Be­hav­ioral ther­apy may ease some repet­i­tive quirks


Lucy Harper, 17, a high school ju­nior who lives in College Sta­tion, Tex., has been pick­ing at her skin for as long as she can re­mem­ber. When she was in sev­enth grade, she also started pulling out her hair.

“For a while my skin pick­ing was un­der the radar, but it was be­cause I was pulling my hair,” she says. “If I wanted my skin to clear up, I’d stop pick­ing and start pulling. If I wanted my hair to grow back, I’d stop pulling and start pick­ing.”

She lost so much hair that her mid­dle school class­mates asked whether she was go­ing bald. “I tried ev­ery­thing to stop pick­ing and pulling,” she says. “I bought tons of fid­get toys. I tried con­strain­ing my arm with a wrist brace. I got per­mis­sion to wear gloves and a hat to school, and I even once went to pi­ano lessons with Band-Aids on ev­ery one of my fin­ger­tips.”

Harper suf­fers from tri­chotil­lo­ma­nia (hair pulling) and ex­co­ri­a­tion (skin pick­ing, also known as der­matil­lo­ma­nia), two of sev­eral disor­ders col­lec­tively known as body­fo­cused repet­i­tive be­hav­iors, or BFRBs. The um­brella term includes a num­ber of repet­i­tive “self-grooming” habits that can cause dam­age or in­jury through pulling, pick­ing or scrap­ing, or bit­ing the hair, skin and nails.

Many peo­ple en­gage to some ex­tent in nail bit­ing or skin pick­ing. But when these be­hav­iors be­come ex­treme and out of con­trol, they are re­garded as se­ri­ous disor­ders.

“There is sig­nif­i­cant psy­choso­cial dam­age,” says Douglas Woods, a pro­fes­sor of psy­chol­ogy at Mar­quette Univer­sity who stud­ies these con­di­tions. Among those who can’t con­tain the urge to pick, pull or bite, “de­pres­sion is rel­a­tively com­mon. Peo­ple be­come very self-con­scious, and self-es­teem suf­fers. They start to avoid so­cial sit­u­a­tions in which peo­ple could no­tice the ef­fects of their be­hav­ior, and of­ten spend tremen­dous amounts of time try­ing to cover the ef­fects.”

His­tor­i­cally, BFRBs had been con­sid­ered im­pulse-con­trol disor­ders, along with klep­to­ma­nia and gam­bling ad­dic­tion. How­ever, in the most re­cent edi­tion of the Di­ag­nos­tic and Sta­tis­ti­cal Man­ual of Men­tal Disor­ders, BFRBs are cat­e­go­rized as ob­ses­sive­com­pul­sive disor­ders, or OCDs. “The truth is, they prob­a­bly be­long in an in-be­tween cat­e­gory,” Woods says.

Al­though now re­garded on the same spec­trum, the two ac­tu­ally are quite dif­fer­ent. Clas­sic OCD oc­curs when some­one ex­pe­ri­ences un­con­trol­lable, re­cur­ring thoughts — such as a dis­pro­por­tion­ate fear of germs — and be­hav­ior she or he feels com­pelled to re­peat over and over, such as ex­ces­sive hand­wash­ing.

Im­pulse-con­trol disor­ders, on the other hand, typ­i­cally in­volve an in­abil­ity to re­sist a po­ten­tially harm­ful or self-de­struc­tive urge.

An es­ti­mated 2 per­cent to 5 per­cent of Amer­i­cans suf­fer from tri­chotil­lo­ma­nia, or hair pulling (which includes eye­lash pulling) and 5 per­cent from skin pick­ing, the two most-com­mon BFRBs, ac­cord­ing to the TLC Foun­da­tion for Body-Fo­cused Repet­i­tive Be­hav­iors. Other BFRBs in­clude hair or skin eating, lip and cheek bit­ing, tongue chew­ing and com­pul­sive hair-cut­ting, ac­cord­ing to the foun­da­tion, a non­profit based in Santa Cruz, Calif.

Be­fore age 12, hair pulling oc­curs equally in boys and girls, but later it pre­dom­i­nantly oc­curs in girls, ac­cord­ing to psy­chol­o­gist Suzanne Mou­tonO­dum, a clin­i­cal as­sis­tant pro­fes­sor at the Bay­lor College of Medicine. “Why is this? We are not cer­tain, but I sus­pect that many more fe­males be­gin to pull around the age of pu­berty,” she says. “Likely there is a hor­monal com­po­nent that af­fects more fe­males than males. Other hy­pothe­ses are that males are more able to cover hair loss, or maybe do not seek treat­ment as they can hide the re­sults of their pulling.”

