- Hi, I'm Dr. Tracey Marks, a psychiatrist
and I make mental health education videos.
Today, I'm answering a viewer question
to talk about body focused repetitive behaviors.
This is a broad term
for a specific type of compulsive behaviors
that cause self-injury.
The two most common behaviors are hair pulling
and skin picking.
These two have official names in the
Diagnostic and Statistical Manual of Mental Disorders.
Hair pulling is called trichotillomania
and skin picking is called excoriation disorder.
Even though trichotillomania has mania in the name,
it has nothing to do with the mania of bipolar disorder.
In fact, trichotillomania used to be listed
under impulse control disorders in the manual
and now it's listed under obsessive-compulsive
and related disorders
and this characterization is a better match
for these behaviors
because they really are more compulsive than impulsive.
You don't just randomly do them.
You can't stop doing them.
There are also other compulsive body focused behaviors
that I'll mention later
but these are the two that are listed
as disorders in the diagnostic manual.
So first, trichotillomania or hair pulling.
With this disorder, you pull out your own hair repeatedly.
It's usually strand by strand.
Have you ever played with your hair
or pulled on it while you were reading or studying?
This is not the same thing.
You can do that with trichotillomania
but it's much more than that.
Usually, the urge to pull the hair is preceded by anxiety
or a buildup of tension
then pulling the hair relieves that tension.
Sometimes, random hairs may satisfy that urge
but many times, it needs to be a certain kind of hair
like the certain hair texture
and some people get a lot of pleasure
from seeing the white root at the end
and you've gotta pull just right to get that white root.
So this is one reason a person can pull many hairs
until they get the right presentation
then it's common to manipulate the hair afterwards.
You may like the way it feels rolling in your hand
or in between your teeth
and some people will even suck on the root of the hair
then there's usually a lot of relief
or gratification from this ritual
but the relief is short lived.
Because part of the criteria for this behavior
is that the behavior ultimately causes distress,
you can feel shame for needing to do this
or frustration over your lack of control.
You make attempts to stop it and you may stop for a while
but then something will trigger you to start up again
and because it's a compulsive behavior,
you can't just do it once.
You can pull hair from anywhere on your body that has hair.
The usual places are the scalp,
the eyebrows and the eyelids or your eyelashes
and you may change up the site from time to time.
Also, you're usually trying to hide this from people.
So if it's a place that's noticeable like your scalp,
you may wear scarves or hats to hide the bald spots
or you may pick different places so that it's not,
you don't have noticeable balding
but instead, your hair just may look thin.
Normally, this behavior is driven by negative emotions
but sometimes you can fall into an automatic behavior
of pulling your hair without much conscious awareness.
An example of this would be pulling your hair
while you're reading or doing something else
and in this case,
the hair pulling can be a soothing behavior
similar to a child sucking her thumb
and it still serves the purpose though
of calming mental tension
but you're not intentionally pulling the hair to get relief.
Some people with trichotillomania may pull other hairs
like the hair from a pet or fibers from a sweater
and this would be an extension of pulling your own hair.
So the problem starts with pulling your own hair first
and then you may do these things later.
Next is skin picking or excoriation disorder.
This behavior has a lot of the characteristics
of hair pulling except you're picking your skin
to the point of creating sores.
The common places are the face, the hands and the arms.
Most people use their fingernails
but some people can use tweezers or bite the skin.
Biting is usually what you see in someone
who bites at their hands or their cuticles.
For example, if you're studying or working,
you may be writing with one hand and then biting or chewing
with the other hand,
Sometimes, you may focus on a pimple or a bump
but most times people pick it healthy skin
until it makes a sore then you'll later pick at the scabs.
Similar to the rituals with trichotillomania,
some people will play with the scabs or even chew on them.
People can spend hours doing this
and they usually hide it from others.
Both of these disorders usually start in adolescence
right around puberty and it's usually chronic
meaning it can last weeks to months
or even years at a time.
It can come and go though with long periods in between
where you're not doing it.
When it's a problem, the problem can be mild or severe.
Mild could look like some hair pulling
that you really don't spend a lot of time on
but you still don't like that you do it.
You may have a few chewed fingers
or a thin area of hair in your temple
that's not very noticeable
and you can manage to break the cycle and stop doing it.
A severe case of skin picking can lead to serious infections
like cellulitis or even severe scarring.
So those are the two body focused repetitive behaviors
that are listed as disorders in the DSM manual.
Oftentimes, a person with either of these
will engage in other repetitive behaviors.
Some other body focused repetitive behaviors
include nail biting, also called onychotillomania,
lip biting and nose picking.
What's the treatment for this?
People with mild cases can go without treatment
and the problem can resolve on its own.
Since it's a compulsive disorder though,
the issue is being able to control the urges.
If you have a mild case,
you can recognize and avoid triggers
or find ways to distract yourself.
When you can't control it on your own, there's therapy.
Some of the things therapies used to help this condition
are habit reversal training
which is a type of cognitive behavior therapy
and a self-help technique called decoupling.
With decoupling, you perform a different behavior
whenever you feel the tension
that normally triggers a compulsion.
The idea is that this other behavior that you do
decouples or disrupts the connections
between the emotion and the compulsion.
Engaging in the other behavior
allows you to gain some control
over the compulsive behavior.
We don't have any medications
that are standardly used for this disorder.
There has been some evidence though
that Inositol and N-acetylcysteine have been helpful.
Both of these are supplements
that you can get without a prescription.
Other alternative therapies include yoga, aerobic exercise,
acupuncture, biofeedback and hypnosis.
Watch this video for more on obsessive-compulsive disorder.
See you next time.