Mental Health

Author: Anxiety Canada

Body-focused repetitive behaviours, or BFRBs, are a cluster of habitual behaviours that include hair pulling, skin picking, nail biting, nose picking, and lip or cheek biting. Currently, the most recent edition of the clinician’s diagnostic manual (DSM-5), has listed both hair pulling, called Trichotillomania, and skin picking, called skin excoriation, as BFRBs that are of clinical concern. These are listed under the section, obsessive compulsive and related disorders, and are described in detail here.

Trichotillomania (TTM)

Three primary features define TTM:

• Ongoing and repetitive pulling out of one’s hair resulting in noticeable hair loss.

  • The most common sites are the head and face (i.e., eye brows and lashes), although youth also pull from other areas such as the arms and legs, the pubic region, under the arm, as well as on other individuals and even from pets, such as cats and dogs. Children are less likely than adults to pull from multiple sites, often favoring a single location.

  • Repeated but unsuccessful attempts to reduce or stop the pulling.

  • Significant impairment or disruption in routine life functioning.

Additional features of TTM:

• Youth with TTM engage in two types of pulling behaviour: focused and/or unfocused/automatic pulling, with many individuals experiencing both types. Focused pulling typically occurs in response to an internal state (e.g., anxiety, boredom, sadness, shame, etc.), often triggered by an external event (e.g., a fight with a friend, or the memory of that fight), and is more common in older adolescents and adults. In contrast, automatic pulling usually occurs out of the individual’s awareness, often during sedentary activities such as watching television, reading, or playing. It is this type of pulling that predominates in children.

• Pulling episodes can last several minutes to over an hour or more in duration.

• In order to successfully extract the hair, the youth may use their thumb and index finger, other finger combinations, or tweezers to pull one hair at a time. Pulling clumps of hair is unusual.

• Pulling episodes often include a variety of component parts as follows:

  • Fingers being close to the area (e.g., elbow resting on arm of chair, and head resting on hand).

  • Fingers touching the area (e.g., smoothing down eye brows or hair twirling).

  • Fingers seeking out the “optimal” hair. For some children this will be a thicker hair, or a hair with a bulbous follicle.

  • Internal arousal or mounting tension (not typical in younger children).

  • Manipulating and then pulling the hair.

  • Playing with the hair. This may be with fingers alone, or rolled on the face and lips, and in some youth, chewed on and even swallowed.

  • As it is rare for an individual to pull only a single hair, throughout the entire pulling episode, the individual typically experiences a flood of pleasurable sensations such as relaxation, as well as relief from negative feelings such as boredom, frustration, or loneliness. Pain often occurs in equal measure with pleasure in children.

• A critical piece that contributes to youth continuing to pull despite the often obvious signs of damage (e.g., bald spots), as well as a strong desire to stop the behaviour often due to shame and embarrassment, are the pleasant feelings that result from pulling, as well as the relief from negative emotional states, during an episode. These aspects are a powerful form of self-soothing that is highly rewarding and thus difficult to resist, when urges to pull arise.

Facts

• TTM occurs in 1-3% of children and adults during their lifetime, with the average age of onset in early adolescence although it can start as early as age one.

• There is no known cause, although research suggests TTM is a neurobiobehavioural disorder with genetics contributing to the onset.

• Younger children are more likely to engage in automatic pulling, with no reported awareness of tension before, and pleasure after, each pull.

• A range of physical effects can occur in individuals with TTM including formation of Trichobezoars, hairballs, in the gastrointestinal tract that sometimes will require surgery, atypical regrowth of hair, dental damage, carpal tunnel syndrome, among other conditions.

Signs and symptoms

Thoughts & Beliefs

(Note: very young children may be unable to identify specific thoughts)

• I must make them symmetrical (eyebrows)

• It's the only thing that makes me feel calm and relaxed

• I can’t stand to have thick hairs growing in

• I’m helpless to control it

• I’m a perfectionist

Physical feelings

• Derealization (out of body experience)

• Exhaustion and fatigue

• Internal arousal or mounting tension

• Muscle tension

• Pleasure, relief, or gratification

• Urges to pull, or even things out

Emotions

• Anxiety/worry/stress

• Boredom

• Frustration and anger

• Guilt

• Loneliness

• Pleasure and happiness

• Sadness

• Shame and embarrassment

Behaviors and external signs

• Avoidance of others and social isolation

• Hair loss

• Missed work or school

• Pulling the hair

• Playing with the hair including eating it

• Reduced academic or job opportunities

• Touching, smoothing, and manipulating the area

Common situations or affected areas

• Avoiding routine activities such as swimming, getting hair cut/colored, medical visits, and more

• Financial strain upon the family due to cosmetic costs to cover or correct hair loss

• Impaired relationships including reduced romantic intimacy and social isolation

• Missed school or related activities

• Trouble concentrating or sustaining attention in school

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Skin excoriation (SE)

Another BFRB of clinical relevance is skin excoriation (SE), which shares many of the same features as TTM. The three primary features of SE are:

• Ongoing and repetitive picking of one’s skin that may or may not be triggered by a visible scab or other mark (e.g., bug bite or pimple), which due to the force of picking, creates or worsens a skin lesion. The most common sites are the face, arms, and hands, although other body parts can also be a target, such as the legs and pubic areas where ingrown hairs may be more frequent.

