Trichotillomania & excoriation

Trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder are the body-focused repetitive behaviors you must separate from OCD, BDD, and self-harm, and the exam expects you to recognize habit reversal training (HRT) and its components.

Criteria at exam depth.

• Trichotillomania: recurrent pulling out of one's own hair, resulting in hair loss; repeated attempts to decrease or stop pulling; clinically significant distress or impairment; not attributable to another medical condition such as a dermatological condition; not better explained by another mental disorder (for example, trying to fix a perceived appearance flaw in BDD).
• Excoriation disorder: recurrent skin picking resulting in skin lesions; repeated attempts to decrease or stop; distress or impairment; not attributable to a substance (such as stimulant-related picking) or a medical condition (such as scabies); not better explained by another mental disorder (delusions or tactile hallucinations in psychosis, BDD, stereotypies, or an intention to self-harm).

Pulling or picking may be focused (in response to an urge, tension, or emotion) or automatic (outside awareness, such as while reading or watching TV). Many clients feel shame and hide hair loss or lesions.

Hinge differentials.

• OCD: compulsions respond to obsessions; in BFRBs there is no obsessional thought content driving the behavior.
• BDD: pulling or picking aims to correct a perceived flaw in appearance; if so, diagnose BDD instead.
• Non-suicidal self-injury: the intent is to cause harm or relieve emotional pain; BFRBs occur across many mood states without intent to injure.
• Medical causes: alopecia, dermatological disease, scabies, or stimulant use explain the hair loss or lesions.
• Psychosis: picking in response to delusions of infestation or tactile hallucinations.

On the NCMHCE. Ask about frequency, triggers, and medical complications, and refer to a primary care provider or dermatologist for skin infection, scarring, or hair loss; ask whether the client eats hair, since swallowed hair can cause dangerous gastrointestinal blockage. First-line treatment is habit reversal training: awareness training (identifying the behavior sequence and warning signs, often the first step), competing response training (such as clenching fists during an urge), and social support. Self-monitoring logs identify sensory, emotional, and environmental triggers. Comprehensive behavioral models add stimulus control (gloves, covering mirrors, changing lighting) and emotion-regulation or acceptance-based strategies. Reduce shame through normalization and person-first framing.

Clinical Pearl: Repeated pulling or picking + repeated failed attempts to stop + no obsession or self-harm intent = a BFRB. Treat with habit reversal: awareness training first, then a competing response.