Although rarely talked about, hair-pulling and skin-picking are surprisingly common, affecting 2 to 5 per cent of the population, or between 200-400 million people worldwide. As a psychologist, I often tell my clients these behaviours are truly the best-kept secret (even haemorrhoids and erectile dysfunction are talked about more freely!) This lack of openness contributes to misunderstanding – people are often blamed unfairly for their pulling or picking, or the behaviour is mistaken to represent some deep psychopathology, resulting in more secrecy and subterfuge. If you are among the many people who pull or pick, I hope to enlighten you about these commonplace behaviours that often carry shame and secrecy, and guide you toward self-acceptance and healing.
What are they?
Problematic hair-pulling (known formally as trichotillomania) and skin-picking (dermatillomania) both fall under the umbrella of body-focused repetitive behaviours (from now on, I’ll mostly refer to them as BFRBs for short). In the Diagnostic and Statistical Manual of Mental Disorders (5th ed, 2013) they are classified as obsessive-compulsive and related disorders. Both pulling and picking are closely related to nail-biting, a more socially acceptable and widely acknowledged behaviour.
BFRBs occur in a breadth of severities, ranging from mild to severe. An occasional pluck or pick may fall under the category of normal grooming (who wouldn’t pull a hair out of their chin, or pick a whitehead off the tip of their nose?) It’s when pulling and picking bothers you or it escalates to the point of causing damage to your hair or tissue that it is time to consider addressing the issue or getting help about it.
Hair-pulling can occur on any part of the body, but most commonly from the scalp, eyelashes, eyebrows, pubic area, arms, legs and face. Skin-picking (including acne/blemish-picking, nail-biting, cuticle-picking/biting, lip/cheek-biting, scab-picking, or any other skin removal) similarly can involve any part of the body.
Hair-pulling can cause damage from hair thinning to complete baldness, depending on the severity of the behaviour. In rare instances, people eat their hair, which can result in digestive problems that sometimes require surgery. Skin-picking can cause scabs, bleeding, infections and permanent scarring of the skin.
As a result of these visible outcomes, you may find that you’ve experienced shame about your behaviour; perhaps you avoid activities where the visible consequences of your BFRB might be noticed (windy places, brightly lit places, wearing bathing suits or other revealing clothing, etc) or you go to lengths to cover up and hide these consequences. In serious cases, the combination of time spent hair-pulling and skin-picking, as well as time spent covering up the results, could constitute hours of your day, thus contributing to harmful consequences – from social isolation to medical problems to financial hardship due to the effects on your ability to work.
Why do people pull and pick?
First, let’s clear up some common misconceptions. BFRBs are not the result of abuse, they are not a symptom of another psychiatric disorder, they are not a predictor of things to come, they are not the result of bad parenting, they are not anyone’s fault, they are not just ‘bad habits’, and they are not easily changed by someone telling you to ‘stop it’.
So, why do people like you engage in BFRBs? Well, from smoking to drinking to unhealthy eating, why do we engage in any behaviour that we know on some level is not good for us? Because, in that moment, it is what we want, what feels good, or what will make us feel better, at least for a short period of time. In this way, BFRBs are self-regulating behaviours. Pioneering research conducted by the clinical psychologist Charles Mansueto in the 1990s identified several domains that BFRBs seem to satisfy, including:
Sensory: pulling or picking to reduce a negative sensory experience (get rid of a bump, scab, pimple or problematic hair) or to increase a sensation such as feeling smooth skin, clean visual hairlines, visual appeal or to achieve a level of stimulation.
Emotional: pulling or picking to either reduce a negative emotion (stress, boredom, anger, frustration) or to increase a positive emotion (satisfaction, excitement, happiness or feelings of accomplishment).
Cognitive: pulling or picking to satisfy a belief or thought (eg, all wiry hairs must be removed, or all pimples must be popped).
In short, your pulling or picking helps to achieve something good: a sensation (eg, smooth skin), an emotion (eg, feeling calm), or an outcome (eg, removing a blemish), at least in the short term. The tendency to engage in BFRBs also runs in families to some extent. You were probably born with a predisposition to pull or pick and, over time, the behaviour got paired with something good, which causes it to persist.
External influences such as places, activities and specific triggers such as bright lights, mirrors and tweezers also impact when and where your BFRBs are more likely to occur. All these factors, from the reinforcing sensations to the triggers, mean that everyone’s BFRBs are different. When other people oversimplify the causes, make accusations of acting out, intentional self-harm or misbehaving, it can lead many people in the BFRB community to feel misunderstood and ashamed – and you may have experienced this too.
Key points
So-called ‘body-focused repetitive behaviours’ (BFRBs) are surprisingly common but rarely talked about. When pulling and picking become excessive, they are classified by psychiatry as obsessive-compulsive and related disorders. If they cause you bodily harm, shame or interfere with your life, it’s time to address them or get help.
Things to know before beginning self-help. BFRBs are common, they often serve a function, they are not a sign of past abuse or underlying psychopathology and, with the right interventions, they can get better. Accepting your urges is key to recovery, as is being curious and patient.
Identify the who, when and where of your BFRB. Try keeping a journal of your high-risk situations for a couple of weeks. This will help you make environmental changes to reduce the urges – and will also give you clues for the next step.
Identify the ‘why’ of your BFRB. The next time you begin to pull or pick, ask yourself: ‘What do I need right now?’ Think about what function the behaviour is serving for you – such as the sensory sensation it causes or the emotional feelings it distracts you from.
