Trichotillomania

by Suzanne Feinstein, Ph.D. and Ori Shinar, Psy.D.

It is common for people to express frustration, anxiety or even boredom by muttering phrases such as "I feel like ripping my hair out" or ‘I'm jumping out of my skin". Most often, these expressions are used figuratively and people find other outlets to alleviate physical tension like punching a wall, yelling into a pillow, venting to a friend, taking a walk, etc. However, there are people who literally rip their hair out and attack their skin in an attempt to alleviate tension. Hair pulling and skin picking can involve any area of the body and frequently are accompanied by like-behaviors such as pulling apart split ends, nail biting, and cuticle picking.

Hair pulling, known as trichotillomania, and skin picking are behaviors which are not well understood by most therapists. Diagnosticians currently struggle to decide on the most appropriate category in which to group these disorders. Some argue that trichotillomania and skin picking most closely resemble obsessive compulsive disorder (OCD) and should be categorized as an OC Spectrum Disorder. OCD is an anxiety disorder in which people perform repetitive behaviors or compulsions to alleviate distress brought on by recurrent thoughts, feelings, fears or preoccupations known as obsessions. Common examples of compulsions include frequent hand washing to alleviate a constant feeling of being unclean, checking the stove to assuage one's doubt of leaving on the gas, and excessive arranging of items in an attempt to satisfy the need for perfect order. Many people engage in hair pulling and skin picking compulsions to satisfy their need for symmetry ("I have a lesion on my left cheek so I need to even it out by making a mark on my right cheek), their need for exactness ("This hair feels more wiry than the others so I need to pull it out") or magical thinking (If I don't pull my eyelash out by the root, something bad will happen").

However, not all people who pull or pick report obsessive thoughts or physical tension to be the reason behind their behaviors. Some people claim that these behaviors are not triggered by stress; rather they occur most frequently when they are involved in sedentary (low stress) behaviors such as watching television, surfing the web, reading, talking on the phone, etc. People frequently report being in a trance-like state when they pull their hair or pick their skin. Thus, therapists recognize that trichotillomania and skin picking cannot be categorized exclusively under an anxiety disorder such as OCD. Diagnosticians have stated that hair pulling and skin picking can be defined as "impulsions" instead of compulsions since these behaviors are not always triggered by thoughts or fears, but rather by an inability to control simple urges or impulses. Thus, certain therapists argue that it is more appropriate to classify trichotillomania and skin picking as impulse control disorders, and feel that they should be grouped with other impulsive disorders, such as compulsive gambling, binge eating and substance abuse.