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Jon Grant's Lecture on BFRBs research at TLC conference 2014

Filmed at the Trichotillomania Learning Center Annual Conference, April 2014

Featuring Jon Grant, JD, MD, MPH
Chair, TLC Scientific Advisory Board

Where are we in terms of treatment and understanding of Body-Focused Repetitive Behaviors (BFRBs, or behaviors like trichotillomania, skin picking, nail biting, etc.), where do we need to go and how will we get there? TLC Scientific Advisory Board Chair, Dr. Jon Grant provides an overview of BFRB research to date and the implications for treatment and recovery moving forward.

We took the liberty to transcribe this fascinating lecture:

"So, this is a very exciting year I think for TLC, and you probably have already seen these buttons, right, that some people are wearing that say BPM, and asked about it.
So you’re gonna see more of these, and, and so, what’s happening this year is, TLC is launching a much sort of bigger, I think much more impressive research agenda for the forthcoming years.

And, this is very exciting, I think the world of treatment and understanding of hair pulling and skin picking is at a great juncture now and this can happen.
But I thought, you know, it would be interesting to also see as we move forward, sometimes it’s also important to figure out where you’ve come from. And to understand what’s happened in history, because every change that we make and everything that we do to try to understand and treat these behaviours is sort of incrementally built on something that’s happened before it.

And so for those of you who have any interest in sort of history there’s a whole range of …there’s a new book out… I blank on the author… about the history of skin! And it discusses picking throughout time, and then there’s something called the encyclopaedia of hair! And so, anyway, there’s a wealth of history about these behaviours, and I’m going to present some of that and highlight some of the accomplishments. And also though, why based on what we’ve done until now although impressive for a small organization, and a small number of people around the world; that we can sort of see where we need to go, and what the next step is going to be. So, I’m hoping it will also get people excited about where the field is moving.
So, I’m gonna talk about the history of the research in both trichotillomania as well as skin picking, and as anyone with skin picking knows, it’s gonna be a little bit shorter history. In that world there’s a little bit less of, so, the lion’s share will be about hair pulling, but it’s simply because that’s the state of the world. It’s not that I’m choosing to talk more about the hair pulling, it’s just that there is more to talk about. And then what’s going on currently and where we would like to see things move. So I think this is a very exciting time, as I mentioned.

So,the history…Everybody by now has heard of François Hallopeau, the French dermatologist, and he was the person who came up with the term trichotillomania for, you know sort of this, hair pulling frenzy. And he had seen this in a case of a young man- and you know this raises the issue of sometimes gender in these behaviours -in the case of a young man, who he had described as having pulled almost every hair out of his body. And this was really the first major scientific report about trichotillomania.

So now what’s interesting about this, so he presents this case, right? So here he is in 1893, and then essentially for 80 years, we get really nothin’, for the most part… or very little. There were 33 articles written in scientific journals around the world at that point! But, I have to say, I like some of these articles very much… I’ll just highlight some of them. But there was a case in the 1920’s,again, of a young fellow, who had been pulling his hair. Now what was interesting, this tells you how science is important, because at that time they had said that, he had other tics, and other behaviours such as nail biting. And there was a question of whether hair pulling and skin picking at that time were connected with sexual perversions (raises his eyebrows at the audience, indicating the questionability of these claims, audience giggles).
So right?! A little education goes a long way, right? To educate people out of these things…but, they also did go in for treatment, and they just simply cut his hair really short to stop him from pulling (pauses, audience giggles).

This is a case, a little girl, 8 years old from the 1920’s again, who had been pulling out her hair…and again the same…and again what people would do in these articles…people would write the case, and then other people, all these doctors from around the world would write in their little comments. You know, so it was about the, you know I guess it was as close to a blog as you know as one would have in the 1920’s. And they were again trying to understand as a personality feature, was it associated with hysteria at that time? And they recognized very early on that hair pulling and nail biting were linked. And this doctor I like mentioned that he felt that it was something like smoking…the sort of habit that people can’t stop on their own, that has almost a kind of an addictive quality to it. And then the president of this medical society, had written in, again about keeping the hair really short, and that would be the treatment. And what I did appreciate from these early reports, and this is always a big topic of debate in mental health…these people simply said they cured it (pauses, audience laughs).

Which I love, you know what I mean? And I think you know that in mental health we end up talking so much about how to manage things…you know, that, perhaps we set our sights too low? I mean, maybe the goal should really be cure, you know, and by using these terms we sort of set our goals higher. So, that’s why I highlighted the word cure here (refers to slides).

Now, we move again 40 years ahead… And with it, is the first case of behaviour therapy that was used in 1963. And this was really, simply the idea of thought stopping, and telling her hands, “stay where you are” every time she noticed that she was pulling, and they found it effective. So, it’s not as if people haven’t been looking…you see bits and pieces through time…even through the sixties. So now we move into the seventies…Now it’s in the seventies things started changing. There were more scientific reports in those 10 years than existed in the 100 years previous to that. And what’s the importance of scientific reports? It says that people are paying attention to the problem, it says that you’re trying to understand it, that you’re trying to treat it. And this is when habit reversal came on the scene…in 1973…with the first cases of 12 clients being treated with habit reversal for trichotillomania and a variety of other habits. This was also the first time hypnosis was used…which, in the seventies was used for lots of things, but it also showed again trichotillomania had earned enough of an interest from the scientific community that people were employing new therapies for the treatment of this problem.

And this is when we started also talking about: what is the illness? And so people…part of what we have to know…and you’ll be hearing a lot about this, is when we try to understand a disorder or a behaviour, and understand how it’s complex…how this person –their trichotillomania is different from this person. It starts with collecting a lot of information from a lot of people, so that you start understanding…well when does this start? You know, when, how, what triggers it, all of these things. And so you need a certain number of people. And this was from the Mayo Clinic in the 1970’s…and they reported 24 cases…and they actually found that over half of their cases were males. Now I highlight this because the gender issue with these behaviours, is still a little bit, I would argue, unknown. You know, we tend to think… always talk about these as more female…but we don’t have large scale studies to actually tell us whether that’s true or not. And a lot of the early science was really looking… again they had a lot more men coming for treatment apparently, than perhaps we do even today. But they found too, at the Mayo Clinic, I thought was sort of wonderfully sort of arrogant about it- in a very good way- they said the treatment was simple and effective…they could treat it. So if you were in 19…you are struggling today, but if you were in 1972 you had a better chance, I guess is the idea…(audience laughs)…or they were just selective in terms of how they presented it. But they were concerned that other habits took the place of hair pulling, and again, this is something we know today, which is that many folks that have hair pulling might have some skin picking, may have some nail biting etc. And when one gets better it’s kind of like one gets better, the other gets worse.