Find an alternative way to meet that need. For instance, if you have high sensory needs, try using sensory-oriented fidget gadgets, toys or items to replicate the sensation. If difficult emotions are your trigger, try focused relaxation, assertiveness training or meditation. If certain beliefs are your trigger (such as ‘I deserve to pull’), challenge them with alternative beliefs (such as ‘I deserve a full head of hair’).
How to reduce your pulling and picking
Three things to know
The first thing is to remind yourself of the facts, many of which I outlined already:that BFRBs are common, they often serve a function, they are not a sign of past abuse or underlying psychopathology and, with the right interventions, they can get better. Thinking of your BFRB as a way you have learned to regulate your body, not a defect or a curse, allows for healing to begin. Remember, your BFRB does not define you (it is actually only a small part of who you are) and there is a path to healing.
The second thing to know is that acceptance is a big part of BFRB recovery.Acceptance is not‘liking’ your BFRB, but it entails acknowledging that, although you did not want this, it is here. Accepting that urges to pull and pick will happen and that you can survive them and can actually take the power away from them. It is not a matter of ‘stopping the urges’, but a matter of managing them as they occur.
The third and final thing to know is that reducing your BFRB is a journey, not a quick trip. Early in therapy with clients I focus with them on identifying realistic goals and treatment expectations. Sometimes clients will say that they expect change to be quick and complete, eg, ‘Once I start to work on my BFRB, I will never pull another hair again.’ But these all-or-nothing expectations can create unrealistic goals and doom your efforts to failure. The truth is that behaviour change is challenging and involves many steps forward and backward. Anyone who has ever tried to change their diet is familiar with this frustrating movement. Having patience and a curious attitude will help to reduce any frustration or feelings of disappointment you might experience along the way.
Identify the who, when, where of your BFRB
The next step is to identify the where, when and with whom your pulling or picking most often occurs. Ask yourself, what is different about the times when you engage in your BFRB? Try keeping notes for a week or two. This will help you to know your ‘high-risk’ situations. If it happened in the bathroom, you might notice why it happens at specific times in the bathroom and not others? Or does it happen when you’re with certain people or after you’ve been with them? Does it happen more when you’re feeling a certain way, such as tired or sad?
This might be enough information to help you plan strategies to help to distract yourself (for example, by using fidget toys, especially sensory rich ones), or to make the BFRB harder to do (you could experiment with barriers such as gloves or hats when you know the risk is high), or by making environmental changes in key places where you are more vulnerable (such as covering mirrors, dimming the lights, or throwing away needles and tweezers). All of these interventions can be a part of your toolkit.
Identify the ‘why’ of your BFRB
The notes you made above will also help you get to the all-important question of why you perform your BFRB – that is, what function is it serving for you or what are you getting out of it. Ask yourself: ‘What would I be missing if I did not do this?’ Many people will respond with a resounding: ‘Nothing, I hate this behaviour and want to get rid of it!’ If this is the case for you, try wearing a hat or gloves/clothing to cover the areas pulled or picked for an extended period of time and see if reducing access to that area helps. For some people, simply not having access is the key to behaviour change. If, however, the gloves come off and the picking/pulling starts, get curious in that moment, ask yourself: ‘What do I need right now?’ The answer could give you a clue as to your ‘why?’
Find an alternative way to meet that need
Once you have an inkling about the function that your BFRB serves, reflect on how you could meet this need in a different, less harmful way. Did you identify any sensory, emotional and cognitive functions that the BFRB serves?
If you have high sensory needs, I suggest trying sensory-oriented fidget gadgets, toys or items (such as slime, smooth objects, things that make noise, things with a pleasant smell, and so on) that might serve the same need, as well as identifying sensory experiences that help you to regulate your nervous system (such as soft blankets, music, certain smells or colours, etc).
If you struggle with emotions that trigger your BFRB, try focused relaxation (deep breathing, taking a time-out), assertiveness training, meditation (there are a host of apps available for this, such as Calm or Headspace) or engaging in more pleasurable activities (including hobbies, social events or simply a hot bath).
Finally, if certain beliefs underly your BFRB, challenging these thoughts can be a valuable tool for overcoming pulling and picking. For example, if a common thought is ‘I deserve to pull, just a little,’ you might challenge that thought with ‘I deserve to have a full head of hair and healed skin.’ Try to substitute more accurate thoughts for the erroneous ones – talking these through with someone you trust will help.
Final notes
I’ve given you a lot of information to take in, especially if you are learning about your BFRB for the first time. Be gentle with yourself and allow yourself time to absorb it. It took years if not decades for you to reach this point, so pause to think about your path forward. Aim to be a cheerleader for yourself, not a harsh critic. We always perform better with a cheerful friend at our side, rather than a critical naysayer. In addition, The TLC Foundation for Body-Focused Repetitive Behaviours (the letters TLC derive from the organisation’s original name, the Trichotillomania Learning Center) and BFRB UK & Ireland are both great sources of support worldwide. They can help connect you with other like-minded people, which can be healing in and of itself. If going it alone is too overwhelming, know that people do get better and that help is out there – the TLC Foundation also has a therapist referral portal to direct you to knowledgeable CBT therapists. Any journey begins with a first step, as well as a desire to travel to a different place. May this be the beginning of your journey.
Disclaimer
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