Trichotillomania or Hair Pulling Disorder (HPD) and Excoriation/Skin Picking Disorder (SPD), usually begin in childhood and are referred to as Body-Focused Repetitive behaviours.
They may appear as habits in childhood that are directed at the child’s own body. Some habits can be self-soothing in the first instance, like thumb sucking or twiddling hair, they may even be seen as ‘cute’ and encouraged by families.
In most cases, these early childhood behaviours are harmless and dropped in later childhood or early teen years. However, for some children and young people, habits directed towards their own bodies can become concerning, becoming the source of shame, disgust and damage.
Who is affected, and why?
BFRBs are thought to affect slightly more girls than boys. They are also thought to have an average onset in early adolescence. It is estimated that approximately 2.5% of the general population will meet the criteria for the diagnosis of BFRB. Skin picking and pulling continues despite having negative outcomes and often increasing in severity.
Body-Focused Repetitive Behaviours are diagnosed by Mental Health Practitioners and Psychiatrists. It is an area of Psychiatry that is not well understood. There are very few research studies, and clinical understanding is continually developing.
BFRB’s are believed to have a genetic and environmental component, much the same as other mental health problems. Body-Focused Repetitive Behaviours may be diagnosed alongside other psychiatric presentations; particularly anxiety and depression. BFRBs are obsessive and compulsive in nature and can often be grouped with other OCD related behaviours.
Tourette’s Syndrome has also been linked to the co-occurring presentation of HPD and SPD. Studies indicate that there may be some increased risk in teenagers and young adults also diagnosed with ADHD (Attention Deficit and Hyperactivity Disorders). Often behavioural issues may appear differently in girls in comparison to boys. More information about ADHD in girls can be found via the blog ADHD in Teenage Girls and Young Women.
Diagnosing hair pulling disorder or skin picking disorder in teenagers.
A Psychiatrist, Mental Health Professional or Psychotherapist can help you and your teenagers to decide on diagnosis or treatment. Looking at the age, severity and impact on day to day living can help you decide on the most appropriate course of treatment.
Mental Health Professionals may use the following to assist them in making a diagnosis:
DSM-5 Guidelines (Diagnostic and Statistical Manual of Mental Disorders. 5th Edition. American Psychiatric Association, 2013)
- Recurrent skin picking that results in skin lesions
- Repeated attempts to stop the behaviour
- The symptoms cause clinically significant distress or impairment
- The symptoms are not caused by a substance or medical, or dermatological condition
- The symptoms are not better explained by another psychiatric disorder.
What leads to picking or pulling?
There are many reasons why young people may engage in picking and pulling behaviours. It is important to work with a team that can help the child or young person to explore the types of feelings and sensations that are experienced.
Some young people may find that they are more susceptible during sedentary activities, like watching TV or studying alone. Others may find that they are more likely to engage in BFRBs when they feel anxious, stressed or under pressure, perhaps in family arguments or before exams.
Some may engage directly to feel pleasure or to soothe themselves to sleep or another feel-good reason. Others may find momentary relief from internal distress.
Researchers have noted that for some young girls, symptoms may become more pronounced during the premenstrual period. It is a great idea to note any patterns on a mood and behavioural record chart to share with your treatment team.
Rituals or associated behaviours
Children, teenagers and young adults may have rituals that are centred around the BFRB. This may include eating the hair or skin tissue that is removed. 5-20% of those diagnosed with Trichotillomania or Dermatillomania also swallow hair or skin, as outlined in research by TLC Foundation for Body-Focused Repetitive Behaviours.
Some young people will focus on the bulb at the end of the hair shaft or the removed skin and chew or swallow. This, in turn, can cause great shame and distress of being seen or caught during the ritual.
Eating skin and hair products can lead to intestinal blockage and cause severe medical complications.
Some young people have particular rituals, which may include lining hair up on paper and collecting skin or nail pieces.
Repetitive behaviours that cause damage are not limited to skin picking or hair pulling
Repetitive behaviours that can cause damage include:
- Hair Pulling or Trichotillomania (TTM)
- Skin Picking or Excoriation (SPD)(ExD)
- Nail biting or Onychophagia
- Cheek Biting
- Thumb Sucking
- Knuckle Cracking
- Teeth Grinding
- Scab Picking
- Callous Picking
- Toe Nail Digging
- Blemish Squeezing.
What else could be happening?
Your Psychiatrist or Mental Health Professional will look at a differential diagnosis. This simply means having a close look to see if anything else could be responsible for the symptoms described.
You may be referred to a dermatologist to look for any causes of irritation or skin conditions. Your Psychiatrist or Psychotherapist will also take time to understand your views on your body and any associated concerns relating to body image or Body Dysmorphic Disorder.
Some substances may also cause a feeling of itchy, crawling, or unpleasant skin sensations. This can be related to the use of opiates and alcohol and can be part of detox or withdrawal from substance use in teenagers.
Some young people who are diagnosed with a developmental disorder or Autism Spectrum Disorder may also describe unpleasant feelings on the skin and body.
Psychosis and Severe Mental Illness can prompt sufferers to describe unusual and unpleasant sensations in the body which may result in them scratching, picking and sometimes harming the body.
Self harm often by intentional and planned episodes of cutting, burning, scratching, pinching, slapping or otherwise harming is common in some mental health presentations. This is different from SPD or HPD, which usually begins in early childhood.