Now the world of picking is a little bit different, because in the seventies, although hair pulling was taking off, as a focus there were only 3 little reports of skin picking. And those were actually done by dermatologists. Are there dermatologists in the room? Nope…see apparently they did their job and then they were done (audience laughs).
So…we don’t have a lot of dermatologists interested today, but they did then and they were actually the first to report that among their patients this was a pretty common problem. And so we knew this as early as the 1970’s, although research in this area has lagged behind. So in the seventies, what we started to learn was: what these behaviours were, who they affected, the ages, the gender, these types of things…and maybe some glimmer of treatment. That was through the seventies. Yes, you’re thinking “oh there’s a lot of years to get through”… don’t stress about it’s still a good journey (audience giggles). So, the 1980’s…(audience laughs at the hairdo picture)… don’t you love it? You know, it is fascinating if you think about it though, particularly on the side of hair…hair really defines whole generations…you know, I mean you can’t help but see Michael Bolton and know instantly you’re in the 1980’s right? I mean it says something about the power of hair, culturally as well as personally…but this was the 1980’s, we had the first report of any medication being used to treat tricholtillomania. An old anti-depressant amitriptyline was used in one person and it was reported, and at the National Institute of Health, Susan Swede and Julie Rapaport and other folks did the very first treatment study using a medication for trichotillomania, which was in the New England Journal of Medicine. It was a big new announcement, because this was the first time that anybody had actually successfully treated trichotillomania with medication, and they used an old medication, which used for obsessive compulsive disorder called clomipramine, and showed that it was beneficial.

So the eighties…and there were more reports, which were looking good, you know, but skin picking still languishing a bit. So you know, only 3 reports for the 10 years, but it became international, I would point out, so people around the world were starting to look at picking, although not looking very hard I would argue. And so from the eighties, we started to get a little bit an idea of what skin picking was, it was a little bit under the radar, and maybe again from a medication stand point what might help. So, now we move to the 1990’s…now you see, the number of scientific reports ballooning. People are really getting interested in trichotillomania. We have Jennifer Aniston and the lovely 30-year olds who played 16-year olds on Beverly Hills 90210 (referring to the hairdo reference of the 90’s –audience laughs). Now what you see is a huge amount of research being done. And this really is where we’re setting the stage for current knowledge of things. So Gary Christianson, started with the largest report of folks, and I still think one of the finest research reports in trichotillomania. Folks started looking at the brain scans of people who had trichotillomania. Folks started to look at the family of folks who had trichotillomania and what their family members are also struggling with. Children were being treated for the first time, in scientific fashion, with collecting data and research. People started looking at the cerebral spinal fluid where you get spinal taps to see what sort of chemicals are bathing the brain… not a pleasant experience! Having been, oddly enough, a healthy “control” for a cerebral spinal fluid study… where I had spinal taps, nine of them in 3 days…I wouldn’t recommend it to people. It you know, it paid the rent (audience laughs). So we started looking at biological markers to see what’s going on in the brains of people. And these scales were created so that we started speaking the same language. So if we say that somebody in California is getting better in a research report, we’re using the same report in New York, so that when we compare things we start using a common knowledge of improvement to see how people do in different types of treatments. The first prevalence study - the 1990’s get a couple of pages. The first prevalence study by Barbara Rothbaum, the first gender study by Gary Christiansen again. They looked at pain receptors in folks with trichotillomania to see if people with trichotillomania register pain differently from people who don’t have, and by the way, folks don’t…but that was a big question…oh do folks pull because it doesn’t hurt them whereas somebody else doesn’t pull because it hurts? It doesn’t seem to be the case. Folks started looking at psychological profiles of people with trichotillomania, and then different brain scan studies, even looking at immune markers…could this be as in the case of OCD example where infectious causes are the root element behind the hair pulling. So somebody gets say a strep throat, this has been the case of some cases of OCD, they develop a strep throat and as they fight the infection it sets off an autoimmune response so then they develop OCD…could this be the case for trichotillomania? So people started looking at a wide range of these things, again to really hone in on, it’s not you know, not only to treat, but how to, sort of, what causes it, and if we understand the cause… how can we prevent it from even developing in people? So, you see the nineties were a good time…even picking started doing more research. Understanding is it different from OCD and the very first drug study looking at Prozac or fluoxetine was done in the treatment of skin picking. So, summary of the nineties, we’re starting to do more, people started to get excited, we actually know more,we have more clinical data, we know what’s going on, at least some glimmers of what’s going on in the brain. We start recognizing we can do something for kids as well and again, picking is still a little bit lacking, but it’s making strides.
Now when it comes to the 2000’s…a lot more being done. And now we have comparison studies. Medication: is medication better than therapy? We have the first glimmers too of what we need to do, which is to subtype people. Meaning we need to be able to look at say 10 people with trichotillomania and finally recognize that there isn’t one illness here, that maybe there’s 10 different things going on in 10 different people and to really understand those sort of subtyping complexities. And that then leads us to start thinking maybe in treatment, maybe one size isn’t gonna fit all…that some people can get better with x and some people can get better with y. People started looking at inositol for the first time, which is vitamin B complex. Again, some more immune studies…and we started getting the first gene studies…so this HOXB8 gene, which is a gene that is associated with our immune function, and what goes on in the bone marrow was examined. We started doing animal research, animals starting to look just like… behaviours starting to look very similar to folks sort of picking and pulling… so mice would chew off their fur repetitively under certain stress conditions etc.

Again, so lots of changes throughout the 2000’s…Cognitive studies out of England…TLC launched the “Tips project” which was really collecting information, and many people probably took part in this - online information with thousands of folks with trichotillomania to really get samples that approach what other illnesses have. You know, so when it comes to hair pulling and skin picking, you will see throughout the conference, people will talk about, “Oh you know we did this study, it was 20 people”, and then you’ll see on CNN tonight there’s a blood pressure study going on and it was 80,000 people!…You know, and you think “hmm we had 20…that’s pretty good right?”(audience laughs) So we started recognizing we needed bigger samples so “Tips” was part it. Some other gene studies that were going on, so people were looking at a chemical called glutamate and the genes that make that. People looked at different genes that help our general structure of the nerve cells, and whether those are relevant to folks that are picking or pulling. And then Carol Novak’s twins study, and then we did our N-Acetyl Cysteine study. And then also, skin picking starts taking off. We had the first cases of CBT for skin picking in 2002…and habit reversal in 2006, the website is analysed and launched, and people can get online therapy through using different modules of CBT through a website. We also had the first gamma knife surgery, brain surgery, for refractory skin picking in a case in Pittsburgh, with a gentleman who picked and picked to the point he had so much blood loss that it was either brain surgery or death. And so they did that successfully in Pittsburgh. And it also suggests I think in a very serious way, that when any type of illness gets very serious we need a range of options in terms of treatment, so that we can have things for people who have sort of mild cases, but we can also have options for people who have more severe problems with their illness…And then [we had] more genetic studies etc. So this was a good time!

