Trichotillomania and Skin Picking

Trichotillomania, or “Trich,” is a disorder that causes people to pull out the hair from their scalp, eyelashes, eyebrows, pubic area, underarms, beard, chest, legs or other parts of the body, resulting in noticeable bald patches or loss of hair density. For some people,  trichotillomania is mild and can be quelled with a bit of extra awareness and concentration. For others, at times the urge may be so strong that it makes thinking of anything else nearly impossible–and the consequences can be devastating.

Trich is presently listed as an impulse control disorder, but there is currently no consensus on how we should classify it. It may seem to resemble a habit, an addiction, a tic disorder, or obsessive-compulsive disorder. Most recently, it has been conceptualized as part of a family of “body-focused repetitive behaviors” (BFRBs) along with skin picking and nail biting.

Similarly, Chronic Skin Picking (CSP) involves repetivitely touching, cratching, picking, or digging into the skin, frequently (though not always) with the motive of removing small imperfections or irreggularities on the skin surface. Like pulling, people may pick in response to boredom, anger, fear, stress, or excitement. They often report picking as pleasurable, but the short-term gains (entertainment, self-soothing, dopamine release, etc) are ultimately eclipsed by the negative long-term consequences: scarring, tissue damage and disfigurement, shame, low self-esteem, and negative impact on family, work, and social relationships.

In treatment, I find it helpful to view both Trich and picking as an addiction–behaviors which, despite numerous attempts to stop and mounting negative consequences, we cannot quit on our own. Pulling and/or picking gives us a dopamine payoff, or your body’s own “feel good” chemicals… and anyone with Trich or CSP knows that prior to pulling or picking, the tension, restlessness, irritability, and distraction we feel is much like the feelings experienced by someone craving a cigarette, or sugar, or drug, or alcohol. After we pull or pick, we immediately feel better, ranging from a sense of ease and comfort, or a mild sense of euphoria only to later feel a sense of remorse and shame at having engaged in the behavior once again. We decide we will “never do it again” starting tomorrow, and the cycle begins again.