This programme is a treatment manual written for mental health professionals. It assumes training in cognitive behavioural therapy, the ability to make a differential diagnosis that includes dermatological and medical causes, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is written neither for the people concerned nor for those close to them. Abdominal pain in a person who swallows their hair, a wound that becomes infected or suicidal thoughts call for medical advice without delay, or for your country's emergency services.
1. The programme at a glance
Indication. Established trichotillomania and excoriation disorder, in adults and in adolescents. The same protocol applies, with the adjustments in section 34, to the neighbouring behaviours: biting the nails, tearing at the small pieces of skin around them, biting the inside of the cheeks or the lips. Younger children have their own section, section 32.
Reference model. A behavioural therapy built around habit reversal (Azrin and Nunn, 1973): awareness of the behaviour, competing response, support. It is completed by barriers in the environment, by an individual analysis of triggers and functions in the spirit of the comprehensive behavioural model (Mansueto et al., 1997), and by two components that gave good results in trials: acceptance of the urge (Woods, Wetterneck and Flessner, 2006) and emotion regulation (Keuthen et al., 2012).
Format. Ten individual 60-minute sessions: eight weekly, then two a fortnight apart, to check that the person is managing alone. Two booster sessions, at one month and at three months. Recent controlled trials run from eight to twelve sessions (Franklin et al., 2011; Carlson et al., 2021; Woods et al., 2022), and the number of contact hours is associated with larger effects (McGuire et al., 2014).
Target mechanism. To make the behaviour visible before it begins, to set an obstacle and an alternative against it, and to change the relationship to the urge: it can be there without being followed. It is not a matter of resisting harder by willpower, nor of disproving a feared catastrophe.
| Session |
Focus |
What the session produces |
| 1 |
Assess and name |
Record started, complications looked for, baseline measures |
| 2 |
Understand the circle |
Circle drawn, functions named, goals written |
| 3 |
See the behaviour coming |
Three early warning signs, successful detection in session |
| 4 |
Triggers and functions |
Map of the five domains, three triggers selected |
| 5 |
The competing response |
Response chosen and rehearsed ten times, one ally named |
| 6 |
Barriers and environment |
Three barriers in place, one of them set up the same day |
| 7 |
Emotions |
One alternative for each main trigger state |
| 8 |
Letting the urge pass |
One urge ridden out in session with no behaviour |
| 9 |
Coming out of hiding |
One avoided situation chosen and prepared |
| 10 |
Lapses and plan |
Measures repeated, plan written, boosters dated |
What the person takes away. Nine printable worksheets, listed in section 37: my record, my circle, seeing the behaviour coming, my triggers and my barriers, my competing response, when the urge is there, what I hide and what I avoid, my plan for what comes next, and the corner for those close to you.
What sets this programme apart from the other manuals on this site. Three things. It treats a disorder neighbouring OCD by means that are not those of OCD, and section 3 explains why. It looks for the function of the behaviour before fighting it, because a competing response placed on a poorly understood behaviour does not hold. And it treats shame and camouflage as targets in their own right, with a session devoted to them.
2. Before you begin
Who this programme is for
This text is addressed to psychologists, psychiatrists, psychotherapists and doctors trained in cognitive behavioural therapy. It assumes that you know how to carry out a functional analysis, and that you are willing to speak concretely about pulled hairs, chewed roots, scabs and wounds, without circumlocution and without letting any discomfort show.
It is written neither for the people concerned nor for those close to them. The worksheets, on the other hand, are written for them.
The four preliminary decisions
Is there a medical complication that comes first? Swallowed hair with abdominal pain, an infected wound, a deep lesion near the eye. Section 10.
Is this really a body-focused repetitive behaviour? Scratching brought on by an itch of dermatological origin, pulling driven by an obsession, excoriation linked to the conviction of being infested, an injury intended to hurt: these are not the same disorders. Section 8.
Is there a comorbidity that takes precedence? A severe depression, a suicide risk, the use of stimulants. Section 9.
And who is asking? An adolescent brought by their parents, a person referred by a dermatologist and a person who comes of their own accord do not commit themselves in the same way. Motivation is worked on in session 2; it is not assumed.
