Engaging in repetitive body-focused behaviors like nail-biting, skin-picking or hair-twirling may mean you are a perfectionist. But how do you know when your habit has gone too far?
A staggering 1 in 50 adults, or as much as four percent of the population, suffers from trichotillomania, or the compulsive urge to pull or twist the hair until it breaks, according to the U.S. National Library of Medicine. While statistics for skin-picking disorder, or dermatillomania, are less widely kept, Laura Lokers, a licensed clinical social worker and cofounder of the Anxiety and OCD Treatment Center of Ann Arbor, Michigan, estimates that between 2 and 5 percent of the population has some sort of body-focused repetitive behavior. To put the number in perspective, autism spectrum disorder affects approximately 1 out of every 68 children, according to the Centers for Disease Control and Prevention.
"Honestly, we’ve had a little bit of a harder time getting accurate numbers [for dermatillomania], mostly because a lot of people have hidden behind dermatological conditions," Lokers said. "'Oh, no. I don’t pick my skin, but I have really bad acne.' Or 'No, I just have bad eczema.'"
Skin-picking is a highly stigmatized and misunderstood disorder. And because of that, despite the fact that millions suffer from a body-focused condition, many people may not realize that their behavior is out of their control -- or even that it has a name. "They’re being told by everyone around them, 'Why don’t you just stop?'" Lokers said.
Of course, it's not that easy. There are very few resources for people who suffer from body-focused repetitive behaviors (although the Trichtillomania Learning Center is one good one), and no psychotropic medications that have been deemed effective treatments thus far. According to Science of Us, the results of trials of the most thoroughly tested medication, Prozac, were inconclusive. And for such a common disorder, practitioners specializing in behavioral therapy for hair-pulling, and especially for skin-picking, are few and far between. We spoke with Lokers to learn more.
The Huffington Post: Are trichotillomania and dermatillomania related to obsessive compulsive disorder? I know they were recently recategorized in the Diagnostic and Statistical Manual of Mental Disorders.
Lokers: They are classified as obsessive compulsive-related disorders. So it’s not OCD, but we think that neurologically, some of that stickiness -- that inability to stop [pulling out hair or picking at skin], even when they really, really want to -- seems to be in that category. They used to be called impulse-control disorders, but that was honestly a throwaway category. They didn’t belong there to begin with.
What's the relationship between anxiety and body-focused repetitive behaviors? Is there one?
That’s interesting, because anxiety can be a significant trigger for the urges, much like we’ve seen with Tourette’s disorder. We certainly see that when people are stressed out, their ticks often get worse. But we also see folks who have no anxiety, who will say they are feeling bored or they’re even asleep and they have this behavior. That’s why it’s not an anxiety disorder.
Sometimes they’re even put in the category of self-harm, like cutting, which is absolutely not true. There is no evidence for that, but unfortunately, that’s how some people view it. It’s not that there’s some deep-seated anxiety and if we resolve that the behavior will just go away. Most of the evidence really does point to it being brain-based.
I pick at my nails when I get stressed out. What's the breaking point when someone should seek treatment?
The biggest thing that we’re looking for is the intensity and the frequency of the behavior. If you’re stressed and once a month you notice for a couple of days that you’re picking at your fingers a little bit more, that’s probably not a big deal. But if you notice that it’s happening every day and you’re having really severe damage that’s being caused -- infection, scarring, that kind of thing -- that’s where it starts to cross that line.
Most people end up seeking treatment because there’s a social cost that has brought it to the forefront. They’re embarrassed because of the way their skin, or their nails, or their hair looks. Sometimes people have infections and other medical complications. In fact, a long-term side effect of this condition is essentially carpal tunnel from repetitive picking. It’s not something you would think of, but it’s that repetitive behavior for years and years.
It is shocking to me how common of a problem this is and there are almost no resources out there for treatment. There’s not a single medical school in the country that has treatment for body-focused repetitive behaviors as part of their standard protocol.
I've been seeing incredibly graphic pimple-popping and ingrown hair videos being shared on social media. (Watch here, at your own risk.) Does viewing these videos qualify as a form of dermatillomania?
It certainly could qualify as a compulsive behavior, if they find themselves getting sort of stuck watching the videos and not being able to stop, to the point where it’s interfering with day-to-day activities. [But] if that were the behavior alone, without any skin picking themselves, I would say probably not.
I think one of the most interesting phenomena of dermatillomania is that it's kind of universal. We’ve all gotten a zit and thought, 'Yes!' But these folks are just not able to turn that off.
I have seen some people almost try and force themselves to replace [picking with watching the videos]. Like 'Maybe if I watch the videos, I’m not going to do it.' But I’ve actually found that the more they watch them, the more they want to do it themselves. So I’ve not found that a helpful strategy.
They find themselves not being able to leave loved ones alone, especially partners [who] have a zit and it kind of drives them crazy, wanting to pop it. I actually had someone in last week, and that was the main reason she was seeking treatment -- her partner was just fed up. Not only was she picking at herself, but she was starting to pick at him. I think that happens more often, at least in my experience, than the videos.
This interview has been edited and condensed for clarity.