Pulling out hair, picking at skin: taking back control

1. Before you begin

It is eleven at night. You are on the sofa, an episode of a series has just started, and your left hand has gone up into your hair without you deciding it should. Your fingers search. They find that one hair that is a little coarser than the others, roll it, and pull it out with a sharp tug. It is a small relief, almost nothing. Then another. By the time the end credits roll, you find a handful of hair on the cushion, and the shame hits you all at once.

Or it is the bathroom. You only meant to brush your teeth. A small bump on your chin caught your eye in the mirror, then your fingers, and forty minutes later you are still leaning towards the glass, your face marked. Tomorrow you will need make-up, or an explanation.

Many people who go through this have never told anyone, not even their doctor. A sentence like this one, given here as an example, sums up what many of them feel: "I can manage a budget and run a team, and I can't leave my eyebrows alone."

Three things, straight away.

What you are going through has a name, and it is common. Repeatedly pulling out your hair is called trichotillomania; scratching, pinching or digging at your skin is called dermatillomania, or skin-picking disorder. Each of these two disorders affects about two people in a hundred. In a room of fifty people, there is therefore probably someone else who does it too, and who hides it too.

It is not a lack of willpower. A share of the episodes, often a large one, begins without the person realising: the hand set off while they were reading, driving or falling asleep. You cannot use willpower to resist a behaviour that you do not see coming. That is one of the reasons why promises to stop fail so often, and it says nothing about your character.

There is a method that works, and it does not ask you to fight harder. It is called habit reversal. It teaches you to see the behaviour coming, to give your hands something else to do at the right moment, and to rearrange the places where the behaviour happens. It is the best-studied treatment for these disorders, and this guide describes it step by step.

2. What you are going through has a name

Trichotillomania

The word comes from Greek and means roughly "a mania for pulling hair". It refers to repeatedly pulling out your own hair, on your head or your body, to the point of losing some, even if this is not always visible, despite having tried several times to stop, and in a way that causes distress or difficulties in everyday life. The scalp is most often affected, but the eyebrows, eyelashes, beard and body hair can be too.

Around the pulling there is often a ritual that people talk about even less. The fingers look for the hair that "is not like the others", thicker or coarser, roll it, examine the root, run it across the lips, and sometimes it gets swallowed. These details are common, and the last one matters for your health (section 6).

Dermatillomania

This word refers to repeatedly scratching, pinching, squeezing or digging at your own skin, to the point of leaving wounds, despite repeated attempts to stop, and with distress or difficulties in your life. The face is most often affected, but so are the fingers, the cuticles (the little strip of skin at the base of the nail), the arms or the back. The behaviour most often starts on an irregularity, such as a spot, a scab or a small bump felt under the finger, and its aim is to make the skin smooth. But there is always a next imperfection, and that is how episodes go on and on.

One family of behaviours

Specialists group these two disorders, along with a few related behaviours, under the name body-focused repetitive behaviours: repeated actions, directed at your own body, which damage it and which you cannot manage to stop. Nail biting, which doctors call onychophagia, is one of them, as is biting the inside of your cheeks or your lips. These behaviours often go together, and trichotillomania and dermatillomania occur in the same person more often than chance alone would predict. The method in this guide applies to each of them.

You are not alone

A survey published in 2020 of more than ten thousand adults, representative of the population of the United States, found that about 1.7% of them had trichotillomania, in the same proportion among men and women, even though the people who seek treatment are mostly women. For dermatillomania, studies carried out in the general population find figures of between 1.4% and 5.4%.

These behaviours most often begin in adolescence, sometimes earlier. Without treatment, they often last for years, with calmer periods and more difficult ones. That does not make them inevitable: in the same American survey, about one person in four who had had trichotillomania at some point in their life no longer had it, without ever having been treated. These behaviours frequently come with anxiety or depression. And few people ask for help: in a series of sixty people who picked their skin, few had ever looked for treatment for it, even though they spent on average more than an hour and a half a day doing it.

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