens than after the behavior starts to occur. Anything that can be done to enhance
awareness of behaviors and situations that lead to picking or pulling and
monitoring the behavior itself will help.
Habit Reversal includes identifying behaviors that are incompatible and interfere with pulling/picking. For example, people with trichotillomania often pull while driving. A
behavior that is both incompatible and interferes with pulling while driving, is keeping both
hands on the wheel. By not pulling when behind the wheel of a car, the
association between pulling and driving diminishes, and eventually the urge to pulls in that situation decreases. Research shows
habit reversal is the most effective treatment for trichotillomania and skin
picking.
Wartel Behavioral Services, P. C. 6346 Orchard Lake Rd., Suite 107 West Bloomfield, Michigan 48322 Phone: (248) 626-1330 Fax: (248) 626-9170 E-mail: drwartel@gmail.com
