Skin picking and hair pulling: very treatable but often missed

Dr. Sanjay Rao

19 April 2019

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Skin picking and hair pulling: very treatable but often missed

In the DSM-5 Trichotillomania (Hair Pulling Disorder) and Excoriation Disorders (Skin Picking Disorder) are included in the Obsessive-Compulsive and Related Disorders section. Each of these disorders is present in about 1-2% of the population. They are common in females and share some similarities with Obsessive Compulsive Disorder (OCD). It generally starts before adulthood but can start later.  

Take steps to detect 

In my practice, at least 9 out of 10 times only direct questioning reveals these problems. It is often present along with other anxiety disorder even though the literature mainly comments on its co-occurrence with OCD. 

It is very treatable  

For something so treatable (and relatively common) it is surprising that there are not many intervention studies. These conditions respond very well to cognitive behavioral therapies, and although useful, medication treatment has not shown robust evidence (Bloch et al., 2007; Lochner, Roos, & Stein, 2017; Rothbart et al., 2013). 

What and how to treat 

The literature chiefly talks about habit reversal treatment as if skin picking is a habit only. There are both habitual and compulsive elements to these conditions, and they require specific attention. Differentiating between these two phenomena is important.  

So, a combination of habit reversal and other cognitive behavioral strategies are needed for their effective management.  

Practice makes it perfect 

No matter how much one reads about the treatments, it is best to have hands-on training. This is because most mental health training programmes do not cover this condition in adequate detail.  

Our workshops hope to provide busy clinicians with just the right skills to help people who have either of these conditions.  

 

Bloch, M. H., Landeros-Weisenberger, A., Dombrowski, P., Kelmendi, B., Wegner, R., Nudel, J., . . . Coric, V. (2007). Systematic Review: Pharmacological and Behavioral Treatment for Trichotillomania. Biological Psychiatry, 62(8), 839-846. Retrieved from http://www.sciencedirect.com/science/article/pii/S0006322307005033. doi:https://doi.org/10.1016/j.biopsych.2007.05.019 

Lochner, C., Roos, A., & Stein, D. J. (2017). Excoriation (skin-picking) disorder: a systematic review of treatment options. Neuropsychiatr Dis Treat, 13, 1867-1872. doi:10.2147/ndt.S121138 

Rothbart, R., Amos, T., Siegfried, N., Ipser, J. C., Fineberg, N., Chamberlain, S. R., & Stein, D. J. (2013). Pharmacotherapy for trichotillomania. Cochrane Database of Systematic Reviews(11). Retrieved from https://doi.org//10.1002/14651858.CD007662.pub2. doi:10.1002/14651858.CD007662.pub2 

About the Author

Dr Sanjay Rao is an experienced teacher and Associate Professor of Psychiatry at the University of Ottawa In 2018 he was awarded a Fellowship of the Canadian Association of Cognitive Behavioural therapy for his contribution to CBT in Canada. He has received an award from the Department of Health, UK for CBT development. He is the Director of Unified CBT training.

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Trichotillomania (hair pulling disorder) and Excoriation Disorders (Skin Picking Disorder) are included in the obsessive-compulsive related disorder section of the DSM-5 and are present in about 1-2% of the population. They are more common in females, often co-morbid with other conditions.


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Attention Deficit Hyperactivity Disorder is a common presentation in adult mental health. It is often co-morbid mood and anxiety disorders. Adult ADHD (AADHD) is frequently missed in presentations. There is also the danger of overdiagnosis in presence of other conditions which disrupt attention and concentration. 


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