Now we move to 2010…so in the last few years, a whole range of things going on, we finally looking at people of colour in terms of the analysis of folks with trichotillomania. People are starting new types of therapies, something called decoupling, which is a therapy which is based somewhat in CBT but has its own unique qualities. So, it’s branching sort of beyond our typical therapies to recognize we need more, we need different in terms of who we’re looking at. And then even a medication study that looked at the N-Acetyl Cysteine in kids. And DSM-5 changed several things, with trichotillomania being changed- its name and the inclusion of skin picking. And then skin picking, a range of also new findings, cognitive findings, prevalence studies, controlled CBT studies…now people are thinking, well then why aren’t they launching anything, well we’ll get to that…but you know this is great ground work. The samples unfortunately are still small, as you notice bits and pieces of things… and first imaging studies as well.

So again, what do we have currently, we have a lot of clinical information…and folks who struggle know this…you can go and see somebody and they can tell you a lot about it, they can tell you about trich and picking, but, how yours may different from other people’s we don’t still know in a very substantive way. They offer treatment options that are sort of what’s been helpful. Can they tell you in particular, this is the kind of thing that’s gonna help you? Can they target that and say 90% of people with your qualities will be improved by this? We just don’t know yet. So we know a lot, we’re moving in the right direction, but we still have a ways to go. I highlight this, just to show that from a scientific standpoint this is why TLC is launching this new initiative…we need more research, and, this is sort of the old chest out…but you know we need bigger research, meaning we need more people and we need more detailed scientific research that’s done across sites. So if you look, these are the number of articles per year on trichotillomania…so currently there are about 45 articles a year from researchers around the world. There are almost 5400 articles per year for schizophrenia. And there are 17000 articles per year for depression. And trichotillomania has 45. Okay so that is pretty good, because it’s better than 1970, right, where there were 4! But you can see my point…we’re not there yet. And so I think, it not that it’s gotta be more, it’s gotta be better, more targeted obviously. But it does speak to the fact that other areas of mental health, when we know people who struggle say with depression, and we can sort of say “wow you’ve got lots of options! You know you go to your doctor, you go to your psychologists, if something doesn’t work they’ve got option A through Z” and when it comes to trichotillomania you got sometimes option A, maybe option A.3…you know? But we don’t have sort of this wealth of options necessarily, and on the picking, it’s quite frankly worse…and again…25 articles per year. It’s moving, but it’s still not good. And so I don’t say that as an excuse, but I wanted to highlight the history to show that amazing advancements have been done. But I think when people want - and everybody wants help - and they want help quickly and they want help effectively, and that’s great…and so what you often find at these conferences, people say “what about about…what about…” And the answer often is “we don’t know…we don’t know…” We do know a lot, though just ask those questions (audience laughs). So, it’s really incumbent upon you to ask the questions that we know the answers to (audience laughs). Because otherwise it highlights all these other things that we don’t yet know… So overall, the state of knowledge is that we know a lot about theses presentations, we have ways to measure improvement by using these scales, when you go to your clinician and they ask you the same questions over and over again, it’s usually from a scale…and again, this is to try to track improvement in an objective fashion and we’ve got good scales to do that for both picking and pulling. We understand how picking and pulling have a lot of co-occurring problems. We understand a lot of these things, and we have glimmers of promising treatments. We can help people… that’s the great news. The flip side though is that we need better treatments and we need more targeted treatments. And we need a lot more information on diversity in populations. So the initiative is trying to fill these gaps, trying to find out what our deficiencies are in our knowledge as we move forward. The current state, where we are right now…we have this brand new hair pulling disorder in DSM-V, it’s not new, but it’s newly renamed, with new criteria and for folks with skin picking as of May last year [2013], it is finally an official mental health classification disorder, and so people, one would hope, can get appropriate treatment through insurance etc.

So this is where we are at, and we have ongoing research at NIMH [National Institute of Mental Health] over the years has funded two studies in the recent memory for psychotherapy, we have an ongoing TLC genetic study, there’s a range of psychotherapy studies at various universities – University of South Florida, University of Wisconsin, and American University, and then some ongoing medication studies that we’re doing in Chicago. So what does this all mean? We have a lot of information, we have a long history of medication, so where does this all take us? So this is where the idea that TLC has come up with, that this has been wonderful but we need to think bigger if we want to offer more treatment and understand the disorder and its complexities on an individual level of how we can tailor treatment, so that it’s not like “Okay come on in, we gonna do the same thing for everybody…oh it didn’t work for you? Oh okay, bye…” you know? So this is really to get enough information on people so we can target treatments in a very logical, objective manner. And so, right now, what we have is, expressed behaviour. This is where the status of our knowledge largely is. And what is expressed behaviour? It’s sort of what would be called in scientific terms a behavioural phenotype which means “what one does”, so we pick too much or we pull too much that’s what we know. But what we wanna do is get layers below that. We wanna understand the brain, we wanna move toward etiology which is called cause…what causes the illness. That’s where we wanna get. So we’re way up there with limited treatments, trying to kind of tunnel our war through, to more substantive, underlying things, that will tell us on an individual level…why, you know, Suzie pulls but hasn’t responded to treatment, but Janie has responded to treatment and pulls. So it’s the same problem but why does some people get better but others do not. So this is the kind of goal, to get core things of what’s going on in the brain, the cognitive piece-how we think through problems, how we think about our behaviour, all of these things to really get at core issues. We’re trying to answer some fundamental questions – is everyone the same, with trichotillomania and skin picking? Well we know that’s not the case. But what are the meaningful differences? And what are the meaningful differences between the two behaviours? You know, how does skin picking differ from trichotillomania, and on the individual level. What’s going on in the brain? And is what we see when we take brain pictures currently, is it cause or effect? I mean, we have not yet been able to figure out, when we see things going on in the brain, is that what the brain looked like before the picking and pulling, or, if you pick and you pull every day, will you modify your brain to make it look like some of the things that you’ll see during the conference, in terms of those pictures. So we really do need to see what happens first as a way to develop early preventions etc; and interventions. And then understanding genetically what’s going on, what genes are turned on, turned off, and how do they differ across people. And then using all of that to turn it into a treatment approach, because this research is meaningless unless people benefit from it right? I mean I can take brain pictures all day of any number of things and then just go home and watch television, that’s kind of silly, so it’s only useful if we can actually make people’s lives better. So this is really why we want this information – to craft it in a way to improve people’s lives.

