What is Trichotillomania? The official diagnostic criteria are:

• Recurrent pulling out of one's hair resulting in noticeable hair loss.

• An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior.

• Pleasure, gratification, or relief when pulling out the hair.

• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

However, these criteria do not seem to apply in all cases. Many people who have TTM do not have the tension/relief cycle described in these diagnostic criteria. Probably the best definition is simply chronic and repetitive hair pulling. Hair is usually pulled from the eye brows, eye lashes or the scalp, but can be pulled from any location on the body where hair grows (genitals, under arms, etc.).

How common is Trichotillomania?

There have been as of yet no large scale epidemiological studies of TTM, so it is difficult to obtain an accurate estimate of the prevalence of TTM. One study done in 1991 using the official diagnostic criteria noted above, estimated a lifetime prevalence rate for TTM of 0.6% for both male and female college freshmen. Once they expanded their definition to "chronic and repetitive hair pulling" and eliminated the requirement for the tension/relief cycle, the lifetime prevalence rose to 2.5% for both sexes combined (3.4% of females and 1.5% of males). Using the more realistic figure of 2.5%, the rate of occurrence of TTM is about the same as that for OCD.

The above figures would seem to suggest that TTM is more frequent in women than in men, yet that may not be the case. Men can more easily hide bald spots by shaving their beards and/or heads. Women often have more of their self-esteem wrapped up in their looks than do men and so may be more apt to be more distressed by their pulling and thus more likely to see pulling as a problem.

What causes Trichotillomania? How does it start?

We don't really know the answer to this question. Some people report that they have pulled for as long as they can recall while others clearly recall a specific time, even moment, when their pulling actually started. Often people report a major change or a particular life stressor seemed to precede the onset of their TTM. More research is needed to adequately answer this question.

How is Trichotillomania treated?

There is no one "gold standard" treatment for TTM. The usual method I use involves first of all keeping a detailed diary of the pulling and trying to understand in as much detail as possible the what, when, where, how and why of pulling and then using this information to custom design interventions based upon this information. Most experts believe the purpose of the pulling is some sort of nervous system regulation. Somehow the pulling helps TTM sufferers regulate their nervous systems in somewhat the same way most of us use a cup of coffee or going for a jog.

What is Dermatillomania?

Excoriation Disorder, also known as skin picking disorder or dermatillomania, is characterized by the repetitive picking of one’s own skin. Individuals who struggle with this disorder touch, rub, scratch, pick at, or dig into their skin in an attempt to improve perceived imperfections, often resulting in tissue damage, discoloration, or scarring. Skin picking disorder is one of a group of behaviors known as body-focused repetitive behaviors (BFRBs), self-grooming behaviors in which individuals pull, pick, scrape, or bite their own hair, skin, or nails, resulting in damage to the body.

Occasional picking at cuticles, acne, scabs, calluses or other skin irregularities is a very common human behavior; however, research indicates that 2% - 5% of the population picks their skin to the extent that it causes noticeable tissue damage and marked distress or impairment in daily functioning. 75% of people affected are female. The behavior typically begins in early adolescence, although skin picking disorder can begin at any age. Without treatment, skin picking disorder tends to be a chronic condition that may wax and wane over time. 

Those who engage in skin picking tend to pick from multiple body sites, for extended periods of time, targeting both healthy and previously damaged skin. Targeted areas of the body may change over time. Commonly reported experiences that lead to picking include: an urge or physical tension prior to picking, unpleasant emotions, cognitions (permission giving thoughts, beliefs about how the skin should look or feel), sensations (a bump, sore spot), and/or a displeasing aspect of one’s own appearance (visible blemish). Commonly reported experiences following picking behavior include: urge reduction, sense of relief or pleasure, psychosocial difficulties or embarrassment, avoidance, reduced productivity, emotional sequelae such as anxiety or depression, skin infections, scars, lesions, and/or disfigurement.

Although the severity of excoriation disorder varies greatly, many people who struggle with skin picking exhibit noticeable skin damage, which they attempt to camouflage with makeup, clothing, or other means of concealing affected areas. Due to shame and embarrassment, individuals may also engage in avoidance behaviors, including the avoidance of certain situations that may lead them to feel vulnerable to being “discovered” (e.g., wearing shorts, being seen by others without makeup, or intimacy).

Impact & Effects

The impact of skin picking disorder on one's life may be significant. Individuals may experience shame and embarrassment, and as a result, may avoid certain social situations or activities (e.g., pools, gyms, beaches), and medical care. These emotional sequelae can lead to painful isolation and result in a great deal of emotional distress, placing them at risk for a co-occurring psychiatric disorder, such as a mood or anxiety disorder. Furthermore, these individuals often go to great lengths to cover, hide, or camouflage damaged skin and may have difficulty with time management due to the significant time involved in engaging in the behavior as well as efforts to conceal it.

Medical complications as a result of excoriation disorder are not uncommon. Infection, which may require medical treatment, scabbing, open wounds, discoloration, scarring, or disfigurement are possible consequences of chronic skin picking behavior. Skin picking can also lead to strained relationships with family members and friends. Family members may need professional help in coping with this problem.