Greater Research Support for Behavior Therapy over Medication
Trichotillomania (or trich for short) is a condition in which people repeatedly pull out their body hair, often leading to bald patches and thinning. The scalp is a common site—as are eyebrows and eyelashes—but some may pick at hair anywhere on the body. A related condition is repetitive skin picking. This condition did not have an official diagnostic name until 2013, when the most recent edition of the DSM psychiatric guide decided on the name excoriation. People with an excoriation disorder pick or scratch at their skin—often at perceived imperfections or blemishes—to the degree that they may cause marks, bleeding, and scarring.
Both are broadly categorized as body-focused repetitive behaviors, and these have recently been more broadly categorized and obsessive-compulsive and related disorders. People with these problems often experience a great deal of shame and embarrassment about their difficulties and have an extremely tough time stopping.
Unfortunately, both conditions are understudied and not well-known. Many people struggle with them without realizing there is even a name for their condition.
The treatment literature is relatively small compared to problems such as depression and anxiety. However, I recently came across a nice summary of treatment options for trichotillomania and skin picking, as well as other conditions more broadly called obsessive-compulsive and related disorders.
Cognitive Behavioral Therapy
For hair pulling, cognitive behavioral therapy has the greatest research support. An intervention called habit reversal training has been the most studied, either by itself or in combination with a more comprehensive cognitive behavioral treatment such as Acceptance and Commitment Therapy (called “act” for short).
With excoriation, there is evidence that treatments that work for hair pulling also work for skin picking. Unfortunately, the treatment evidence for excoriation is more limited. Although it was studied for decades before being given an official diagnosis in 2013, I suspect not having an official diagnosis slowed research interest. Hopefully, we will begin to see more research on skin picking.
Rigorous research on the use of medication is much less robust than the research on therapy. There’s some evidence that the antidepressant clomipramine may help reduce hair pulling, but controlled studies on the use of SSRI’s—the most common class of antidepressants—have not shown much effectiveness. Of the SSRI’s, fluoxetine has been the most studied, but it’s effectiveness with hair pulling has been very mixed.
There’s some research support for the use of antidepressants in reducing skin picking; however, there have been no large controlled trials.
The research matches my experience as a therapist. Many people I’ve treated for hair pulling or skin picking have tried medication first and have either not found it helpful at all or have been unclear about whether it was effective or not. If someone’s anxiety is contributing to pulling or picking behavior, medication may help reduce the tendency somewhat but is not likely to be a total cure.
I should also acknowledge that behavioral treatment for picking and pulling is hard work. It takes a lot of attention and effort to change these habits, and many people who do well with treatment continue to struggle with it to some degree. For these reasons, it is important to see a specialist in hair pulling and skin picking. Generic talk therapy is unlikely to be of much help.
In sum, some form of cognitive behavioral treatment—especially with habit reversal training—with an experienced specialist should be the first-line treatment for hair pulling and skin picking.
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Source: Portland Psychotherapy Clinic