So this then led to TLC working on a bigger project moving forward. And for a small organization to move for a big project, this is really a big deal! And so the BFRB (body focussed repetitive behaviour), we wanted it to be inclusive and developing what we call precision medicine. And precision is medicine really targeted to the individual, and to understand on the individual level what we need to know so that the person who comes in for example Suzie Johnson, who pulls, but her disorder’s not being treated…she is being treated, if that makes sense. And that’s the precision element. So you know we don’t treat disorders…we shouldn’t be treating disorders, we treat people. So this was the idea of TLC, to put together a project moving forward that could be big in terms of really making in-roads, because you know after 130 years of that wonderful history, we would like to see a bit more advancement. And we’re setting goals pretty high, and I think they are achievable. So the idea is, we would really like to see folks who have picking, pulling and other body focussed repetitive behaviours in the next 5 to 7 year be able to increase remission rates from what would now be maybe 10-20% of people who ‘remit’ - you know meaning who stop the behaviour for the sort of long haul - and we would like to increase that to maybe about 70%. This is in-line with some other health initiatives that really are not tolerant of people just going along in a sort of half okay way. I mean the target is really…to get people better! And to do that we really do need all these little bits and pieces…I know you’re thinking “but you told us there were brain scans, and somebody had a spinal tap…”, right? These gave us little bits and pieces of information, but we’re building on that to really launch sort of a full focus on what’s going on biologically in terms of the brain in folks who have trich and picking. And so to really understand that, and by really understanding that on a molecular level, I mean even the molecules in the brain that do this! This gives us new targeted options for psychotherapy as well as pharmacological treatments, as well as all natural treatments. You know sort of the inositol and N-Acetyl Cysteine route too. So by understanding on the minutest level of what goes on in the brain, this is sort of the target for treatment improvement. And what we have, which is unlike any other mental health thing that I’ve ever heard about, or problem, the TLC is a small world, and it’s a small collaborative world, really across the entire country, so people know what everyone else is doing. And this affords us the opportunity to work together from coast to coast to really use what everybody knows and does best to move the field forward as opposed to “oh there’s a little study going on in Phoenix” or “there’s a little study over here doing this” and then you know, if somebody takes the time to read all these studies and piece it all together, and that takes a really long time and people don’t really take the time to read all these studies as I have learned over the years.

So there’s this collaboration that we can provide that no other field of medicine can because of the TLC and because everybody in the field of trich and picking research really knows each other and is part of this community. And the goal again is to really focus on the science and to really focus on what’s going on in the brain. And by the brain I’m not talking about environmental pieces that also is a big piece-developmental, environmental - it is ultimately processed through the brain, but those are all incredibly important variables. So I don’t wanna just say brain as though that means just some floating head or something…

And what the goal of this is, because as you see the lack of scientific reports and even the lack of research support from federal and larger institutions, the goal of the BPM [BFRB precision medicine] was to leverage private investment money from donors to really start putting this on the path, with the idea that, as we make in-roads then we can work more collaboratively with the National Institute of Mental Health, and even larger corporations to take what we learned to the development of future things. So we need more science from the private sector. You know, people read the article in the New York Times recently about the field of science, because of dwindling federal funds, is really relying on private investors. So TLC thought why shouldn’t we look to private investment? You know, because this is really the place where we are going to find the research dollars. And so what’s the goal with that investment, is to really understand what I call phenotype – these kind of terms nobody uses in the real world- but what it means is all of the ways that the behaviour or disorder shows up and is exhibited. So, is it automatic pulling versus very focussed pulling, is it stress-induced pulling versus etc… So [to] understand that complexity of clinical presentation from hundreds of folks across the country as opposed to twenty folks, to really start getting at that. To understand not just the behaviour – I pull too much- okay yes that’s a piece of it, but what goes on, on a thought process? Is that because I can’t stop pulling? So is it a problem of being able to inhibit my behaviour? Is it that enjoy pulling, and I’ve made an assessment that my joy wins out over the consequences? And these are different for every individual, but it’s very important to understand that also from a therapy standpoint to develop therapies to understand how those differ across people, because the driving forces and the motivations often differ. And again, this is the individualized, the precision quality of this. And then, actually to do brain imaging work as well. It’s one of the tools that really allows us to understand not only what the brain looks like, but actually see how it functions in real time so to speak. When people sit in scanners and they do things, and they do certain tasks, and you can actually see what parts of the brain sort of turn on, and which parts of the brain turn off. And that allows us to understand, and we hope, and the goal of this, is to know how that then fuels the picking and pulling behaviour , if that makes sense. And so again, to do this to not just 10 or 12 people, which has been the standard, but to do this in hundreds of people to really understand this in the big picture, not just on the micro level. And then as I said before, to use all of that information to really say okay, you know, how do we put this all into a puzzle. And so the goal would be ultimately…wouldn’t it be wonderful if you know somebody could come in…you know I would love to see somebody come into my office, and I’d chat to the person about their pulling, and I’d say, “you know what, we gonna take a walk down the hall, we gonna take a picture of your brain, and, we gonna do a little blood on you to see what’s going on genetically”, and we can feed it into an algorithm based on what we’ve learned from this project and then you can say to the person, “in your case, if we do x, y, and z, you’ve got a 90% chance of stopping pulling. But if we did a, b, and c, it’s not gonna help you at all”. So, that would be the ultimate goal…how we use that information when we look to the person sitting in front of us and say, this is the approach we’re gonna take, and it’s based on scientific information. What we have now is, and you know, most clinicians, gotta love them, it’s a tough chore, would say, you know, “maybe based on what you told me, maybe…” You know and it’s the precision, that is what we want to hone in, so that the person doesn’t feel , “oh great, they’ve tried 12 things and nothings worked, and now we’re moving on to…!” Or like one of my patients, I said to her the other day, okay, we’re moving on to plan B”, and she’s like, “no…actually it’s more like plan H!”And I realised, oh yes right because you live with this every day, so you know how many things we’ve tried that hasn’t worked…and it’s frustrating! And I can be all cheerleader about this, but we know that after you’ve tried things over and over again and they don’t work, what do most people do? They give up and think I’ll just live with it…and that’s unfortunate. So, this is the approach of this [project], and this is a nationwide collaboration as I said. So, there are all these centres around the United States that are committed to understanding and treating hair pulling and skin picking, and that’s the goal. Because this collaborative effort, you know, we don’t have to just see the folks sitting in front of us, it’s really using the information that everybody is gathering in a systematic, organized fashion to move everything forward in the field of medicine. And so, we’re very confident that this is the best way to move the field forward to get the best options, because otherwise in a few years from now we might be saying, “oh you know, between 2020 and 2030, we had another few cases, and we had another few cases”, and you know that’s great, but we need more information and it needs to be more useful in a timely fashion.
So, that was the history of things, and where we’re headed with the BPM initiative…questions?


With this new BPM initiative, what are some of the obstacles to your goal? And are people in higher academic circles accepting the scientific legitimacy of trichotillomania and skin picking?


