Does your brain like to pick skin or pull hair?

2024 update

As I move each and every blog post from the old platform to the new one (UUUGGGGHH) I have been re-reading a lot of old blogs. I realized that although I wrote this one somewhat recently in 2022, I’ve learned a lot in the past two years about BFRBs (picking, pulling, etc.). Below, I describe Habit Reversal Training or HRT. However, the way I have always implemented this type of treatment, with functional analysis, is actually called Comprehensive Behavioral Treatment (OR ComB) for BFRBs. Someone much smarter than me actually took all of the techniques described below, organized them, and named a protocol for the whole package. If you want more information about this treatment, look up “ComB for BFRB” rather than “HRT for BFRB.”

The Original

The technical terms for these experiences include trichotillomania, dermatillomania, body-focused repetitive behaviors (BFRBs), and sensory self stimulation (stimming) and a lot of folks with anxiety do these things. A lot of folks without anxiety also do these things. Because these behaviors can be anxiety-mediated or stand on their own, it can be tricky to treat them and to give advice on treating them!

Stimulation that helps folks cope

I have a confession: I TOTALLY get picking. I’ll peel paint off a house, polish off my fingernails, a hole in fabric if it’s starting to go; the list goes on. And if I have dry or peeling skin, I would LOVE to pick it and I will tear up my hands or feet doing it. My picking is NOT anxiety mediated. Its a stim that I unconsciously use to concentrate when my focus is running thin. I have ADHD and it’s one of the ways I’ve learned to cope. I now know that I need something to hold in meetings or long conversations, to keep my brain focused on what people are saying. I also rock in my chair which is probably annoying to my telehealth clients. Picking for me, functions as a stim. It helps me manage my often-wandering brain. It shifts me from a state of distraction to hyper-focus.

Autistic folks also use stimming as a way to cope with intense experiences in their inner and outer worlds and to modulate the intensity of their experiences.

I would argue that in BOTH of these cases, stimming isn’t hurting anyone and a therapist and client can work together to work on advocating for acceptance in the outer world for stimming behavior and flexibility within the behavior so that less harmful (to the skin and hair) alternatives can be chosen if the behavior is leading to physical damage.

Anxious picking and pulling

Other folks pick or pull as a response to anxiety. Amy Schumer recently revealed that she has trichotillomania or hair pulling. Based on the bit of information shared in articles about her news, it seems like her hair pulling is more anxiety-mediated than a sensory stimulation.

Anxious picking and pulling can be focused on the skin or hair imperfection itself: The look or feel of gray hairs, or the look or feel of skin bumps. This type of picking is often accompanied by visual and tactical monitoring of the offending area is essentially a body-focused form of OCD. It keeps picking on a bothersome involuntary experience (noticing skin or hair imperfections) and keeps doubling down on control efforts until the cycle is broken. It’s not appearance-based usually. Appearance-based picking is more body dysmorphia and can be the focus of another discussion but picking/pulling can be RELATED to an inflated sense of imperfection and disfigurement. Sometimes it’s just about how it feels and the reward loop that occurs when the imperfection is “smoothed out.”

Differential treatment based on function of picking/pulling behavior

To effectively treat picking or pulling that’s become unmanageable, we must understand the FUNCTION of the behavior. If the function of picking or pulling is to reduce anxiety, then exposure and response prevention (ERP) in a more traditional form can be helpful, teaching clients to tolerate anxiety without picking or pulling, increasing intensity of stimuli over time. If the function of the behavior is stimming, however, regular ERP is unlikely to work as there’s no anxiety preceding the event.

Folks with stimming behavior typically don’t remember feeling anxious or even meaning to pick or pull. They often do it when concentrating on other activities. Neurodivergent folks, especially, have sensory needs that aren't met by a neurotypical world and stimming is often a bridge that helps them function. For this reason, I try to be very careful in targeting treatment only to the areas of stimming that are causing my client harm and distress. To do this, I ask my client to identify the areas they’d like more flexibility in their picking and pulling behavior and we then implement habit reversal training (HRT).

Is HRT just ERP?

I mean basically, yes. It’s the same underlying theory. I now differentiate the two in my own practice by whether the goal is to “reduce anxiety AND not pick/pull/stim (ERP)” vs. “choose a less harmful stim (HRT)”

In my version of HRT, we analyze when a client is likely to pick, set up harm reduction tools like fidgets in high risk areas to provide for sensory needs but reduce harm, practice turning on all the risk factors for picking or pulling, and then ask them to practice a new and less destructive stim. ERP for anxious picking is a little more involved, in my experience.

When I first learned about HRT, it was done WITHOUT a substitute behavior to provide for sensory needs. Instead, we analyzed the behaviors, increased awareness, taught folks relaxation exercises, and practiced NOT picking while doing high risk activities. This is more like traditional ERP, but as I’ve begun treating more and more neurodivergent folks, I’ve shifted to the softer “put fidgets everywhere,” meet your sensory needs, and just learn to use those rather than picking your body apart, approach.

So if you are a picker or puller, consider the function of the behavior as you choose the therapy approach that’s best for you. If you know you’re neurodivergent, please ask your clinician to help you meet your sensory needs rather than simply neglecting them in the service of ERP!