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									Picking and Pulling 101
    (BFRBs: An Overview)

   TLC National Conference
        April 23, 2010

          Fred Penzel, Ph.D.
 Western Suffolk Psychological Services
         Huntington, New York
All human beings (and most other
 mammals) pull, pick, and bite at
   themselves to one degree or
 another. It is therefore really a
matter of degree when we begin to
 call these behaviors „disorders.‟
What are the disorders that
involve picking and pulling?
       TRICHOTILLOMANIA (312.39)
            DSM-IV CRITERIA
• Recurrent pulling out of hair resulting in
  noticeable loss
• Increasing sense of tension before or when
  attempting to resist
• Pleasure, gratification or relief when pulling out
  the hair
• Disturbance not accounted for by any other
• The disturbance causes significant distress or
  impairment in social, occupational or other
  important areas of functioning
  (312.20) DSM-IV CRITERIA

     This category is for disorders of
  impulse control that do not meet the
criteria for any specific Impulse-Control
Disorder or for another mental disorder
    having features involving impulse
   control described elsewhere in the
manual ( e.g., Substance Dependence,
               a Paraphilia).
François Henri


 A French
 dermatologist who
 first used the term
 Trichotillomania in
 1889 to describe a
 patient who had
 pulled out his hair.
Louis Bracq
(1856 – 1928)

 A French dermatologist
 who coined the term
 “Acne Excoriee” in

•   Intermittent Explosive Disorder
•   Kleptomania
•   Pathological Gambling
•   Pyromania
•   Trichotillomania
•   Impulse Control Disorder Not Otherwise
    Specified (NOS)
Body Focused Repetitive Behaviors

• Trichotillomania (compulsive hair pulling)
• Onychophagia (compulsive nail biting)
• Dermatotillomania (compulsive skin
• Compulsive nose picking
• Compulsive biting of the inside of the
• Lip biting or picking
     How Common are BFRBs?
• Trichotillomania (Christensen and Mackenzie, 1994)
      1.5 % males – nonclinical college sample
      3.6 % females – nonclinical college sample

• Skin Picking (Bohne et al, 2002)
      4.6 % of a nonclinical college sample

• Nail Biting (Teng et al, 2002)
       6.4 % of a nonclinical college sample

• Mouth, lip, or cheek chewing (Teng et al, 2002)
     5.7 % of a nonclinical college sample
      What Is The Sex Ratio In TTM?

Christenson et al (1994)
65% of those with TTM found to be female

Stemberger et al (2003)
90% of adult TTM sufferers in study reported to be female

Kress et al (2004)
Males may be statistically underrepresented as they have a
wider variety of areas to pull from, and may
be better able to conceal their pulling. They may also be
able to blame their pulling on male pattern baldness.
What do people with these
 disorders actually do?
     Three Major Types Of BFRBs

• Automatic – done with little awareness during
  some other activity. May be more tic-like.
  May account for up to 75% of hair pulling.

• Deliberate or focused – starts with an urge
  and is done in place of any other activity.
  May be more compulsive with perfectionistic
  and ritualistic features.

• A combination of both - done at various times
  and in different situations.
Types of Stimulation Sought After in
Body-focused Repetitive Behaviors

            • Tactile
            • Visual
            • Oral
        Pulling Sites In TTM

Location                % Endorsing

Scalp                         79
Eyebrows                      65
Eyelashes                     59
Pubic Area                    59
Legs                          30
Arms                          17
Other                         25

 (N = 1,697)   (TIP unpublished data, 2006)

  Location                           Percentage

Pimples and scabs                            87
Red, swollen, or infected spots              58
Healthy skin                                 52
Mosquito bites                               48
Scars                                        42

  (N = 31)                   (Wilhelm et al, 1999)
Post-pulling Behaviors Seen In TTM

• Stroking the hair against the mouth, face, or tongue
• Staring at/studying the hair, or parts of the hair (e.g.
  root, looking for a drop of blood, etc.)
• Rolling it in a ball
• Tying it in a knot
• Playing with the hair
• Winding it around a finger
• Saving it in a special spot or container
• Performing a ritual or ceremony with it
• Biting or chewing the hair, or pulling it between the
• Breaking the hair or pulling off the bulb at the end
• Biting off and/or chewing the bulb at the end of the hair
• Swallowing the hair
What Impact Do BFRBs Have
    On People‟s Lives?

