Have you ever caught yourself twirling a lock of hair while reading or picking a scab as you watch TV?
Most of us are susceptible to unconscious, repetitive behaviors when we’re feeling stressed, bored, or uncomfortable. But for some people, these behaviors are not just a habit. They can be signs of two common and often misdiagnosed conditions: skin picking (excoriation disorder) or hair pulling (trichotillomania).
The hallmark of these disorders is a relentless, subconscious cycle of behaviors accompanied by a mix of positive and negative emotions.
They may also result in scarring or physical injury. The behavior pattern may look something like this:
- You notice or seek an imperfection, such as a hair that feels different or an acne spot on the chin.
- Anxiety rises. Your brain tells you the imperfection needs to be fixed.
- You pluck the hair or scratch the blemish and feel a brief sense of relief or satisfaction.
- Then you find another and another until a good span of time has passed.
- You feel frustrated or shameful about the action or time spent.
- A new cycle begins.
If this sounds familiar, you are not alone. Research estimates that trichotillomania and excoriation disorders affect up to 4% of the general population of the U.S., which means millions of people struggle with symptoms.
These disorders are not “bad habits” or moral failings. These are complex neurobehavioral conditions – and both are highly treatable with evidence-based treatments and specialized care.
What are the symptoms to watch for?
Almost everyone engages in occasional preening, such as messing with a cuticle or absently running a hand through their hair. But trichotillomania and excoriation disorders cross a threshold of severity with the ritualistic nature of the behaviors and the resulting damage and distress.
For most patients, the relief of perfectly eliminating the blemish provides a strong yet transient form of self-soothing. Many patients “set the stage” for their sessions in a particular room or specific chair. Some may have special tools such as a lighted mirror, tweezers, or pins to target specific areas and heighten their satisfaction. Others may not even notice what they are doing until minutes have passed, and they suddenly realize their hand is on their face or in their hair.
Psychiatrists and psychologists at the Peter O’Donnell Jr. Brain Institute at UT Southwestern look for two criteria to help make a diagnosis:
- Physical harm: This might include visible bald spots, patchy hair loss, skin lesions, chronic scabs, or scarring.
- Excessive time involved: The behavior is considered clinically significant if you are spending an hour a day or more on it, avoiding social situations, experiencing significant emotional distress, or falling behind at work or school to engage in these behaviors.
Symptoms of trichotillomania include pulling hair from the scalp, eyelashes, eyebrows, arms and underarms, legs, and/or pubic area. Most will develop bald patches, and many examine the hair to see whether the follicle is intact, manipulate it into a particular shape or size, or chew and swallow the hair (trichophagia). Ingested hair can form into a clump in the digestive tract called a trichobezoar, which can cause constipation or serious gastrointestinal problems.
Symptoms of excoriation disorder involve repeatedly seeking and picking at skin irregularities, often on the face, arms, or scalp. Over time, this can cause bleeding, open wounds, infections, and scarring.
Because of shame or fear of being found out, many people go to great lengths to disguise their behaviors. They wear hats or wigs to hide hair loss or cover up skin-picking scabs with long sleeves, even during the summer months. They may self-isolate by canceling appointments and avoiding the gym, doctor visits, or social outings. Others pay for cosmetic procedures to repair skin damage (chemical peels) caused by excoriation only to repeat the process of damaging their skin again.
What causes hair pulling and skin picking?
Hair-pulling and skin-picking disorders fall into a cluster of conditions called body-focused repetitive behaviors (BFRBs). Medically, these conditions are categorized in a cluster of illnesses alongside obsessive-compulsive related disorders.
BFRBs are a complex interplay of genetic, psychological, neurobiological, and environmental factors. Research among twins shows a strong correlation between genetics and BFRBs, suggesting that hair pulling and skin picking can run in families:
- If you have excoriation disorder, genetics might account for more than 40% of differences seen across the population.
- If you have trichotillomania, your genes may account for 32% to 78% of the likelihood that you develop the condition.
These disorders are deeply wired into the brain’s circuitry, functioning more like a neurological process than a conscious choice. Research shows that patients with BFRBs have structural and functional differences in specific regions of the brain:
- Reward processing: Dysfunction with the brain’s “reward pathway” can result in an immediate gratification response to the act of pulling or picking.
- Inhibitory control and habit formation: BFRB conditions have been linked to differences in executive function, impulse control, and focus, making it harder to stop repetitive behaviors.
The behavior/reward cycle with these disorders can be likened to playing a slot machine. Not every hair pulls out with the follicle intact, and not every scab comes off in a perfect piece. But when it does, the patient gets both a physical release and a sense of internal satisfaction, and they continue chasing that feeling with each repeated behavior.
