Trichotillomania & Skin Picking (Excoriation Disorder)

Trichotillomania & Skin Picking (Excoriation Disorder)

Trichotillomania & Skin Picking (Excoriation Disorder)

These conditions are two of the more commonly known Obsessive Compulsive Related Disorders. Trichotillomania is characterized by the urge to pull out hair on one’s body, resulting in hair loss. The typical age of onset is between the ages of 11-13 and the condition appears to be more prevalent in females.

Females seem to be ten times more likely than males to have the disorder. In some instances (between 5-20 % of diagnosed individuals), clients will ingest the pulled hair, which can result in serious medical problems.

  • Frequently individuals will report a feeling of tension just prior to the pulling of the hair or a feeling of tension when trying to resist the behavior.
  • Individuals will also frequently report a feeling of relief or pleasure when engaging in such behavior, which serves to reinforce the behavior.
  • Common sites of hair pulling are the scalp, eyebrows and eyelashes. At times, attempts are made to cover-up the areas of hair loss with hats or makeup.
  • The condition most often results in varying degrees of shame or embarrassment which can then lead to depression and anxiety. Impairment in academic, occupational, social or leisure activities can also result as the individual may begin to consistently avoid these settings or activities.


Skin Picking

Known also as Excoriation Disorder, Skin Picking is another Obsessive Compulsive Related Disorder. Individuals with this condition will repetitively scratch, pick, dig or touch their skin in an effort to ‘fix’ perceived imperfections or skin irregularities. The age of onset can vary from pre-teen to adult. Often, a vicious cycle ensues where the individual may create a worse imperfection and then feel compelled to ‘fix’ it by continued scratching or picking. Scarring or skin discoloration can result or in more serious cases, the outcome is an infection and or tissue damage. Nail biting and lip chewing often co-occur with these disorders.



Favored treatments for Trichotillomania and Body Focused Repetitive Disorders include both Habit Reversal Training and Stimulus Control.


Habit Reversal Training involves two components:

  • Awareness Training
  • Competing Response Training

Awareness Training has the individual note when and where the hair pulling occurs.

  • Does it happen when watching T.V., or when reading?
  • Does it when happen when driving?

Another type of Awareness Training involves noting what feeling the individual is experiencing when the undesirable behavior occurs.

  • Does the feeling of anxiety or boredom coexist with the behavior at the time the behavior is noticed?

Competing Responses involve creating incompatible responses which make undesirable behavior like hair-pulling either difficult or impossible.

For example, if an individual watching T.V., finds him/herself pulling hair from the scalp with his/her right hand, then trying to sit on the right hand or to make a fist with that hand could be proposed as a competing response.


Stimulus Control refers to introducing preventative measures which aim to make it less conducive to engage in the undesirable hair pulling behavior.

For example, if an adolescent repeatedly pulls out her eyelashes when near a bathroom mirror, stimulus control might consist of dimming the lights in the bathroom to obscure the mirror, making it more difficult to engage in the undesirable behavior.

These interventions used in the treatment of Trichotillomania and Excoriation Disorder are also used in the treatment of Tics.