Last week I had written an article about how a person having an ADHD diagnosis can also have other co-existing conditions including depression, Bipolar Disorder, and learning disabilities among many others. I did leave out one co-morbid condition which one parent pointed out to me. Some people with ADHD also have what is known as Obsessive Compulsive Disorder (OCD). OCD behaviors can include things like washing your hands repeatedly until they are raw and chafed, checking things repeatedly, or having to maintain certain order in the arrangement of objects or actions. There is another subset diagnosis to OCD which is called Impulse Control Disorder. Under this diagnostic category you can find behaviors such as picking at the body including the skin, fingernails and scalp. Pulling out hair may also be included as an Obsessive Compulsive behavior.
Since two of our members had mentioned that their children who have a diagnosis of ADHD were also exhibiting compulsive picking at fingernails and scalp I decided to do a little research on this topic and I will now share what I found. In looking at ADHD forums and news boards these behaviors may not be as uncommon as you might think. ADDITUDE magazine, for example has an on-line forum where this topic has been discussed. Likewise, on this ADD forum thread you can find people talking about picking their skin and scalp.
Of course there are fancy names for these behaviors. Compulsively picking at one's skin is called "Dermatillomania" and people who have "Trichotillomania" will compulsively pull out their own hair from their scalp, eyelashes, eyebrows, and even pubic area. The problem is that this excessive picking can cause permanent scarring and infection. And hair pulling can cause the person to have bald patches on their scalp.
The DSM-IVR includes 5 criterion that must be present for a diagnosis of Trichotillomania (pulling out one's own hair) to be made and they include:
- Recurrent plucking of one's hair resulting in noticeable hair loss
- Increasing build-up of tension immediately before the plucking which is is follow by:
- Sense of relief or reduction in tension when the hair is pulled
- The problem is not better explained by an alternative mental or medical disorder
- The problem results in significant distress or impairment to the individual in social, vocational or other areas of life
There are no formal diagnostic criteria for Dermatillomania (compulsive picking at one's skin) but behaviors can include:
- Repeated skin picking of the face, lips, scalp, hands, fingernails, or arms
- Tension increase immediately before picking
- Tension decrease or relief when skin picking
- The picking causes significant difficulties in life or stress sensations like itching, tingling, or burning or an uncontrollable urge to pick their skin.
Why do some people compulsively pick at their skin or pull out their hair?
Much of the literature suggests that these compulsions can be both biological and psychological in nature. There are many people who describe a tension release to these behaviors in reducing a build up of anxiety. Others maintain that it is not any conscious thing. Some may be unaware of when they are pulling out their hair for example. On some ADHD support group forums, there is a belief that the over use of stimulants can actually cause hair pulling or skin picking behaviors. In looking for research to substantiate this claim I did find a study which linked certain medications to these behaviors.
In a report entitled, "Trichotillomania: Apparent CYP 2D6 Interaction with Amphetamine and Paroxetine" printed in Primary Psychiatry, authors Nathaniel Parker and Charles Parker describe how a certain combination of stimulant and antidepressant can cause hair pulling behavior. The authors conclude that: "In this report, the onset of trichotillomania appears to have been initiated by long-term adjunctive treatment of amphetamine salts in a patient receiving paroxetine. Symptoms of trichotillomania in this patient abated with a reduction in the amphetamine salts and a discontinuation of paroxetine."
This is a limited finding but it still raises questions about how certain combinations of drugs to help with the symptoms of ADHD and other co-existing conditions can cause other behavioral side effects. If your child is exhibiting hair pulling or skin picking behaviors, it may be wise to ask your child's doctor if the combination of drugs they are taking could have such behavioral side effects. Anything is possible and it doesn't hurt to ask.
What treatment is there for Trichotillomania and Dermatillomania?
The following is a list I have gleaned from both the research on these disorders and also from support group forums.
- Wearing gloves or band aids so you don't have access to your favorite picking spot. Wear a hat to cover your scalp for people who pull their hair.
- Wear a rubber band on your wrist and snap it each time you are about to engage in picking or pulling out your hair.
- Keep your hands busy doing other things. Buy yourself a koosh ball, silly putty, or other toy to keep your hands occupied.
- The Brain Physics Mental Health Resource site suggests that SSRI antidepressants can help those with skin picking problems. They also say that the drug, clomipramine, may help those who engage in compulsive hair pulling. But they also give this cautionary advice: "Usually, 65 percent improvement from a medication is considered a good result. Medication should never be considered an end in itself, but a tool to help with therapy."
- Cognitive Behavioral Therapy as a treatment for both Trichotillomania and Dermatillomania show the best results from both the research and from anecdotal reports from sufferers of these disorders. One study cited in the literature by Azrin, Nunn, & Frantz (1980) demonstrated a reduction in hair pulling of over 90%. Part of this therapy can include something called Habit Reversal Training (HRT) where the person may keep a journal of times when they pick their skin or pull out their hair to try to determine what their personal triggers to this behavior might be. Once the patient is more aware of what circumstances may bring on an episode, they can try to make changes to eliminate these triggers or choose another action than hair pulling or skin picking as a response.
Resources to help with Dermatillomania:
Resources to help with Trichotillomania:
- Trichotillomania Learning Center
- Yahoo Support Group for Parents who have children with Trichotillomania
If you have a story to tell about how you or your child have been dealing with these behaviors please do share that story here. We want to hear from you!