What this programme does not treat
Non-suicidal self-injury. Cutting, burning or hitting oneself in order to hurt calls for a different assessment and a different programme, for example Suicidal behaviour and self-harm in adolescents: a therapist's manual.
Stereotypies in a person with a severe neurodevelopmental disorder, even if some of the techniques apply. Section 34.
Delusional infestation, nor scratching secondary to a psychotic disorder or to a substance.
And a skin disease. Acne, eczema or hair loss of another origin are treated in parallel, with a doctor.
How to use it
Read the whole text before the first session, in particular sections 3, 6, 10 and 28. Every session follows the same frame: the aim, the steps, what you say, the common mistakes, and the criterion for moving on.
Three warnings specific to this presenting problem.
The problem is not willpower. A large proportion of episodes begin without the person noticing. Asking them to "make an effort" amounts to asking them to resist what they cannot see.
Shame is in the room. The person's, who has often hidden the disorder for years, and sometimes your own, faced with a wound or a bald patch. Section 31 begins with your own attitude.
A lapse is the rule. Gains often erode in the months that follow treatment (Keijsers et al., 2006). Relapse prevention begins in session 2, when the goals are written down.
3. Why this is not OCD
Trichotillomania and excoriation disorder are classified among the obsessive-compulsive and related disorders, in DSM-5-TR as in ICD-11. This neighbourhood is useful: it prompts you to look for comorbidities. But it leads to a common error, which consists in treating them like OCD, whereas the effective approaches are different and some first-line treatments for OCD appear ineffective here (Grant and Chamberlain, 2016).
What comes before the behaviour
In OCD, an obsession: an unwanted thought, image or impulse, which frightens.
Here, most often an urge, a sensation, a state — boredom, tension, tiredness, concentration — or nothing at all. The person describes a hair that "is not like the others", a rough patch under the finger, a spot that "has to" go, or nothing, because they were reading.
What follows the behaviour
In OCD, a relief of anxiety: the ritual is performed to prevent something.
Here, often a pleasure, a release, the sense of having "finished" — then shame, regret and anger with oneself. The behaviour prevents nothing; it brings something at the time, and that is what makes it so tenacious.
Awareness of the behaviour
In OCD, the ritual is almost always conscious.
Here, many people describe episodes carried out without full awareness, at least some of the time (Grant and Chamberlain, 2016): in front of a screen, while driving, in bed. Others are entirely deliberate. These two styles — automatic and focused — are not mutually exclusive: the same person can have high levels of both (Flessner et al., 2008).
What works
In OCD, exposure with response prevention, and serotonin reuptake inhibitors as the first-line medication.
Here, habit reversal and its variants, which obtain large effects (McGuire et al., 2014; Farhat et al., 2020), whereas serotonin reuptake inhibitors, effective in OCD, are generally not effective in trichotillomania (Grant and Chamberlain, 2016). Section 14.
What this changes in practice
You do not look for the obsession. If it is not there, you do not construct it. Asking "what do you fear if that hair stays?" manufactures an answer made for the occasion and points towards a false trail.
You do not carry out exposure with response prevention in the classical sense. There is no catastrophic prediction to test. The exercise in session 8 — letting the urge rise without giving in to it — resembles it, but its purpose is to discover that the urge passes, not that no misfortune occurs.
You look for the function. What does the behaviour bring, at that moment? That is the central question of this programme.
And you stay alert to overlap. Some people also have OCD, and some highly focused pulling has a compulsive quality, such as the search for a perfect symmetry of the eyebrows. When OCD dominates, Treating obsessive-compulsive disorder in adults: a therapist's manual takes over, and the person can draw on OCD: the eight-step exposure programme.
4. The two disorders and their neighbours
Trichotillomania
What you observe. The repeated pulling out of one's own hair, with a resulting loss. The scalp is the most frequent site; in a survey of children and adolescents, the eyelashes and the eyebrows came next (Franklin et al., 2008). Any body hair can be involved.
What surrounds the pulling. Searching with the fingers for the hair that "is not like the others" — thicker, coarser, curlier. Rolling it between the fingers, examining the root, running it over the lips, biting it, and sometimes swallowing it: this is trichophagia. In a clinical series of 68 people, about one in five was eating their hair or its root at the time of the study, and a further 13% did so from time to time (Grant and Odlaug, 2008). These behaviours are not reported spontaneously and they have medical consequences. Section 10.