Long-term shame, guilt and distress can cause extensive psychological harm. Some young people may develop extended periods of low mood, depression and may describe feeling suicidal or having suicidal thoughts.
Treatment for BFRBs is not as readily available as a treatment for other co-occurring psychiatric presentations. It is important to locate a treatment provider who has experience and knowledge of BFRBs.
The treatment team in The Wave Young Adults Programs have received supplementary and ongoing training from the specialist BFRB research centre at Massachusetts General Hospital. Current training and acknowledgement of the latest research and treatment methods are essential working with young people diagnosed with BFRB.
CBT that is not specifically tailored to symptom profile is unlikely to work, and professionals are encouraged to refer on. Young people often describe treatment episodes that have failed to address the BFRB despite it being the most pronounced or gateway symptom that they experience.
Treatment plans and self-help strategies
Treatment plans and self-help strategies should help young people to reduce or manage urges, feelings and cognitions.
The single most important aspect of care is acknowledging the distress, shame and pain in young people. A safe and supportive space is essential in creating a healing environment.
Providing young people with other behaviours to occupy hands and distraction techniques is a great first line behavioural intervention. It is generally accepted that in the case of children and adolescents, behavioural therapies should be considered prior to medication being introduced; except in the case of co-occurring mental illness (eating disorders, general anxiety disorder, mood disorders etc.). Some medications can cause serious effects in children and young people and should be carefully monitored by Mental Health Professionals.
Your treatment team may suggest :
- Habit reversal training (HRT), incorporating
- Awareness training, competing response training, social support
- Acceptance and Commitment Therapy (ACT)
- Cognitive Behaviour Therapy (CBT)
- Comprehensive Behavioural Treatment incorporating;
- Self-assessment and monitoring, choosing strategies, trigger identification
- Dialectical Behaviour Therapy (DBT)
- Social support (online support group)
- Parental involvement
- Distress Tolerance
Adolescents often need assistance with motivation and reminders to practice skills. Gentle encouragement works wonders, particularly in the 12-14 year age group. Older teens often choose to engage in treatment which in turn promotes active involvement.
There are currently no FDA approved medications for BFRBs. There has been limited research into medication use in the treatment of all type of BFRB. Some medications have been used ‘off label’, and many individuals have reported great benefits, in conjunction with regular psychotherapy.
Medications are often used to numb or lessen the sensation of pulling or picking. Some research suggests that short-term use of medications can allow for therapeutic or habit reversal benefits to take place. Behavioural techniques, in conjunction with medication, have the best long-term results.
Clomipramine (Anafranil) has been shown to have a positive effect on both urges and associated low moods. All medications should be prescribed for you, following a consultation with a psychiatrist specialising in the treatment of adolescents.
Olanzepine (HPD), Fluoxatine (SPD) and Naltrexone have had promising early results in the treatment of trichotillamania.
Our top tips for self-care
Providing a distraction or setting goals can be a great way to begin to notice when and how BFRB behaviours are most powerful. Journaling, noting and documenting can help build an understanding of the patterns involved. It is a great way to begin the treatment journey and will be incredibly valuable to your healthcare team.
- Limit time alone (sedentary activities or sitting/studying alone when tired)
- Not studying alone, use a library or join a study group (if possible)
- Remove or cover mirrors in bathrooms
- Turn down the lights, avoid bright lights and overstimulation
- Use plasters, fingers covers, or silicone finger protectors to stop biting
- Topical medications to reduce any itch
- Change or modify activities if you feel drawn to repetitive movements
- Set a timer when engaged in sedentary activities. Move through tasks and move location at set times
- Post-it notes or reminders. Bright coloured stickies to remind you to stop!
- Ribbon or string on items, to provide a playful distraction
- Jewellery charms, ring, bracelets to provide sensory stimulation
- Alert or distract bracelets or intelligent alarm systems
- Tumulus control techniques
- Playdoh, bubble wrap, sensory awakening
- Pets. Brushing, stroking, care and washing
- Knitting, crochet and other creative activities.
- The application of astringent lotions following any picking or pulling
- Application of local anaesthetic on known areas to reduce sensation.
Treatment in progress – watch out
Body-Focused Repetitive Behaviours are tricky to navigate for families, young people and treatment teams. The one step forward and two steps back can be disheartening.
They are, however work in progress. Skin and hair, unlike many other compulsive behaviours, is forever with us and close by. The readily available access makes treatment difficult; both patience and commitment are essential.
BFRBs can reappear even after a period of sustained recovery and is important to remain vigilant. A lapse in behaviour is not a failure; it is another opportunity to problem solve. It simply requires getting back to basics and moving forward with the help of a great support network.
Families need support too
Family Therapy is an essential part of great treatment outcomes for young people. BFRB is no exception.
Families can often feel overwhelmed and powerless. Therapy can help both young people and families plan together and communicate. Family members may benefit from individual or couples therapy, particularly during times of high anxiety relating to young adults in the family unit.
The Psychiatric Team at The Wave have extensive experience in BFRB in teenagers and young adults and have completed the training provided by Massachusetts General Hospital Psychiatry Academy; in specialised CBT and Medication Treatment provision. The team is led by Medical Director and Consultant Psychiatrist, Dr R Suliaman. The team have a specialist interest in BFRB where it occurs in conjunction with Eating Disorders and Adverse Childhood Experiences, PTSD and C-PTSD.