Trichotillomania and Excoriation Disorder
Understanding Body-Focused Repetitive Behaviors
Hair pulling, skin picking, and related behaviors are more common than many people realize—and far more complex than simple “bad habits.” Trichotillomania and excoriation disorder are classified as body-focused repetitive behaviors (BFRBs), and they can cause significant distress, shame, and impairment in daily life. While they share some features with obsessive-compulsive disorder (OCD), they are distinct conditions with unique treatment considerations.
Understanding these differences is an important step toward compassion, accurate diagnosis, and effective care.
What Are Body-Focused Repetitive Behaviors?
Body-focused repetitive behaviors are repetitive actions directed toward the body that result in physical damage and are difficult to stop, even when the person wants to. These behaviors are not intentional self-harm, but rather coping mechanisms often linked to stress, boredom, emotional regulation, or sensory relief.
The most well-known BFRBs include:
Trichotillomania (hair-pulling disorder)
Excoriation disorder (skin-picking disorder)
Trichotillomania (Hair-Pulling Disorder)
Trichotillomania involves recurrent pulling out of one’s hair, most commonly from the scalp, eyebrows, eyelashes, or other body areas. The behavior often leads to noticeable hair loss and significant distress.
People with trichotillomania may:
Pull hair automatically (without full awareness) or deliberately, often due to perceived textural differences
Experience a sense of tension before pulling and relief afterward
Feel shame, embarrassment, or fear of being judged
Attempt repeatedly to stop or reduce the behavior without success
Trichotillomania often begins in childhood or adolescence and may fluctuate in severity over time.
Excoriation Disorder (Skin-Picking Disorder)
Excoriation disorder involves recurrent picking at the skin, leading to lesions, scarring, or infection. Common areas include the face, arms, hands, and legs.
Individuals with excoriation disorder may:
Pick at perceived imperfections such as acne or scabs
Spend significant time picking or thinking about picking
Feel relief, satisfaction, or numbness during the behavior
Experience guilt, shame, or frustration afterward
Like trichotillomania, skin picking can occur both consciously and automatically.
FAQ:
No. These behaviors are not driven by a desire to cause harm. They are body-focused repetitive behaviors linked to urges, emotional regulation, or sensory relief.
OCD behaviors are performed to neutralize intrusive fears, while hair pulling and skin picking are typically driven by urges or sensory experiences rather than obsessions.
Yes. These conditions can co-occur, which is why a comprehensive evaluation is important.
How BFRBs Compare to OCD
Trichotillomania and excoriation disorder are grouped in the DSM alongside OCD and related disorders because of shared features—but they are not the same as OCD.
Key similarities include:
Repetitive behaviors that are difficult to control
Temporary relief or reduction in distress after the behavior
High levels of shame, secrecy, and impairment
Important differences include:
1. Motivation behind the behavior
OCD: Behaviors (compulsions) are generally performed to neutralize intrusive, unwanted thoughts or fears (obsessions).
BFRBs: Behaviors are often driven by sensory experiences, emotional regulation, or habit—not by intrusive fears.
2. Presence of obsessions
OCD: Obsessions are a core feature.
Trichotillomania and excoriation disorder: Obsessions are typically absent, though distress and urges are present.
3. Experience during the behavior
OCD: Compulsions are usually experienced as unwanted and anxiety-driven.
BFRBs: Behaviors may feel soothing, relieving, or even pleasurable in the moment, despite later distress.
4. Treatment response
While there is overlap, treatment approaches differ and should be tailored to the specific condition.
Why Misdiagnosis Matters
Because BFRBs can look similar to OCD from the outside, people are sometimes misdiagnosed and placed in treatments that are less effective for their symptoms. Accurate diagnosis helps guide the most appropriate therapy and medication strategies.
Evidence-Based Treatment Options
Habit Reversal Training (HRT)
HRT is considered a first-line treatment for trichotillomania and excoriation disorder. It focuses on increasing awareness of the behavior and replacing it with competing responses.
Cognitive Behavioral Therapy (CBT)
CBT can help address emotional triggers, stress management, and thought patterns that maintain the behavior.
Acceptance and Commitment Therapy (ACT)
ACT helps individuals tolerate urges without acting on them and reduce shame and avoidance.
Medication
Medication may be helpful for some individuals, particularly when anxiety, depression, or OCD symptoms are also present. Options are individualized and should be guided by a psychiatric provider.
Living With a BFRB
Living with trichotillomania or excoriation disorder can feel isolating. Many people hide their symptoms for years before seeking help. Recovery does not mean never having urges—it means developing tools to respond differently and reduce the impact on your life.
Final Thoughts
Trichotillomania and excoriation disorder are real, treatable mental health conditions—not habits or failures of willpower. While they share features with OCD, they require thoughtful assessment and tailored care.
If you or someone you love struggles with hair pulling or skin picking, support is available.
If you’re struggling with hair pulling, skin picking, or related behaviors, you’re not alone—and help is available. At Tranquility Psychiatry, we provide compassionate, evidence-based care for OCD, BFRBs, and related conditions. Contact us today to schedule an appointment and take the next step toward relief.