I don’t think legitimacy is an obstacle because of DSM-V including skin picking, so I think that shows an awareness from massive amounts of mental health professionals that this is real. Because let me tell you, there are lots and lots of things that people tried to get onto the DSM-V, that did not! So the fact that skin picking made it on speaks very well, not only to the people who did research on it, and God love all of them for providing all of that information, but I think it was persuasive, that people said yes this is real…there’s a history to it, you know, this wasn’t created in 2010 because people were bored and said oh let’s just make up something. So I think people recognized that. I think that the one obstacle, and it’s not the people, because I think people with trich and picking have been very excited about taking part in research, they’re very altruistic in the sense that they know that what we learn from every individual helps somebody else...which I think is beautiful. I think that part of the problem with dwindling dollars on any kind of big federal level is you start getting into what one calls “serious mental health problems” as taking priority, and the reality is that a lot of folks with trich and picking, although struggling, often much more internally, people are not as aware of say people with schizophrenia who are living in a group home, who can’t function. And so you know the high function quality of folks with picking and trich, has sort of made it I think fall off the radar in terms of this “serious mental illness” and so when it comes time to dividing up the dollars, and you know, the Feds say well you know we’ve got money that can go to schizophrenia (on one hand) and crystal meth addiction (on the other hand), and then you know trich and picking not so much… I think it’s good that they’ve done some is good, but I think that is more of the obstacle, is to let people know that people struggling isn’t a comparative thing necessarily. You know we don’t have to think; oh you don’t struggle as much as somebody else, and also we have a lot of high functioning people whose quality of life is definitely hampered, and why isn’t quality of life also on the priority as functioning. These are the sort of cultural debates going on about where should money go. I think that’s been the bigger hurdle, which is why this goal has been to leverage private funds.


In terms of the pharmacological studies you mentioned, in my experience, while these medications do help with the associated anxiety or mood disorders, it doesn’t seem to treat the underlying trichitillomania or skin picking, so where are we in terms of pharmacological studies?


I will answer that in general terms, in more specific terms, I will be giving a talk later on the specific pharmacological studies and how good they were, so I will defer my answer on specific medications to this afternoon. In the big picture though I think the pharmacological treatment arm, much like anything else, you know you have to know what you’re treating, right? And so you need biological basis to know why you give what you give. I think that given the little bits of data that we have, some of the options have made sense at least in theory. The goal of the BPM is that by collecting enough information on hundreds of people that you really are beginning to target a clear biology that seems to be sort of either the most common, or this one’s pretty common you know so you know what you’re targeting, you know, as opposed to just taking a pill and trying to use it. So the goal of the BPM is, that we will have better medication options, with better information about the brain. And until we do, there’s always a little bit of shooting in the dark so to speak. You know, quite frankly like there sometimes is with even the behaviour therapies.


If we live in Southern California or really any part of the United States and we want to be part of the research, how do we help or become part of the research?


Right now research options are available through the website for current ongoing research ideas, and those then direct people wherever in the country research is going on, that’s the one piece. The research that’s part of the BPM initiative has not started yet, the goal at this point is really fundraising so that we can get the funds to launch the research. But, one doesn’t have to wait for this because there are a fair amount of research that’s being done across the country that people can participate in if they have the time and interest. And I know that the investigators at these places are always appreciative if somebody is interested.


In terms of medications used to treat mood disorders that sometimes trigger hair pulling or skin picking, is there a list of medications that that don’t have an adverse reaction that we could give doctors, you know who are not educated?


There are a range of research studies already on medications and if you are able to come to the session I’m doing this afternoon I think that will be the best place to get the information. If you’re not able to, the website does have some information that we’ve written up for them about medications, what’s been used, what doesn’t work and things like that. "

Celebrities with Dermatillomania

As with any condition of the body or mind, dermatillomania does not discriminate. Celebrities are often heralded by fans as being perfect and untouchable. Yet, celebrities also experience the trials and tribulations of human emotion, and are also vulnerable to stress and anxiety. Unfortunately conditions like dermatillomania evoke feelings of shame and embarrassment in the person challenged by it, and is therefore not a condition that is publicized, especially by those in the limelight. However, in 2012, a well known singer-songwriter became one of the first celebrities to publicly admit to having dermatillomania.

Putting dermatillomania in the spotlight

Tulisa Contostavios is famous in the United Kingdom for being part of the four-time platinum award winning hip hop group N-Dubz. She is more recently known for her role as a judge on the reality talent show X-Factor UK. In her autobiography titled “Honest: My Story So Far”, published in 2012, Tulisa provides a vivid account of her experiences with skin-picking disorder. Her memoires of her experiences with skin-picking shocked the celebrity gossip media, leading to interviews and gossip column articles quoting extracts from her book. Most of the extracts focussed on her description of the skin-picking behaviour she engaged in, which she describes quite graphically in the book. For example she describes picking at her face with nail clippers and tweezers “leaving gaping, weeping holes”. What the media fails to highlight though is her very real account of the immense anxiety and emotional anguish she endured that led to her skin-picking behaviour.

In her book Tulisa describes living with a mother with schizophrenia and enduring destructive personal relationships which left her feeling depressed and anxious. But perhaps the most important admission Tulisa makes are the feelings of guilt and shame she experienced because of dermatillomania. She describes finding out that she was not the only one who engaged in this behaviour and that it was a recognised as a clinical condition called dermaillomania, and that knowledge gave her the impetus to share her experiences with those close to her.

She says in her book, “I Googled the condition, sending links to my management and the people I was working with”, but explains that it was still difficult to come to terms with it because people still struggled to understand the behaviour.

Raising awareness and setting an example

Tulisa is one of the first celebrities known to publicize her battle with skin-picking, and it is hoped that if there are other celebrities out there who also struggle with dermatillomania, that they will be inspired by Tulisa’s courage and recognize the value a celebrity platform would add to raising awareness and support about and for Dermatillomania and those suffering with the condition.

Still an unnamed shame

Despite it being recognized as a clinical disorder, skin-picking is still undiagnosed in many who suffer with the habit in shame. There are other well known personalities who have alluded to the fact that they have in the past, or currently do have the compulsive habit of picking at their skin, most notably skin imperfections. In many cases their revelation describes the condition dermatillomania but it is not identified as such.

Reality-TV star Brandi Glanville, from “The Real Housewives of Beverly Hills” fame has admitted to obsessively picking at her acne when she breaks out.

Another well known personality with dermatillomania is celebrated author of “I'm No Saint: A Nasty Little Memoir of Love and Leaving” – Elizabeth Hayt. Elizabeth describes her skin-picking habit for Elle magazine

Renée Rouleau is a celebrity esthetician who has also suffered from the condition for many years. Ironically it is because of her skin-picking that she has chosen her career path and is now recognized by the rich and famous as an expert in skin care. She talk frankly about her condition in this blog post.

There are rumours and unconfirmed reports of other, more well-known celebrities like Cameron Diaz being a skin-picker. However this cannot be stated as fact either because the celebrity is not necessarily aware they have the condition despite symptoms indicating so; or the reports are based on speculation based on past interviews or quotes from these celebrities.

Either way, it would not be surprising if there were many more famous or celebrated personalities with dermatillomania. The more awareness is raised about the condition, the more people, famous or not will come forward with their symptoms and receive the support and help they need.

