Body Focused Repetitive Behaviors (Hair Pulling, Skin Picking, Nail Biting, Cheek Biting)

Body focused repetitive behaviors are a group of actions that are often mystifying and frustrating to the people who perform them. They include hair pulling, skin picking, nail biting, and cheek biting, among others. People often want to stop but find it surprisingly difficult to do so. You may be ashamed of these behaviors because you don’t know why you engage in them and can’t stop doing them.

It is embarrassing to be questioned, criticized, or nagged about them. You may be ashamed of bald places or scabs and not want anyone to see them. This can result in low self-esteem and social isolation. Most likely, you do not engage in these repetitive behaviors to deliberately cause pain or harm. Although there are many things that aren’t well understood about these disorders, there is increasing awareness of them and research being conducted on causes and effective treatments.

Trichotillomania (Hair pulling)

Trichotillomania is also known as compulsive hair pulling. Although many of us may pull out a hair or two (plucking eyebrows, pulling out gray hairs), some people take it further.

Indications of a problem are 1) Repeated pulling out of hair that results in noticeable hair loss, 2) Increasing sense of tension immediately before pulling out hair or when attempting to resist the behavior, 3) Pleasure, satisfaction, or relief when pulling out the hair, 4) Significant distress or interference in living your life, 5) No other mental or medical condition.

Although you might feel alone, somewhere between 2 and 6% of the population engages in compulsive hair pulling. You may aware of doing it but find you can’t stop once you have started. Maybe you start pulling without conscious awareness. Many people like the feeling of the hair coming out, although not everyone does. You might think that pulling helps you to concentrate or find it is useful to manage upsetting feelings. Maybe you pull during relaxing activities, such as reading or watching TV, or stressful ones, such as rushing to meet a deadline. The urge to pull is often difficult to resist, and you might experience distress and shame after a pulling episode.

There Are Effective Treatments

In my experience, a combination of cognitive behavioral therapy and mindfulness/awareness training is most effective in helping curb the hair pulling impulse. Some people are able to eliminate the behavior and urges; others find it to be a lifelong condition. Treatment often improves hair pulling and helps with the anxiety, low self-image, and depression that often accompany it.

One of the first steps is to develop an increased awareness of the internal and external triggers for your pulling. External triggers include, among other things, your physical environment, physical sensations, time of day, and posture. Internal triggers include your thoughts, feelings, memories, and sensations. In sessions, we can develop a plan to recognize and structure the times you feel most vulnerable. Some people benefit from behavioral techniques such as bandages on the fingers, keeping records of hair pulling, or changing environmental cues that trigger the behavior. Habit reversal training has been well documented as an effective strategy.

I also emphasize awareness of the precursors to pulling through mindfulness training and stress management. Mindfulness is both a cognitive and a behavioral process. When you consciously respond differently to thoughts, feelings, and stressors, you are able to also act differently. If you are suffering from trichotillomania, our ultimate goal  is to help you develop the ability to experience uncomfortable thoughts, feelings, sensations, and urges, without pulling your hair.

Dermotillomania (Skin Picking)

Also called dermotillomania or excoriation disorder, skin picking is a poorly understood problem. People who suffer from it repetitively touch, rub, scratch, pick at, or dig into their skin, often in an attempt to remove small irregularities or perceived imperfections. This behavior may result in skin discoloration or scarring. In more serious cases, picking can cause tissue damage and visible disfigurement.

Skin picking frequently exists on its own, but it also may be a symptom of other disorders, such as autoimmune problems, drug or medication related issues, or dermatological problems. There may be an underlying genetic predisposition to engage in body focused repetitive behaviors.

There is no universally agreed-upon standard as to when skin picking becomes a serious problem. However, when your picking is 1) taking significant time, 2) results in noticeable tissue damage, 3) causing you emotional distress, and 4) causing impairment in your social, occupational, or physical functioning, it may be time to seek help.

Although this behavior can be harmful, it is not done with the intent to hurt yourself. There are many reasons skin picking and related behaviors get established. You might have found it useful as a way to regulate feelings and get relief from the usual chatter of thoughts and worries. Sometimes, you may pick primarily as a means to self-soothe when depressed, angry, bored or tired. It may happen when you are doing something else, such as driving, working on the computer, or reading, or when you feel overly stressed, anxious, or agitated. Although picking your skin may feel pleasurable or rewarding at the time, you may feel regret and distress afterwards.

Treatment Can Help You Stop Unhealthy Habits

It is very important that you are carefully assessed so that treatment can be individualized. Although picking problems may look the same from person to person, your individual experience is different on the inside. Treatment needs to be matched to your personality and the internal forces behind your picking.

With mindfulness based cognitive behavioral therapy, you can challenge static beliefs and deal with uncomfortable feelings. This is a way to slow down reactions and increase awareness so that you can see different choices. The starting point involves awareness, acceptance, decreasing unthinking action, and decreasing shame. In sessions, I can teach you cognitive behavioral techniques such as habit reversal training (learning alternative coping strategies) and stimulus control (modifying aspects of the environment to reduce sensory input that leads to picking). Many skin pickers are perfectionists and find it hard to accept flaws of any sort in themselves or others. When you develop tools to recognize and tolerate imperfections, you can lessen the internal pressure to be perfect.

Exposure and response prevention (ERP) combined with mindfulness helps you build tolerance for urges and increases your ability to resist acting on them. Modifying picking behavior is a complex process; using several approaches could have the best result. As habits begin to change, so do neural pathways in the brain. As different neural pathways and networks are created, the urges become more manageable. You can train your mind away from harmful habits.

Other Body Focused Behaviors Including Cheek Biting and Nail Biting

I have training, experience, and success in helping people to greatly reduce or eliminate hair-pulling, skin-picking, and other BFRB’s. Therapy involves looking at the history of you behavior, triggers, cognitive and emotional influences, and learning about the function it serves. We will consider the impact of anxiety, stress, perfectionism, and the physical activation that often drives these behaviors. Together we will come up with strategies and ways to change your triggers and responses so that you can manage your emotional, mental, and physical impulses in a healthy, mindful way.