Hair Pulling (AKA Trichotillomania) and Skin Picking Problems – Greater Research Support for Behavior Therapy over Medication

Trichotillomania (or trich for short) is a condition in which people repeatedly pull out their body hair, often leading to bald patches and thinning. The scalp is a common site—as are eyebrows and eyelashes—but some may pick at hair anywhere on the body. A related condition is repetitive skin picking. This condition did not have an official diagnostic name until 2013, when the most recent edition of the DSM psychiatric guide decided on the name excoriation. People with an excoriation disorder pick or scratch at their skin—often at perceived imperfections or blemishes—to the degree that they may cause marks, bleeding, and scarring.

Both are broadly categorized as body-focused repetitive behaviors, and these have recently been more broadly categorized and obsessive-compulsive and related disorders. People with these problems often experience a great deal of shame and embarrassment about their difficulties and have an extremely tough time stopping.

Unfortunately, both conditions are understudied and not well-known. Many people struggle with them without realizing there is even a name for their condition.

The treatment literature is relatively small compared to problems such as depression and anxiety. However, I recently came across a nice summary of treatment options for trichotillomania and skin picking, as well as other conditions more broadly called obsessive-compulsive and related disorders.

Cognitive Behavioral Therapy

For hair pulling, cognitive behavioral therapy has the greatest research support. An intervention called habit reversal training has been the most studied, either by itself or in combination with a more comprehensive cognitive behavioral treatment such as Acceptance and Commitment Therapy (called “act” for short).

With excoriation, there is evidence that treatments that work for hair pulling also work for skin picking. Unfortunately, the treatment evidence for excoriation is more limited. Although it was studied for decades before being given an official diagnosis in 2013, I suspect not having an official diagnosis slowed research interest. Hopefully, we will begin to see more research on skin picking.

Medication

Rigorous research on the use of medication is much less robust than the research on therapy. There’s some evidence that the antidepressant clomipramine may help reduce hair pulling, but controlled studies on the use of SSRI’s—the most common class of antidepressants—have not shown much effectiveness. Of the SSRI’s, fluoxetine has been the most studied, but it’s effectiveness with hair pulling has been very mixed.

There’s some research support for the use of antidepressants in reducing skin picking; however, there have been no large controlled trials.

My Impressions

The research matches my experience as a therapist. Many people I’ve treated for hair pulling or skin picking have tried medication first and have either not found it helpful at all or have been unclear about whether it was effective or not. If someone’s anxiety is contributing to pulling or picking behavior, medication may help reduce the tendency somewhat but is not likely to be a total cure.

I should also acknowledge that behavioral treatment for picking and pulling is hard work. It takes a lot of attention and effort to change these habits, and many people who do well with treatment continue to struggle with it to some degree. For these reasons, it is important to see a specialist in hair pulling and skin picking. Generic talk therapy is unlikely to be of much help.

Summary

In sum, some form of cognitive behavioral treatment—especially with habit reversal training—with an experienced specialist should be the first-line treatment for hair pulling and skin picking.

As I’ve written about before, the Trichotillomania Learning Center is a great grassroots resource for learning more about hair pulling and skin picking.

If you’d like to read the full article yourself, you can download it here.

Pain, values, compassion, and a dying dog

“Grief can be the garden of compassion. If you keep your heart open through everything, your pain can become your greatest ally in your life’s search for love and wisdom.”

 — Rumi

Just about three years ago, I wrote a blog post titled “Pain and values: two sides of the same coin” about our amazing dog Dalai. That post turned out to be one of the most popular pieces I’ve written. I wrote about the simultaneous, and I would say inseparably linked, love and pain that was consistently present for me when I was with Dalai, who was somewhere around 17-18 years old at the time. Because so many people have talked to me about that piece, I thought I would share an update and also some new thoughts I have on the topic of pain and values. If you want to read the original piece, you can find it here.

Dalai is still here, and so is the pain.

Believe it or not, Dalai is still with us, and at around 20+ years old, I’d say that little old lady is doing something right! She comes to work with us every day, usually riding in a trailer pulled behind the bike. She was diagnosed with thyroid cancer about a year ago and has been on palliative care since. With the help of our amazing veterinarian, Heather Dillon, DVM, we’re able to manage her physical pain quite well and Dalai still has a wonderful quality of life.

And though I feel incredibly fortunate that Dalai is still with us, so too is the pain, anxiety, and sadness I feel when I think about what is to come. In fact, it’s difficult to admit, but there are even times when the pain is so intense that I notice having the thought that I wish it was over. Then of course I feel incredible pain at having that thought and the cycle goes on.

Compassion as palliative care

In my last post about this, I focused on the idea that I can’t move in the direction of my values if I’m not willing to experience painful thoughts and feelings – If I’m not willing to have those painful thoughts and the sadness that shows up when I’m with Dalai, I can’t care for her in the way I would choose to during this time in her life. The only way to get away from these difficult thoughts and feelings is to not be around her. And while it’s still very painful for me to be around Dalai, I’m not willing to give up one moment I could have with her just to avoid that pain. And in these past few years as both she and I have been working through the process of her aging and dying, I’ve learned a few things about how I want to be with that pain. So I thought I’d share something that for me has become an essential component in that equation of values and pain– compassion.

Just as my loved ones and I have been very intentional over these past several years about attending to Dalai’s physical pain as best we can, it’s also been helpful for me to attend to the emotional pain that those of us who love Dalai feel as we see her dying. Compassion, which literally means “to suffer together”, is a willingness to be present to suffering (another’s or your own) and a desire to ease that suffering. Compassion, including self-compassion, is my palliative care. It is what I am using to help ease the suffering my loved ones and I are feeling. Even though I help people develop self-compassion and be intentional about their values for a living, I found that although I wasn’t avoiding being with Dalai in order to avoid feeling the pain, I wasn’t fully present to it either; it was more like, “Well, that’s there and there’s nothing I can do about it, so I’m just not going to think about it.” And that can be helpful at times. But that isn’t how I treat others that I love when they are in pain and it felt incongruent with my values to treat my own pain in that way. So, over the past couple of years I have focused more and more on using compassion exercises in my own life, as a way to not only ease the pain I am feeling, but also honor it.

Quick self-compassion break

One of my favorite compassion exercises that I’ve incorporated into my life is Kristen Neff’s Self Compassion Break. The self-compassion break exercise gives me a way to treat myself with gentleness and kindness and also connect to the common humanity that is suffering. It is very quick and you can do it anywhere, which is great given that pain does not conveniently just show up when I have time to do a 30 minute compassion meditation. You can find an audio of the exercise here and a written script here. So next time you notice struggling with painful thoughts or feelings, especially when you know they are linked with something you care very deeply about, you might consider giving this exercise a try. And If you’re interested in reading more about compassion, my colleagues Jason Luoma (who also happens to be Dalai’s guardian too!) and Melissa Platt and I have a site dedicated to our work in that area called “ACT With Compassion” that you can check out here.

Thomas Merton once wrote that “Compassion is the keen awareness of the interdependence of all things.” When I am practicing compassion, I also often notice being more connected to all beings, including that little old dog at the heart of this all.

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