Skin Picking Success Story by Caroline C. [TLC conference 2014]

One of the first and greatest hurdles to overcome to successfully be skin-pick free is to open up to someone who cares and to seek help and support. So imagine the courage it must take to stand up in from of hundreds of people, in front of a camera, and admit that you are a skin-picker. In this video clip, a brave woman named Caroline does just that.

Not only does she admit to being a skin-picker, but she also describes her skin-picking habits in detail and gives an emotional account of how skin-picking has impacted her life socially and academically. She describes the journey that so many with dermatillomania can relate to, in which the shame and guilt of her skin-picking habits drove her to engage in other destructive behaviours such as drug abuse. She describes a life spiraling out of control and failed attempts at managing her condition with therapy and support groups.

But there is joy to be found in Caroline’s story. She shares a lesson of hope and perseverance and most importantly the value of having the support of someone who understands you and understands your condition. Caroline does not dismiss the mainstream therapeutic approaches or support groups, describing them as having provided her with important tools that helped her on her journey to recovery. But it was having someone in her corner at her times of greatest need that helped her put those tools to effective use.

At the time of this clip, Caroline had gone from being an aggressive daily picker to having picked no more than 50 times within 6 months. Caroline is proud of what she has achieved and is so confident in her ability to manage her condition that she has chosen a strapless wedding gown in her upcoming wedding. But most importantly, Caroline has dispelled the feelings of shame and guilt, and has instead embraced confidence and hope for her future…a beautiful example of the possibility for all those suffering with dermatillomania.

"She's Lost Control" - Short Film on Dermatillomania and the Loneliness of Shame

Dermatillomania or excoriation (skin picking) disorder is not a very well known condition, primarily because the behaviours that manifests in this disorder are not often shared by people who engage in them. As a skin-picker you are often riddled with shame and guilt about your behaviour, covering up the ‘evidence’ to protect your closely guarded humiliating secret. Ironically the secrecy often isolates you from those you care about and, ironically, prevents you from receiving the much needed support and help you need to overcome it.

This short film (by Rhiannon Harris) called “She’s lost control” portrays just how lonely the shame of dermatillomania can be. In the film, a young beautiful girl is shown picking at sores (most likely created by her in the first place) until they bleed. She is disturbed by her mother knocking at the bathroom door asking her why she was taking so long. The film is very graphic, but it captures the urgency with which skin-picking engulfs the person while they are engaging in it. It also shows the distress the girl experiences when she hears her mother knocking at the door. In the audio you hear a therapist asking her questions about her skin-picking. In her answers you can hear that she doesn’t know how this habit came about or why she continues to do it, but she is clear that she does not want her mother to find out. In the end though, her secret is revealed. The humiliation felt as a skin-picker is one of the greatest hurdles one needs to overcome in order to deal with the condition. The loneliness and shame can lead to self-loathing. It is only through sharing ones experiences and gaining support will the burden feel lighter to bear and life as a skin-picker will feel far less alone.

Onychophagia (Compulsive Nail Biting) - An Overview

What is Onychophagia

Onychophagia nail biting

Onychophagia is a behavioral disorder characterized by compulsive nail biting. It is categorized with other disorders such as skin picking disorder (aka dermatillomania or excoriation disorder) and hair pulling disorder (trichotillomania) under the umbrella term body-focused repetitive behaviors (BFRB). These are compulsive habits that are automatic in nature and in its mildest forms are not perceived as socially unacceptable and therefore often not recognized by the individual as a clinical problem. Of the BFRBs, compulsive nail biting is the most socially accepted habits, viewed as simply a ‘nervous habit’. It is also commonly occurring in childhood with frequency tending to decrease by adulthood. However, the behaviour is known to intensify or persist through adulthood, and the severity of onychophagia can range from a very mild presentation to behaviours that are so severe that physiological complications occur.

Causes and complications

Onychophagia, as with other BFRBs are believed to be caused by feelings of anxiety and the individual’s inability to cope with these feelings in an effective way. The act of nail biting is believed to serve two functions:

1. Self-soothing: during times of stress, tiredness, or intense emotion, the human brain experiences sensory overload. Self-soothing is a mechanism human beings use to cope with these overwhelming sensory processes. However, sometimes people adopt unhealthy self-soothing behaviours such as nail biting. The act of nail biting provides immediate relief to the person, but it is short-term causing the individual to seek out its soothing effects more often resulting in the behaviour becoming repetitive and compulsive.

2. Stimulation: In contrast, human beings also crave healthy stimulation of the sensory processes. When the sensory pathways are under stimulated through, for example, inactivity or boredom, BFRBs such as nail biting provides the necessary stimulation.

However, nail biting is a destructive habit which can lead to a number of different physiological complications. If one considers the amount of germs the human hand comes into contact with throughout the day, nail biters are vulnerable to infections such as gastroenteritis and the spread of viral infections such as the Herpes. In other cases the nail biter may bite so close to the cuticle causing the cuticles to bleed and abscess to develop at the nail site.

Treatment of Onychophagia

There are two levels of treatment. On the one level one can treat the symptom of the disorder by taking measures to stop or guard against the actual act of nail biting. On another level one can try to address the underlying cause of the nail biting behaviour. A combined treatment approach is probably the most effective in achieving habit reversal. Treatment methods include:

Bitter varnish: bitter varnish made with a natural extract and is therefore harmless if ingested can be applied to the nails. This may deter the person from biting at the nails or reduce the severity of the problem

Manicures: beautifully manicured nails may offer the nail biter a visual reminder of the habit as nail biting is often an automatic response

Acrylic nails: the nail biter may not achieve the same stimuli from biting nails that are not their own so this may also reduce or deter the habit

Self-monitoring: This method can be employed as a physical deterrent as well as a psychological one. This method requires the nail biter to keep a log of their nail biting behaviour. Bringing the automatic habit into the conscious mind may interrupt the habit thereby reducing the habit. On a psychological level the individual may be encouraged to use the log to identify patterns in behaviour to identify what the stressors are that elicits the behaviour. This can then be linked with more intensive cognitive-behavioural therapy

Stimulus control: this method is used in conjunction with self-monitoring as it requires the person to identify triggers to the behaviour and to be aware of these triggers in their daily functioning. The person is then encouraged to develop alternate, less destructive coping mechanisms

Competing Response: the principle behind this method is to identify a competing habitual behaviour that provides a competing stimulus to biting the nails. These preferably should preoccupy the hands and/or the mouth e.g. chewing gum

Cognitive-behavioural therapy: CBT is a more intensive approach that addresses the underlying causes of the behaviour. The individual is made aware of how their thoughts impact on their behaviours, and how negative behaviours further reinforce negative thinking patterns. The individual is encouraged to adapt their thinking patterns and to adopt healthy coping and stress relieving behaviours. This method is used in conjunction with self-monitoring, stimulus control and competing response.

Pharmocological: When the underlying cause is primarily due to high levels of anxiety, it may be appropriate to treat the anxiety with anti-anxiety medications. These may be prescription medication or natural or homeopathic remedies to relieve stress and anxiety.