Environmental triggers: Stress, anxiety, and boredom
While genetic and biological predispositions play a role, hair-pulling and skin-picking behaviors are almost always triggered or sustained by one’s emotions or environment:
- Sensory cues: The irresistible desire to remove a perceived imperfection, such as a rough patch of skin, a stray eyelash, or a hair with an unusual texture.
- Tension and anxiety: The act of pulling or picking can be an attempt to regulate or distract from overwhelming or uncomfortable emotions.
- Boredom or sedentary activities: Many patients pick or pull when their hands are idle, such as while reading, watching television, driving, or studying. The behavior becomes an automatic form of self-stimulation.
Excoriation disorder and trichotillomania often occur together. Many people with BFRBs also have other neurological or mental health conditions. For example, in a large U.S. study, 79% of adults with trichotillomania had at least one co‑occurring condition, such as anxiety, depression, OCD, attention deficit hyperactivity disorder, autism spectrum disorder, or a psychotic disorder.
What are the treatment options?
Treatment that targets both the physical habit and the emotional aspects of the behavior cycle can be highly effective. To begin, a UTSW specialist will ask questions about your symptoms and how they affect your daily life: when and where sessions happen, the tools and rituals you use, and how you dispose of or handle the hair or skin afterward.
We also screen for co‑occurring disorders and complications such as skin infections or digestive concerns if hair is swallowed.
Be honest with the specialist. Tell us how much time you spend, the damage you’ve noticed, and what you do before, during, and after sessions. We will not judge you – providing accurate details helps us recommend the right treatment options and will put you on the quickest path to recovery. Most patients benefit from therapy, medication, or a combination of both.
Habit reversal training
The cornerstone of treatment is habit reversal training, a specialized form of cognitive behavioral therapy developed specifically for BFRBs. This therapy is not just about stopping the behavior; it’s about understanding the function it serves and replacing it with a healthy, incompatible response.
Habit reversal therapy involves three core components:
1. Awareness training: The first step is teaching the individual to become acutely aware of the behavior. This includes:
- Identifying the precursors: Recognizing the specific environmental and emotional triggers, such as anxiety, stress, or the moment the hands become idle.
- Identifying the premonitory urge: Pinpointing the subtle physical sensation or muscle tension that occurs just before the pulling or picking begins. Awareness training brings the automatic action back into conscious control.
2. Competing response training: The patient practices another physical action for a set period when they feel the urge to partake in the ritual. This helps the brain form a new habit loop. For example, we may ask you to practice the exact motion of pulling a hair right up to the moment of plucking, then ask you to clench your first or sit on your hands for 60 seconds instead of removing the hair.
3. Stimulus control: This involves modifying the environment to intercept the behavior. It may include:
- Removing potentially dangerous tools, such as sharp pins, from the ritual space.
- Wearing physical barriers such as gloves or long sleeves.
- Avoiding triggers such as brightly lit bathroom mirrors.
Other forms of cognitive behavioral therapy can help to address underlying thought patterns such as striving for perfection (“I just need to fix this spot”) or feeling disgust with perceived imperfections. Participating in therapy uses mindfulness to restructure your thoughts and help you tolerate discomfort.
Is medication an option?
Though no medications are specifically approved for BFRBs, several have been shown to help patients undergoing habit reversal training to reach their goals. Other medications can help with co-occurring anxiety or depression or to directly target neurobiological urges that drive the behavior. Medications can include:
- N-acetylcysteine (NAC): Glutamate is the brain’s primary excitatory neurotransmitter, and its dysregulation is implicated in compulsive behaviors. NAC is an over-the-counter amino acid derivative that helps regulate glutamate levels, indirectly decreasing the strength of the compulsive urge and the seeking behavior. This drug has been a gamechanger for helping to manage BFRBs.
- Memantine: Recent research with this glutamate modulator, which is commonly used for Alzheimer’s disease, has shown promise in reducing both hair-pulling and skin-picking symptoms in adults.
If NAC or memantine are insufficient, we might consider other agents tailored to the patient's needs, such as:
- Naltrexone: This opioid antagonist can be helpful for patients with a personal or family history of addiction.
- Clomipramine or olanzapine: These agents are used only in treatment-refractory cases. Research has shown some evidence of effectiveness, but these medications can cause unwanted side effects, including agitation, dizziness, and increased risk of infection.
Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine or sertraline, which are commonly used in depression, are generally not effective for BFRBs. While SSRIs may help with underlying anxiety or depression, they often do not disrupt the core repetitive behavior.
Living with trichotillomania or excoriation disorder can feel isolating, but you are not alone. Talk with a BFRB specialist about your symptoms. We can develop a precise, effective treatment plan to help you break the cycle and improve your quality of life.
To talk with an expert about body-focused repetitive behaviors (BFRBs), make an appointment by calling 214-645-8500 or request an appointment online.
