Body Focused Repetitive Behaviors: Hair-Pulling & Skin-Picking
Seeing clients virtually throughout Illinois and in-person in Northbrook, IL
There are a lot of different ways that individuals choose to cope with stress and anxiety. For many, they may bite their cuticles, pick at their skin, and some individuals may pull at their hair. These grooming behaviors are relatively common and harmless at lesser frequencies. However, for a handful of individuals, these behaviors are not just habits. Instead, they are complex disorders known as Body-Focused Repetitive Behaviors (the most common are trichotillomania and excoriation) that occur frequently enough to lead to significant distress and cause damage to parts of the body.
What is Trichotillomania (Hair-pulling Disorder)?
Recurrent pulling out of one’s hair, resulting in noticeable hair loss. Individuals typically pull from their scalp, eyelashes, and eyebrows; but people also pull their arm, leg, and body hair.
Repeated attempts to decrease or stop hair pulling.
The hair pulling causes significant distress or impairment in social, occupational, or other important areas of functioning.
Research indicates that about 1 or 2 in 50 people experience trichotillomania in their lifetime.
Pulling can occur AUTOMATICALLY, in which the individual is absorbed in thought or involved in another task and unaware of the pulling.
Pulling can also be more FOCUSED, in which the pulling is associated with more intense urges, tension, and thoughts of hair-pulling.
What is Excoriation (Skin-picking Disorder)?
Recurrent skin picking resulting in skin discoloration, scarring, and skin lesions. Individuals tend to pick from multiple areas of the body and may pick both healthy and previously damaged skin.
Repeated attempts to decrease or stop skin picking.
The picking causes significant distress or impairment in social, occupational, or other important areas of functioning.
Research indicates that 2% - 5% of the population picks their skin to the extent that it causes noticeable damage and marked distress or impairment in daily functioning.
Although picking can be either AUTOMATIC or FOCUSED (similar to Trichotillomania), many individuals report an urge or physical tension prior to picking. Individuals also report that beliefs about how the skin should look or feel and being unhappy with a part of one’s appearance (e.g., a pimple or scar) can lead to picking events.
How it is Treated
Habit Reversal
A multi-component treatment that consists of the following:
Awareness Training - Helps the individual focus on the circumstances during which pulling or picking is most likely to occur.
Competing Response Training - Teaches the individual to substitute another response for the pulling or picking behavior that is incompatible with the picking or pulling.
Social Support - Brings loved ones and family members into the therapy process in order to provide positive feedback and reminders to employ strategies.
Comprehensive Behavioral Model
Focuses on understanding why, where, and how a person engages in their pulling or picking so that individualized interventions can be selected. Consists of the following components:
Assessment – Assessment and monitoring of internal and external triggers for pulling or picking, as well as understanding the functions of those behaviors.
Identify and Choose Individualized Strategies – Client and therapist identify specific treatments that target the triggers of the pulling or picking. Strategies can include: awareness training, competing response training, sensory replacements (brush hair, nibble food, koosh balls, Vaseline, dying gray hairs, etc.), and/or environmental changes (covering mirrors, eliminate tweezers, etc.).
Evaluation - Evaluation of the effectiveness of each strategy.
Acceptance and Commitment Therapy (ACT)-Enhanced Behavior Therapy
Consists of trigger reduction, habit reversal, and acceptance and commitment therapy
The goal is to help people change their relationship with the urge to pull their hair or pick their skin rather than trying to eliminate the urge itself (Woods and Twohig, 2023).
ACT gives strategies for responding to internal experiences (cognitions, urges, emotions, and sensations) with the following skills:
Values - The things we care about that can motivate us to make changes.
Defusion - The practice of creating psychological distance from thoughts, urges, and sensations. It is the ability to see your internal experiences for what they are (e.g. a thought is a thought or an emotion is just an emotion).
Acceptance - The ability to make room for internal experiences and allowing them to be there without judgment.
Being Present - The ability to shift one’s attention to the present moment when the urge to pull or pick arises.
Self-as-Context - Noticing self-evaluations, rather than identifying with them.
Behavioral Commitments - Values-driven behaviors and changes that aim to reduce pulling and picking.
Sources: The TLC Foundation for Body-Focused Repetitive Behaviors (https://www.bfrb.org/index.php); Trichotillomania: Therapist Guide: An ACT-enhanced Behavior Therapy Approach Therapist Guide (Twohig and Woods, 2023)