Onychophagia may not be perceived as a problem when the behaviours do not interfere with daily functioning. However the nature of the condition, being a body-focused repetitive behaviour is that the longer the habit is left untreated the stronger the habitual response becomes. This is particularly a risk when underlying causes of anxiety or stress are elevated in the person’s life. When the nail biting habit becomes so severe that it impedes functions like driving, typing, writing, cooking, or poses a physiological risk to the person due to some of the complications noted earlier, it has also reached a habitual level that is harder to break and therefore harder to treat.

Habit reversal training is best addressed when the automatic response is still weak. The principle behind habit reversal is the belief that the less the behaviour is enacted, the weaker the habitual response becomes, thereby eliminating the destructive habit completely. It is also vital that the nail biter has good social support and does not try to address the condition alone. Aside from family and friends, online support groups and websites can be a great source of support, information and motivation.

A Survey: Discovering the Needs of the Skin Picking community survey skin picking

The Trichotillomania Learning Centre (TLC) was initially aimed at providing support to people with thrichotillomania (hair pulling disorder). However as TLC has grown it has come to recognised the links between trichotillomania and other conditions such as skin-picking disorder (SPD) which are classified as body-focussed repetitive behaviours (BFRB). They have since evolved into a prolific organization in the support of education, awareness and research into the cause and treatment of all BFRBs including skin picking. However, since skin picking, also known as dermatillomania or excoriation disorder, is still a growing community, resources and support to the skin-picking community is not at the same level as programs focused on hair pulling. As such TLC are conducting a survey to understand needs of the skin-picking community to guide them in creating and improving programs that will benefit those suffering from skin-picking disorder.

TLC therefore invites you or anyone you may know with skin-picking disorder to participate in a short 10 minute survey to share your views. Your responses will be anonymous, but you also have the option to enter into a draw with a chance to win a $100 gift certificate which is redeemable at the TLC online store.

Take the survey here >>

Skin Picking and Body-Focussed Repetitive Behaviours (BFRB)

There has been disagreement in the medical fraternity about the classification of skin-picking disorder (SPD) with some grouping it with obsessive compulsive disorders (OCD), while others categorising it as a body-focussed repetitive behaviour (BFRB). One might question what the importance is of classifying the skin-picking disorder into any specific category when they are all so similar. The importance lies in the advancement of knowledge and understanding of the causes and developing guidance of treatment of the condition. There are distinct clinical differences in the presentation of obsessive compulsive disorders and the underlying causes, and those of BFRBs. As such, there are also differences in the treatment approaches that are most effective within each category of disorder. In a recent 2012 internet study comparing the rates of problematic BFRBs in individuals with SPD, it was found that skin-picking disorder is associated with body-focussed repetitive behaviours.

What are BFRBs?

According to Angela hartlin's skin-picking support website, Body- Focused Repetitive Behaviours (BFRB’s) “is an umbrella term for any chronic behavior that causes a person to consistently cause physical damage to oneself unintentionally through a compulsive act in order to relieve anxiety.” The key difference between BFRB and other compulsive behaviours that cause harm to the body is that BFRBs are characterised by direct body-to-body contact. The website goes on to list other BFRBs such as: hair-pulling disorder (trichotillomania), hair eating disorder (trichophagia), skin biting disorder (dermatophagia), nail biting disorder (onychophagia), and nose picking disorder (rhinotillexomania).

The link between Compulsive Skin Picking and BFRBs

In the study linking skin-picking to BFRBs, it was found that there was a strong co-occurrence of the different BFRBs where individuals who skin-pick also tend to bite nails or pull hair obsessively. There was also a strong correlation between individuals with skin-picking disorder and a familial history of one or other BRFB. This suggests that the cluster of BFRBs may have familial traits rather than the specific behaviour itself. There are some other sub-categories of BFRBs that develop as an extension of the main habit. For example skin-pickers may also develop the habit of picking at scabs that form on healing sites where skin picking previously occurred. This can develop into the habit of eating the scabs. In the same vein, it is not uncommon for individuals with hair pulling disorder to develop the habit of eating hair which evolves into a BFRB on its own. From the research it is suggested that BFRBs are automatic habits in that there is no reflective awareness or cognitive awareness of deliberate harm to the body. Skin-picking disorder presents in a similar fashion in that the individual does not initially start out intentionally trying to harm or damage the skin. However the regulatory effect experienced by the person engaging in this behaviour on overwhelming emotions or cognitive thought patterns such as intense anxiety, causes the person to habitually seek out this effect through continued picking. This mounts to obsessive repetition of the behaviour without the person realizing until it has developed into a clinical condition. In this way skin-picking, as with other BFRBs respond well to similar treatment methods such as habit reversal.

Is Dermatillomania Genetic?

dermatillomania genetic?

Dermatilloma is a skin-picking disorder that not only leads to skin damage, but the severity of the behaviour is directly proportional to the social and emotional distress experienced by the person who engages in the behaviour. Anyone with a skin-picking disorder will testify to the shame and embarrassment the condition causes. People with dermatillomania (official term: excoriation disorder) often suffer in silence, unaware of how common the condition actually is. The explosion of web-based technology has given millions of people suffering from dermatillomania access to information and enabled individuals to seek support anonymously. One of the most common questions asked by people seeking information about skin-picking disorder is, “did I inherit it?”, or, “is it genetic?” Often people asking this question have noticed members of their immediate or extended family having similar habits, which leads them to conclude that they must have inherited the behaviour. This is also a concern for people who do not suffer with skin picking, but have witnessed the debilitating impact it can have on a relative’s life, and are concerned that there may be a possibility that they could inherit the condition. These concerns are not unwarranted as existing family history data seems to suggest that skin-picking disorder is familial.

Heritability of skin-picking disorder

In one study of 60 participants with skin-picking disorders, 28.3% of their first degree family members had the disorder. Skin-picking is also often associated with Obsessive-Compulsive Disorder (OCD). Scientists have identified a genetic marker for OCD, but the onset of OCD is also believed to be triggered by a combination of genetic and external factors. So the question remains, is the familial aspect of skin-picking disorder due to the genetic component of OCD, or are there independent genetic factors associated with skin-picking disorder? A study has shown that individuals with skin-picking disorder, without OCD, are more likely to have a first degree relative with the disorder than individuals with OCD. This suggests that there may be genetic factors associated with skin-picking disorders independent of the genetic contribution to OCD. However, the reality is that research into the condition is still very limited and its causes are unknown. A 2012 twin study examining heritability of skin-picking symptoms, found that skin picking was a relatively common problem, particularly among women and that it tends to run in families mainly due to genetic factors. However, the study also concluded that non-shared environmental factors were also instrumental in the onset of skin-picking symptoms. These findings are backed up by other similar prevalence studies that have found skin-picking disorder to be as common as many other psychiatric disorders, with the most recent suggesting it affects between 2% to 3% of the general population.