       •   Depression
       •   Shame
       •   Secrecy
       •   Isolation
       •   Loneliness
       •   Feelings of unattractiveness
           and defectiveness
    Strategies Used by BFRB Sufferers to
           Conceal Their Problems

•   wigs                    • comb hair over bare
•   kerchiefs               • spray-on hair
•   hats                    • not going out
•   false eyelashes           publicly
•   eyebrow pencil          • cover makeup
                            • band-aids
•   cut other hairs short   • avoiding bright light
•   shave entire head       • hands in pockets
•   hairpiece               • covering with
  Emotional Responses to TTM

Low self-esteem                           84
Diminished sense of attractiveness        82
Shame and embarrassment                   80
Problems with tension or anxiety          68
Depression or mood problems               66

                            (Mansueto et al, 1990)
Activities Avoided by TTM Sufferers

  Haircuts                   87
  Swimming                   62
  Being outside in the wind  42
  Sports                     35
  Sexual Intimacy            35
  Lighted areas              25
  Public activities           22

                  (Stemberger et al, 2000)
       Problems Seen To Co-occur With TTM
                 (Christenson et al, 1995)

     (N = 186)                        Percent

•   Major Depression                    51.6
•   Generalized Anxiety Disorder        27.0
•   Alcohol Abuse                       19.4
•   Other substance abuse               16.1
•   OCD                                 13.4
•   Social Phobia                       11.3
•   Bulimia                              8.1
•   Chronic motor tics                   3.2
•   Anorexia                             1.6
•   Tourette‟s Disorder                  0.005
Problems Seen To Co-occur With TTM
             (Woods et al, 2006)

• 55% of adults with trichotillomania have a
  comorbid psychiatric diagnosis
• 26% have an obsessive-compulsive
• 23% have major depression
• 23% have generalized anxiety disorder
Life Impairment Among Adult TTM Sufferers
              (TIP – A Study)

•   Avoided social events                        40
•   Avoided group activities                     36
•   Interfered with work on a daily basis        23
•   Avoided going on vacation                    20

    (N = 1697)              (Franklin et al, 2006)
 Life Impairment Among Child TTM
      Sufferers (TIP – C Study)

Based on parent report:
• 55.6% (n = 74) reported that their child avoided
  social events as a direct result of pulling.

Based on child report:
• 54.9% (n = 67) of the child sample reported that
  TTM made it more difficult to study
• 36.1% (n = 44) reported that their ability to do well
  academically was impaired as a direct result of
Medical Problems Associated With BFRBs

• Repetitive strain injuries – back, shoulders
• Tendonitis – wrists
• Eye irritations
• Trichobezoars – Gastrointestinal blockage
• Eye and gynecological problems due to
  avoidance of medical visits
• Skin infections
• Scarring of the skin
What Causes BFRBs?
    Various Explanations For Causes Of

• Psychodynamic
   – Defense against sexual impulses or conflicts
• Biological
• Behavioral
  - Self-reinforcing habit
• Ethological (Animal)
   – Grooming disorder – hard-wired behaviors gone awry
   – Displacement behaviors becoming stereotypys
• Emotional Self-regulation
• Addiction
• Genetic predisposition
    – Stimulus Regulation – attempt to externally regulate
        the central nervous system


  Provides stimulation   Reduces stimulation
       to relieve            to relieve

    Boredom                    Stress
     Inactivity               Excitement
   Body-focused Repetitive Behaviors
  Have Also Been Observed In Animals

• Dogs - Canine Acral Lick
• Cats - Psychogenic Alopecia
• Horses - Equine Self-mutilation Syndrome (ESMS)
                   -   Cribbing
                   -   Flank Biting
                   -   Weaving
                   -   Stall Walking
• Birds - Feather Picking
Canine acral
lick dermatitis
Canine acral
lick dermatitis
Barbering Mice
TTM and other Body-focused Repetitive Behaviors
  (BFRBs) have many inputs, and the treatment
requires a comprehensive approach that deals with
           as many of these as possible.

                   • Biological
                   • Behavioral
                   • Emotional
                   • Sensory
                   • Cognitive
                   • Physical
                   • Environmental
  Why Is It So Hard To Find
Proper Treatment For BFRBs?
     TIP-A Study – Provider Knowledge


•   Treatment provider an expert in TTM            3
•   Provider knew a lot about the disorder        12
•   Provider had “some“ knowledge of TTM          32
•   Provider had at least heard of TTM            26
•   Provider was “not at all knowledgeable”       27
    about TTM

                              Woods et al, 2006
    Sources of BFRB Referrals
• The Obsessive Compulsive Foundation
• Association for Behavioral and Cognitive Therapy
• The closest trich or OCD clinical expert (they often know
  of other specialists in the region)
• Local trich or OCD support group
• University hospitals that have OCD/anxiety disorder
• Your county psychological association
• Trich websites on the internet (with certain reservations)
            What To Ask When You
           Finally Do Find Someone

• What degrees do you have, and are you licensed in this
• Do you actually specialize in treating trichotillomania (or
  skin-picking or nail-biting)?
• What are your qualifications for treating trich (or skin-
  picking or nail-biting)? Have you had some type of
  supervised training?
• How long have you been in practice?
• What is your orientation?
         What To Ask When You
     Finally Do Find Someone (cont.)

• What techniques do you use?
• What is your fee? Are your services covered by
  insurance? Do you accept insurance reimbursement?
• On the average, how long will it take for me to see some
  results with this treatment?
The End

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