Re­searchers be­lieve that these disor­ders prob­a­bly have a ge­netic com­po­nent, be­cause they tend to run in fam­i­lies. Sci­en­tists are study­ing the genes of af­fected peo­ple, try­ing to iden­tify mark­ers that can pro­vide clues to their ori­gins. Sev­eral stud­ies have shown a fa­mil­ial con­nec­tion; one, for ex­am­ple, found higher rates of OCD in im­me­di­ate fam­ily mem­bers of those with ex­treme cases of hair pulling than in the gen­eral pop­u­la­tion.

Also, ev­i­dence from a twins study sug­gested a higher oc­cur­rence of hair pulling in iden­ti­cal com­pared with fraternal twins. Re­search also has shown dif­fer­ences in the brains of peo­ple with these disor­ders com­pared with the brains of those who don’t have them.

“Each per­son seems to pull or pick for dif­fer­ent rea­sons, or in dif­fer­ent sit­u­a­tions,” Mou­tonO­dum says. “Some do it in re­sponse to emo­tion — anger, anx­i­ety, hap­pi­ness — while oth­ers in re­sponse to need­ing to feel a cer­tain sen­sory sen­sa­tion, while oth­ers pull or pick in re­sponse to cer­tain en­vi­ron­men­tal trig­gers, such as ac­tiv­i­ties, places, mir­rors.”

Woods agrees. “The be­hav­iors seem to be both a prob­lem of a habit gone awry and a way of cop­ing with emo­tional dis­tress,” he says.

Med­i­ca­tion such as clomipramine, an an­tide­pres­sant used to treat OCD, can help, but ex­perts say the most ef­fec­tive ther­apy is be­hav­ioral. There are two fre­quently used ap­proaches.

The first is habit-re­ver­sal train­ing, which teaches pa­tients to be more aware of their pulling and pick­ing, and its cues, and trains them to use a “com­pet­ing re­sponse” when the urge hits, such as clench­ing the fist with the hair-pulling hand and press­ing it to the side of the body.

The sec­ond is com­pre­hen­sive be­hav­ioral treat­ment, or ComB, which “looks at each per­son as an in­di­vid­ual and eval­u­ates [his or her] in­di­vid­ual pulling/ pick­ing pro­file,” Mou­ton-Odum says. ComB al­lows clin­i­cians to de­sign a treat­ment plan specif­i­cally for that per­son. “Strate­gies are of­fered based upon their unique pulling/ pick­ing trig­gers,” she adds. “It is not a one-size-fits-all ap­proach. It is quite tai­lored.”

Be­cause peo­ple of­ten are un­aware of when they pull or pick, some have found that us­ing an app-equipped bracelet called Keen helps con­trol the habit. The bracelets are pro­grammed to de­tect when the be­hav­iors be­gin, then send a gen­tle vi­bra­tion to alert the in­di­vid­ual to stop. The bracelet has not been stud­ied in clin­i­cal tri­als, but anec­do­tal re­ports sug­gest it can be a valu­able tool. Its price starts at $129.

Les­ley Stevens, 37, an on­line con­tent cre­ator who lives near Phoenix, is a hair puller, skin picker, nail biter and thumb sucker. She wears one bracelet on each wrist — be­cause she picks and pulls with both hands — and says they have been very use­ful in keep­ing her habits un­der con­trol. “They buzz my wrist and make me aware when I’m do­ing any­thing I have trained it for,” she says.

For Harper, the Texas teenager, con­nect­ing with other BFRB peo­ple “who com­pletely un­der­stand my strug­gles” has en­abled her to cope, as has at­tend­ing ther­apy work­shops “that re­mind me that I am so much more than my BFRBs.” She says she still strug­gles “a lit­tle” with skin-pick­ing, “but it doesn’t con­trol my life any­more, and be­ing open about it al­lows me to not be ashamed,” she says.

Be­fore age 12, hair pulling oc­curs equally in boys and girls, but later it pre­dom­i­nantly oc­curs in girls, ac­cord­ing to one ex­pert.

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