The age-old Nature vs Nurture Debate

The reality is that there is still very little hard evidence as to the cause of dermatillomania. There are experts who believe that there definitely is an underlying genetic component resulting in some people having a greater predisposition to becoming skin pickers than others. On the other hand there are many experts who view skin picking as a maladaptive behaviour associated with:

  • poor coping skills
  • obsessive and compulsive thinking
  • poor frustration tolerance

By this definition, skin picking is an impaired response in times of high stress. Studies with mice do seem to suggest that there is a strong genetic component to the cluster of behaviour known as Body-Focussed Repetitive Behaviours (BFRB). In these studies, the removal of a gene led to the mice engaging in excessive grooming similar in presentation to hair–pulling and skin-picking, causing damage to the skin of the mice. This has led researchers to conclude that there is an underlying genetic cause for skin-picking and hair-pulling disorders, and that these disorders are a manifestation of excessive grooming. Genetic factors identified by animal studies include mutation of the Hoxb8 gene, and deficiency of the scaffolding protein SAPAP3. This was consistent with a human genetic association study that variation in the SAPAP3 gene is linked to the onset of grooming disorders.

Future Genetic Research

The good news is that research interest in Body-Focussed Repetitive Behaviours such as skin picking disorder has grown in recent years. The Trichotillomania Learning Centre (TLC) is at the forefront of such research. Trichotillomania, a hair pulling disorder, is clustered with skin picking disorder as a Body-Focused Repetitive Behaviour. The TLC is engaged in an international collaborative research project named the Trichotillomania International Consortium for Research. The ambitious project aims to gain a better understanding of the underlying risk factors for trichotillomania and dermatillomania through genetic research. Genetic information such as blood samples, DNA, and cell lines; as well as clinical data collected through in-depth interviews, will be collected and stored for use in present and future studies. The biological samples and clinical data will be stored in a biobank, which is a type of biorepository, and will become an important resource in hair-pulling and skin-picking disorder research. The biobanks will give multiple researchers in the scientific community worldwide access to data representing larger numbers of people than may be possible if they were to collect this data independently. It also enables multiple uses of the data. The Psychiatric and Neurodevelopmental Genetics Unit (PNGU) in the centre for Human Genetic Research and the Massachusetts General Hospital will be the coordinating site for data collection and management. Additional biobanks have also been established at the University of Cape Town and the University of Stellenbosch in South Africa, with plans to establish additional sites in the near future. It is hoped that this resource will facilitate the much needed research into this condition. However, it is important to recognize that even though research points to genetic influence, the role that neurological, behavioural and environmental factors play in the onset of the condition should not be minimized if effective treatment approaches are to be developed.

Skin Picking and Hair Loss

dermatillomania and baldness

Dermatillomania or skin-picking disorder manifests in many forms. Common areas that are the focus of skin picking include the face, arms, neck, and scalp. Skin-picking disorder is part of a cluster of disorders known as Body-Focussed Repetitive Behaviour (BFRB). When dermatillomania presents as an obsessive-compulsive scalp-picking behaviour, it can often be confused with another BFRB called trichotillomania. Trichotillomania is a hair-pulling disorder, which leads to hair loss and sometimes baldness. However, scalp-picking is motivated specifically by the person’s urge to pick at the skin of the scalp, whereas hair-pulling is the urge to pull the hair out of the scalp.

Does picking scalp cause hair loss?

While hair-pulling directly removes hair from the scalp, causing immediate hair loss, scalp-picking does not directly target the hair strands or follicles. Unfortunately the hair strands and follicles inevitably become damaged with repetitive picking at scalp skin. Constant picking at the scalp skin can cause the area to become sensitive and sore, sometimes causing bleeding and open wounds on the scalp. This can result in the skin cells on sensitive areas losing its ability to heal efficiently, often leading to hair loss. Sometimes scalp-pickers do pull hair out in order to gain easier access to the scalp. The formation of scar tissue on the scalp after an area of skin has been picked open can exacerbate the picking behaviour, with the person resorting to picking at the scab. This further damages the skin tissue, reinforcing the cycle.

Can scalp-picking cause baldness?

Repeated picking at the scalp skin can also cause damage to the hair follicles. The damage occurs below the surface of the skin so it is not visible to the naked eye, apart from patchy hair loss or thinning of the hair that occurs. It is important to distinguish between scratching of the scalp due to a dermatological condition which may cause itching; and scratching or picking at the scalp skin due to an obsessive compulsion to fulfill the urge to pick or scratch. People who suffer with dermatillomania pick and scratch at the scalp regardless of the discomfort or pain that follows. In severe cases the picking can cause the open skin to become sensitive to shampoos, water, and even air, impeding the person’s daily function. Yet, despite this, the person cannot resist the urge to continue picking at the scalp. This can result in the removal of the protective covering on the individual hairs, from the hair shaft. This weakens the hair shaft, leading to permanent damage, breakage and hair loss. When the hair follicles are permanently damaged, and are replaced with scar tissue, this is known as scarring alopescia. Initially the person may experience gradual hair loss with no noticeable symptoms, and can go undetected for a long time. In some cases where follicles on the periphery of a bald patch are not completely destroyed, the hair is able to re-grow. However, if the person continues to engage in repetitive scalp picking, often all that remains are scars on the scalp to show where the follicles once were. When the follicles are damaged beyond repair, this can lead to baldness.

Ad Campaign Encouraging Positive Self-Expression

Cosmetics brand Dermablend Professional recently launched an advertising campaign on YouTube called the Camo Confession Campaign. The cosmetics industry is often slated for being superficial and encouraging women and girls to strive for the unrealistic ideal of perfection. Dermablend Professional hopes to challenge this view with the Camo Confession ad campaign. The campaign kicks off with a young model named Cassandra removing her make-up and sharing her personal story of shame and ridicule as a young teenager because of her terrible facial acne. Even though she is talking about acne, we thought the heart of the story is something that many who suffer with skin-picking disorder can relate to.

The clip is just over 2 minutes long, but it has a powerful message. For many patients, skin-picking started with the onset of acne as a teenager. Scratching and picking at the acne sets off a cycle of repetitive obsessive compulsive behaviours. Picking acne can cause permanent marks and scarring, which is a source of great embarrassment for the person, especially if it is in the face. Many skin-pickers therefore feel the need to camouflage these marks cosmetics. The teenage years can be especially traumatizing when aesthetics and appearance play such a big role in social acceptance and formation of self-identity.

Dermablend Professional’s corrective cosmetics are used by people with mild to severe skin conditions. The message from the ad campaign is that the Dermablend brand is not about vanity, but about having the freedom to express oneself positively, free from ridicule, and living a normal life. This is achieved through the heartfelt testimonials two women who describe their stories of shame and embarrassment because of a skin disorder that made them the centre of much ridicule. As they speak the make-up on their faces start to disappear and they leave us with a parting message that the Dermablend’s concealing products empowers them to reveal who they truly are, because their imperfections do not become the centre of distraction.

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