"I feel for hairs that are course and thicker than the others and 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, and 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 it smooth. I feel I have to get rid of the imperfections. Then I zone out and keep picking. At first it feels like a relief, but then I feel guilty and ashamed. Sometimes, my skin becomes infected.”

What are Trichotillomania and Chronic Skin Picking?
Chronic hair pulling (trichotillomania), chronic skin picking (CSP), biting insides of cheeks and severe nail biting are considered Body-Focused Repetitive Behaviors (BFRBs)

Chronic skin picking is similar to hair pulling. It is a repetitive behavior that involves recurrent picking, scratching or biting the skin. People with CSP pick at bumps, pimples, scabs, or discolorations in the skin.

Most people will pull a hair or pick a scab from time to time. These behaviors become clinical concerns when the person is unable to stop the behaviors despite significant hair loss or skin damage and scarring.

Cognitive-behavioral model of Trichotillomania and Chronic Skin Picking
The causes of trichotillomania, skin picking, and other BFRBs are not clear. A person may be vulnerable to pulling or picking behaviors due to an imbalance of neurotransmitters in the brain and/or deficits in the brain’s ability to control certain motor behaviors involved in grooming. Biological vulnerabilities combined with environmental factors, cognitions, and behaviors can feed one another to cause and maintain hair pulling or skin picking problems.

The cognitive-behavioral model stresses the role of different modalities (cognitive, behavioral, and sensory) that contribute to the problem and the sequence of events leading to and following pulling/picking. Certain situations (such as watching TV, reading, driving, or spending time alone) can make a person more vulnerable to urges. Pulling or picking may serve a role in regulating 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 behaviors (such as scanning for bumps or feeling the scalp) 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

• Education: Learning about your condition to understand the problem and treatment components. Eliminating stigma and providing helpful resources.
• Monitoring and awareness training: Increasing knowledge about the situations, behaviors, sensations, feelings, and thoughts that trigger or facilitate pulling/picking.
• Relaxation training and stress management skills: Learning self-regulation strategies to reduce tension or manage stressors
• Competing response training/stimulus substitution: Learning strategies to replace hair pulling and skin picking with alternative behaviors (for example, squeezing a rubber ball) that are incompatible with pulling/picking and can provide similar benefits (i.e. pleasure, stimulation) without the same detrimental effects (i.e. hair loss, skin damage, shame).
• Stimulus control: Changing the environment to decrease risk for pulling/picking episodes
• Cognitive restructuring: Developing responses to “talk back” to unhelpful thoughts about pulling such as “I’ll only pull this one. Once I get this one, I’ll be done.”
• Contingency management: Providing incentives for skill use and behavior change.

Web links:
Trichotillomania Learning Center
The Association for Behavioral and Cognitive Therapies
The Obsessive-Compulsive Foundation

Books:
For links to purchase these books and others, please go to Self-Help Books for Adults

Keuthen, N. J., Stein, D. J., & Christenson, G. A. (2001). Help for hair pullers: Understanding and coping with trichotillomania. Oakland, CA: New Harbinger Publications.

Golomb, R. G., & Vavrichek, S. M. (2000). The hair pulling "habit" and you: How to solve the trichotillomania puzzle. Silver Spring, MD: Writers' Cooperative of Greater Washington.