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Trichotillomania and Dermatillomania

Symptoms and Treatment

Have you ever found your self picking an imperfection on your skin or becoming preoccupied with removing some unwanted hair from time to time? When we are looking at a person with Trichotillomania or Dermatillomania, a hair-pulling disorder and skin-picking disorder respectively, they can experience these behaviours 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 behaviours (BFRB’s), categorised under Obsessive-Compulsive Disorder. Although there are similar patterns, what people are aiming for with these disorders are worlds apart from OCD – “While both have repetitive behaviours, there is not always a thought or obsession with BFRB’s.”

Trichotillomania – Hair-Pulling Disorder Symptoms

Criteria 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.

Dermatillomania – Skin-Picking Disorder Symptoms

Criteria 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-picking 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.

Misconceptions About Trichotillomania and Dermatillomania

1. It’s a bad habit.

People with a skin-picking disorder or hair-pulling disorder tend to feel urges well beyond any normal level. They see things as imperfections that others don’t, and have difficulty stopping, They know they’ve done damage and can’t leave it alone. There may be lots of embarrassment and shame around what they have done.

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, but people presenting with these disorders go above and beyond what’s just a typical act for appearances. They may have bald spots on their head or scars on their body. Discontinuing the behaviour is complicated by the fact that in some cases, people don’t realise they’re engaging in the behaviour until they’re in the middle of it.

3. It’s a self-harming behaviour.

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 may be very concerned they’re self-harming like someone who would self-injure, but it’s not the same thing. Both acts can cause damage and scars, but the motivations are different. In some cases, they’re aware of the behaviour, 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.

Although Trichotillomania and Dermatillomania are classified under the umbrella of Obsessive-Compulsive Disorders, they’re different from OCD. Unlike people with OCD, those with skin-picking disorder and/or hair-pulling disorder don’t always experience obsessive thoughts around the behaviour. There may not be any awareness of the skin picking or hair pulling, at least not immediately. This can be an automatic reaction. Also, unlike people with OCD who feel a sense of relief once they’ve engaged in the compulsive behaviour, people with Trichotillomania and Dermatillomania tend to feel shame and embarrassment after the act.

Emotional regulation issues

people with body-focused repetitive behaviours may have less tolerance for strong emotions and stress than those without these disorders.

Treatment options for Trichotillomania and Dermatillomania

Treatment for skin-pulling disorder and hair-pulling disorder aims to increase the individual’s awareness of the behaviour and target strategies to decrease it. 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.

Functional assessment

The way I work is by separating the experience before, during and after skin picking or hair pulling to try to “slow down” the behaviour. For instance, I 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 me determine what therapeutic tools to use.

Habit-reversal training (HRT)

HRT helps clients become more aware of destructive behaviours before they take place, so people with skin-picking disorder might make a fist or play with a fidget toy, for example, when they feel the urge to pick their skin coming on.

Stimulus control

This is a good technique for people to try to change the environmental components of their behaviours. Say they always pull their hair or pick their skin in the morning after their shower; we would simply look at having a shower at a different time of the day. This approach can be useful with clients that don’t necessarily feel the urge coming on, but rather become aware of their behaviour while in the midst of it.

“I use my knowledge and expertise to help clients consider new ways of viewing the world and offer guidance on ways they may consider towards changing their behaviours.”

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