A little respect for skin pickers, hair pullers

January 3, 2014 by Melissa Dribben, The Philadelphia Inquirer

Do you pick your skin until your arms are pitted with scabs? Bite your nails down to bloody nubs? Tear the calluses off your heels until walking is painful?

This year, you won a small, bittersweet victory.

Your condition made it into the 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Its name: "excoriation disorder."

With this published acknowledgment of the problem, sufferers may now be eligible for health insurance coverage for the cost of treatment. But they also run the risk of feeling pathologized for behavior that may fall within the range of normal, said Doug Woods, director of the department of psychology at Texas A&M University.

When stressed or bored, it is natural to engage in some sort of self-soothing behavior such as twisting a lock of hair or biting a ragged cuticle.

"Any type of repetitive motor movement can calm people down," said Woods, a national expert on body focused repetitive behaviors.

A 2006 study of 1,300 college students at the University of Delaware found nearly 15 percent pulled their hair occasionally and more than 30 percent picked their skin, with women far more likely than men to report the behavior.

At least 4 percent of the population take these habits to an extreme, said Woods, who noted the number could be higher because many are too embarrassed and ashamed to seek help.

"It's a disorder. You keep quiet," said Abby Shaine, 23, an aesthetician from Somerdale, N.J. Until recently, Shaine, who started picking at her face when she was 16, had never met anyone who shared the problem.

Incrementally, with help from social media, support networks, and glancing references in the public sphere, Shaine and others are feeling less alone - and less odd.

"It's way more common than people think," said Shaine, who has found hundreds of kindred souls on Facebook pages such as the Dermatillomania Support Group. As evidence that public awareness is growing, she also cites the recent film "The Internship." Goofy as it was (starring Owen Wilson and Vince Vaughn, need she say more?), the plot featured a character, Yo-Yo, who tweezed his eyebrow into nonexistence.

Shaine could totally relate. "I finally threw out my tweezers," she said.

Unlike those who cut themselves, people who pick and pull are not intentionally trying to punish or inflict pain on themselves, Woods said.

Until these activities begin to hurt, they feel good.

There is a primal satisfaction in evening out the rough edge of a nail or peeling off dead skin. This behavior, Woods said, is similar to hair-pulling, or trichotillomania, another disorder in the DSM, the psychiatrists' manual.

You get tactile pleasure from the feeling of tugging on your hair, having the hair in your fingers, he said.

For some people, it's unconscious. They may be watching television or reading a book and not realize their hands have been busily plucking until they see a pile of hair on the floor.

Others, Woods said, are fully aware and give themselves permission to indulge, even if they are conflicted about the outcome. "They may be feeling a negative emotion and wanting the pleasure."

Like most, Laurie Piotrowski started in her early teens. Rather than pull her hair out from the roots, she would twist it into tiny balls and then break them off.

"I had really long hair and I thought if I cut it I wouldn't pull it out," she said. "It didn't work."

After finding hair balls scattered around the house, her mother took Piotrowski to the pediatrician - the first of a succession of doctors she would see over the next 20 years who would offer various medications, psychological counseling, and behavioral suggestions.

None did the trick.

Now 40, Piotrowski, an administrator at Fort Dix, N.J., said she still has to fight the urge to pull her hair.

With help from psychologists at the Center for Emotional Health of Greater Philadelphia and a monthly support group, she said, she has managed to let her hair grow for as long as two months before relapsing.

"These habits tend to wax and wane over time," said Marla Diebler, founder and director of the center, which specializes in treating anxiety-related disorders, including trichotillomania.

So far, Diebler said, no medication has been found effective, although some studies have shown that in adults, the over-the-counter supplement n-acetylcysteine may help.

Behavioral treatments seem to offer the most promise.

One technique, habit-reversal training, attempts to substitute a new, more benign habit for the old. People are given objects to hold or play with - rocks, rubber bands, clay, and Koosh balls.

A second method, stimulus control, makes the environment less conducive.

Diebler offers the example of a patient who pulled her hair while watching TV, always sitting with her elbow resting on the arm of the couch so she could reach her scalp. By merely shifting her position to the middle of the couch, Diebler said, the woman would at least be more aware of her behavior and perhaps less likely to do it.

And, finally, people who pick and pull without thinking are trained to be aware of their behavior. Those patients, Diebler said, may benefit from sensory cues, such as wearing bracelets that jingle when a hand begins to move toward the face.

Piotrowski has tried everything.

To keep herself from biting her , she periodically glues on fake ones. To stop herself from breaking off hair, she has worn gloves, put on bandanas and wigs, and oiled her hair to make it slippery.

"But I can't do that at work," she said.

Her husband sympathizes and has grown to accept that she can't change, but her two sons have less tolerance.

One, she said, "watches me like a hawk. He screams at me, 'Mom! Hair!' So I can't do it much when he's around."

She wishes she could stop completely. "I need to do it to feel better, but when I do it, I feel like crap."

It may be comforting to the afflicted to know most creatures are prone to hypergroom themselves bare.

"Nobody really knows what causes it," Woods said. "But every species with some kind of or soft covering seems to do a version of this. Dogs lick themselves in a particular area and open a bald spot. Cats and chimpanzees take the fur off themselves and others. Mice do barbering. Birds pull out their feathers."

Animal behaviorists have found all these animals, like humans, start the habit around puberty.

"It might be a predilection that you inherit," said Martin Franklin, director of the Child and Adolescent OCD, Tic, Trich & Anxiety Group at the University of Pennsylvania. "Once you start the process, you are vulnerable to it."

Franklin and his colleagues are organizing a study of children and adolescents to evaluate the efficacy of the three primary treatment techniques.

Therapists have also found people benefit from learning to recognize and better manage their emotions.

Piotrowski still holds out hope.

"Since it started at puberty, maybe when I go into menopause, it will stop."

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