Excoriation disorder
What you observe. The repeated scratching, squeezing, digging into or tearing at one's own skin, with resulting lesions. The face is often to the fore, but the fingers, the cuticles, the arms, the back and the scalp are affected too. Methods and sites vary a great deal from one person to another (Tucker et al., 2011).
What most often sets it off. An irregularity: a spot, a scab, an ingrown hair, dry skin, a bump felt under the finger or seen in the mirror. The mirror itself, under a strong light, and the bathroom, where sessions of more than an hour are not rare.
Two styles that coexist
The automatic style. The behaviour happens during another activity — reading, watching a screen, driving, falling asleep — and the person discovers afterwards the hairs on the desk or the blood under the nail. It calls above all for awareness and for barriers.
The focused style. The behaviour is deliberate, often preceded by an urge, a tension or an emotion, and it absorbs all the attention: in front of the mirror, with tweezers, for long minutes. It calls above all for work on the urge and on the emotions.
What you need to know. The people who had high levels of both styles described a more severe disorder and a greater impact than those who had low levels of both (Flessner et al., 2008). Episodes can be brief and scattered — a few hairs, a hundred times a day — or rare and long: you count the former, you time the latter.
The neighbours
Biting the nails and tearing at the small pieces of skin around them; biting the inside of the cheeks and the lips, often missed because it is invisible; the repeated rubbing of the hair, which breaks it without pulling it out. These behaviours often coexist: trichotillomania and excoriation disorder go together more often than chance would have it and share many clinical features (Snorrason, Belleau and Woods, 2012). Ask about them all, once.
Some epidemiological markers
Trichotillomania has an estimated point prevalence of between 0.5% and 2% in the general population (Grant and Chamberlain, 2016). Excoriation disorder has reported prevalences of between 1.4% and 5.4% depending on the study (Grant et al., 2012).
Clinical samples are very largely female, whereas a general-population survey in the United States did not find a significant difference between men and women (Grant, Dougherty and Chamberlain, 2020). Men probably consult less; the question therefore arises for them too.
Onset is most often in childhood or in adolescence, and a minority begins in adulthood (Flessner et al., 2010). Without treatment, the course is often chronic, with fluctuations in intensity (Grant and Chamberlain, 2016).
5. What keeps the disorder going
What the behaviour brings
A sensation. The texture of a hair, the resistance and then the release of the root, the smooth surface after a scab has been removed. This reinforcement is immediate and physical, and it is underestimated because it is hard to admit to.
A change of state. The behaviour calms when the person is tense, stimulates when they are bored, occupies them when they have to stay seated. These behaviours can be understood as a costly way of regulating an emotional state (Roberts, O'Connor and Bélanger, 2013), and the people who pick their skin describe functions that are at once emotional, sensory and cognitive (Tucker et al., 2011).
A sense of completion. The irregular hair has been removed, the skin is "clean" — until the next imperfection.
Automaticity
A behaviour repeated thousands of times, in the same places and the same postures, ends up triggering by itself. The sofa, the desk, the car, the bed, the hand near the face: the context is enough. That is why awareness and barriers are at the heart of the treatment.
Bans and battles
Almost everyone has tried to stop by willpower and promises. These attempts bear on the behaviour and not on what brings it about; they increase vigilance towards the urge, frustration when it wins, and the conviction of being incapable. In the trial by Woods, Wetterneck and Flessner (2006), the decrease in the avoidance of what is felt accompanied the decrease in severity.
Shame and secrecy
After the episode comes shame. It drives hiding — hairstyles, make-up, covering clothes — and avoiding: the swimming pool, the hairdresser, the wind, intimacy. Camouflage takes time in front of the mirror, which is a place where episodes start; avoidance leaves more empty moments; and shame itself calls up the next episode.
The complete circle
A trigger produces an urge, or directly an automatic behaviour. The behaviour brings something at the time. Then come the damage and the shame, which drive hiding and avoiding, and which in their turn trigger. The person promises to stop, which changes nothing about the next trigger. That is the diagram on worksheet 2, drawn in session 2.