Body Focused Repetitive Behaviors Explained: Trichotillomania and Excoriation Disorder

Dr. Tracey Marks introduces Body Focused Repetitive Behaviors (BFRBs) as a category of compulsive, self-injurious actions, focusing primarily on trichotillomania (hair pulling) and excoriation disorder (skin picking). She clarifies that while trichotillomania contains 'mania' in its name, it is unrelated to bipolar disorder's mania. Historically classified under impulse control disorders, BFRBs are now more accurately placed under obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM) due to their compulsive nature rather than impulsivity. The episode delves into the characteristics of these behaviors, explaining that they are often preceded by anxiety or a buildup of tension, with the act itself providing temporary relief, followed by distress, shame, and a sense of lack of control. These behaviors can manifest as focused, intentional acts or as automatic, unconscious soothing mechanisms.

The podcast details the specific manifestations of both disorders. Trichotillomania involves repeatedly pulling out one's own hair, often with a ritualistic component like seeking a specific hair texture or the 'white root,' and manipulating the pulled hair afterward. Common sites include the scalp, eyebrows, and eyelashes, with individuals often attempting to hide bald spots or thinning hair. Excoriation disorder involves picking at one's skin to the point of creating sores, frequently on the face, hands, and arms, using fingernails, tweezers, or biting. Similar to hair pulling, skin picking can involve manipulating scabs or chewing on them. Both disorders typically emerge in adolescence around puberty and can be chronic, though they may wax and wane in severity, ranging from mild, manageable cases to severe instances leading to infections like cellulitis or significant scarring.

Dr. Marks also briefly mentions other BFRBs not formally listed in the DSM, such as nail biting (onychotillomania), lip biting, and nose picking, noting that individuals with trichotillomania or excoriation disorder often engage in these as well. The discussion then shifts to treatment approaches. For mild cases, self-management strategies like recognizing and avoiding triggers or distraction techniques can be effective. When self-control is insufficient, therapy is recommended. Key therapeutic interventions include Habit Reversal Training, a form of cognitive behavior therapy, and a self-help technique called Decoupling, which involves performing a different behavior to disrupt the connection between emotional tension and the compulsive act.

Regarding pharmacological interventions, Dr. Marks states that there are no standard medications for BFRBs, but some evidence suggests the supplements Inositol and N-acetylcysteine may be helpful. She also lists several alternative therapies that can be beneficial, including yoga, aerobic exercise, acupuncture, biofeedback, and hypnosis. The episode concludes by highlighting the significant impact these behaviors can have on an individual's mental and physical health, emphasizing the importance of understanding and addressing these often-hidden struggles.

"This is a broad term for a specific type of compulsive behaviors that cause self-injury."

"Even though trichotillomania has mania in the name, it has nothing to do with the mania of bipolar disorder."

"Usually, the urge to pull the hair is preceded by anxiety or a buildup of tension then pulling the hair relieves that tension."

"Because part of the criteria for this behavior is that the behavior ultimately causes distress, you can feel shame for needing to do this or frustration over your lack of control."

"Normally, this behavior is driven by negative emotions but sometimes you can fall into an automatic behavior of pulling your hair without much conscious awareness."

"A severe case of skin picking can lead to serious infections like cellulitis or even severe scarring."

"Since it's a compulsive disorder though, the issue is being able to control the urges."

"With decoupling, you perform a different behavior whenever you feel the tension that normally triggers a compulsion."

"We don't have any medications that are standardly used for this disorder."