• Repeated but unsuccessful attempts to reduce or stop picking.

• Significant impairment or disruption in routine life functioning, such as social isolation and/or problems with academic or job success, permanent scaring, low self-esteem, financial strain upon the family, and more.

Additional features of SE:

• As in youth with TTM, youth with SE also report that the picking behaviour exists as either a focused or unfocused/automatic activity. Focused picking typically occurs in response to an internal state (e.g., anxiety, sadness, shame, etc.), often triggered by an external event (e.g., seeing themselves in the mirror or feeling a pimple), whereas automatic picking usually occurs out of the individual’s awareness often during more sedentary activities such as watching television, reading, or typing. This latter type of picking often also involves touching, rubbing, squeezing, biting, and other forms of manipulation of the area.

• Prior to picking, some children report internal arousal or mounting tension, that will increase in intensity if the urge is not met, followed by pleasure or relief after picking.

• Picking episodes can last several minutes to over an hour or more in duration. If one also includes time spent anticipating a picking episode and thus being distracted from the task at hand (e.g., schoolwork), episodes can consume hours each day.

• The child or adolescent typically will use the fingernails to pick, but other methods can include tweezers, pins and other related objects. The youth may play then with, or even eat, the resulting scab or skin.

• Once more, like youth with TTM, a critical piece that contributes to ongoing picking despite the often obvious signs of damage (e.g., open sores and scaring), as well as a strong desire to stop the behaviour often due to shame and embarrassment, are the pleasant feelings that result from picking, as well as the relief from negative emotional states, during an episode. These aspects are a powerful form of self-soothing that is highly rewarding and thus difficult to resist, when urges to pull arise.

Facts

• SE occurs in approximately 1.5% of individuals during their lifespan.

• SE is a secretive behaviour, and thus with the exception of close family members, most children will only pick in private.

• A range of physical effects can occur in youth with SE including tissue damage, scaring and infection, with surgery required in extreme cases.

Signs and symptoms

Thoughts & Beliefs

(Note: very young children may be unable to identify specific thoughts)

• I must make do something to make this look better

• It's the only thing that makes me feel calm and relaxed

• I can’t stand to have imperfections in my skin

• I look ugly

• I’m helpless to control it

Physical feelings

• Exhaustion and fatigue

• Internal arousal or mounting tension

• Loss of control

• Muscle tension

• Pleasure

• Relief

• Urges to pick or clean things out

Emotions

• Anxiety/worry/stress

• Boredom

• Frustration and anger

• Guilt

• Loneliness

• Pleasure and happiness

• Sadness

• Shame and embarrassment

Behaviors and external signs

• Avoidance of others and social isolation

• Missed work or school

• Picking at skin

• Playing with the skin including eating it

• Reduced academic or job opportunities

• Scars and skin lesions

• Touching, smoothing, and manipulating the area

Common situations or affected areas

• Family financial strain due to cosmetic costs to cover or correct skin damage

• Impaired relationships including reduced romantic intimacy and social isolation

• Missed school or related activities

• Modifying hair, and using hats, long shirts, and other clothing to hide lesions, scabs, etc.

• Trouble concentrating or sustaining attention in school

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Jane's story

Jane first started pulling her eyelashes, followed by her eyebrows, shortly after she turned 12 and she and her friends started wearing makeup. Jane had not intended to pull, but rather was learning how to apply mascara and use a lash curler, when a few isolated hairs failed to curl correctly. When she then removed them with tweezers, she noticed the pull provided a pleasant sensation. At first she pulled out only 1-2 lashes when they were positioned oddly, but within a few weeks she found she was seeking out these types of lashes, and pulling with greater frequency. As this created an a-symmetrical result, she felt forced to pull more. However, despite the pleasant sensations, she was afraid that the loss of lashes was becoming noticeable, so she started to pull her eyebrows. It has been 1.5 years since the pulling started, and Jane no longer has lashes or brows, and must wear fake eyelashes and draw in her eyebrows. Although she has tried to grow them back, whenever she is marginally successful, she quickly resorts to pulling them out and must start over. Jane is embarrassed about how she looks and has started avoiding social events with her friends.

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Sam's story

Sam has a long history of picking starting in childhood. Sam would spend her summer’s picking at various bug bites, and routine cuts and scrapes from riding her bike and climbing trees. She experienced a certain comfort in the picking, which usually happened during boring car journeys or as she watched TV. She was usually unaware of her picking until her mother would yell at her to stop. The picking continued into adolescence when she struggled with acne, which she tried to control through intentional efforts to extract the black heads. This became a nightly ritual when washing her face. Unfortunately, the pimples continued no matter her efforts, and her picking only resulted in the creation of scars, but by then she felt powerless to control her urges to pick. By adulthood her acne had stopped, but the picking transferred to her cuticles, which she would pick at during her long rides to work and as she sat at the computer editing manuscripts for her job. Although her picking has waxed and waned over the past decade, including a few years when she was not picking at all, she has recently noticed her son copying her, picking at his own cuticles. She feels deeply ashamed at this and wants to stop this behaviour once and for all.

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