"I feel for hairs that are coarser and thicker than the others, and I pull out each one, rolling the root between my thumb and finger. It feels relaxing to do this-- until I notice all the hairs I've pulled. Then I feel deeply ashamed."

"I can't stand the bumps on my skin. When I find a bump or scab, I need to pick it and make my skin smooth. I feel I have to get rid of the imperfections. Once I start, I zone out and keep picking. At first it feels like a relief, but then I feel guilty and ashamed, and sometimes my skin becomes infected."

Hair pulling (Trichotillomania), skin picking, biting the insides of the cheeks, and nail biting are considered Body-Focused Repetitive Behaviors (BFRBs).

Trichotillomania is repetitive pulling out of one's hair. People with Trichotillomania pull hair from any location on the body, including the scalp, eyelashes, eyebrows, and pubic area. Prior to pulling, some people notice a mounting tension or urge, and while pulling, they may feel relief or pleasure. After pulling, the person may play with or eat the hair. Pulling may be focused and planned or it may occur in a less focused manner when people feel "zoned out." Over time, the pulling can result in notable hair loss that can significantly interfere with a person's functioning and happiness.

Pathological skin picking is a repetitive behavior that involves recurrent picking, scratching or biting the skin. People commonly pick at scabs, acne or other skin imperfections.

Most of us pull a hair or pick a scab from time to time. These behaviors become clinical concerns when a person is unable to stop the behavior despite significant hair loss or skin damage, or when the behavior leads to significant distress.

Cognitive-behavioral Model of Trichotillomania and Chronic Skin Picking
The cognitive-behavioral model stresses understanding the role of different modalities (sensory, cognitive, affective (emotions or level of arousal), motor, and environmental) involved with pulling or picking episodes and the sequence of events leading to and following them. Certain situations (such as watching TV, working on the computer, reading, driving, or spending time alone) can make a person more vulnerable to pulling or picking. Pulling or picking may serve a role in regulating emotional or internal states of sensory imbalance (feeling bored or overly stressed). Cognitions (such as "I'll just pull out one or two of the worst ones") and motor behaviors (such as scanning for bumps or playing with hair) contribute to the sequence of events leading to pulling or picking episodes. Sometimes the pulling or picking provides immediate relief from the discomfort of sensations (itching or tingling) or a pleasurable sensation, thus reinforcing the behavior.

Cognitive-behavior Therapy for Trichotillomania and Chronic Skin Picking
Cognitive-behavior therapy for trichotillomania and skin picking and other Body-Focused Repetitive Behaviors (BFRBs) includes the following components:

• Education: Learn about your condition to understand the problem and treatment components. Reduce stigma and access helpful resources.
• Monitoring and awareness training: Increase knowledge about the situations, sensations, emotions, cognitions, and behaviors prior to, during, and after pulling/picking.
• Habit Reversal Training (HRT): Substitute another behavior that is incompatible with pulling or picking, and do this in conjunction with awareness training and social supports.
• Contingency management: Provide incentives for skill use and behavior change. Reward yourself for steps taken to decrease pulling or picking.
• Reduce shame, isolation, and low self-esteem: If you experience these problems as a result of struggling with hair pulling or skin picking, your therapist will work with you to improve mood, address how you think about your problem, and increase social supports.
• Comprehensive Behavioral Treatment: Combine HRT with other cognitive-behavioral techniques to identify a full range of behaviors and strategies within the five modalities of sensory, cognitive, affective, motor, and place (environment). Techniques may include:
  • Using sensory substitutes (e.g., fiddle toys, koosh balls, yarn) that can provide similar benefits (i.e. pleasure, stimulation) without the same detrimental effects (i.e. hair loss, skin damage, shame)
  • Developing responses to "talk back" to unhelpful thoughts about pulling such as, "I'll only pull this one."
  • Using strategies (e.g., relaxation, assertiveness, self-regulation strategies) to directly address emotional states prior to, during, or following episodes
  • Making changes to decrease automatic motor behaviors (e.g., sit without arm resting on side of chair, wear gloves, use band-aids)
  • Changing the environment to decrease risk for pulling/picking episodes