The Impulse to Self-Disfigurement

"There is significant psycho-social damage."
"Depression is relatively common. People become very self-conscious, and self-esteem suffers. They start to avoid social situations in which people could notice the effects of their behaviour, and often spend tremendous amounts of time trying to cover the effects."
"The behaviours seem to be both a problem of a habit gone awry and a way of coping with emotional distress."
Douglas Woods, professor of psychology, Marquette University, Milwaukee, Wisconsin

"Why is this [that girls tend to react to body-focused repetitive behaviours and obsessive-compulsive disorders more than boys do]? We are not certain, but I suspect that many more females begin to pull [their hair out] around the age of puberty."
"Likely, there is a hormonal component that affects more females than males. Other hypotheses are that males are more able to cover hair loss, or maybe do not seek treatment as they can hide the results of their pulling."
"Some do it in response to emotion -- anger, anxiety, happiness -- while others in response to needing to feel a certain sensory sensation, while others pull or pick [at their skin] in response to certain environmental triggers, such as activities, places, mirrors."
"[ComB, as a treatment] looks at each person as an individual and evaluates [his or her] individual pulling/picking profile."
"Strategies are offered based upon their unique pulling/picking triggers. It is not a one-size-fits-all approach. It is quite tailored."
Suzanne Mouton-Odum, clinical assistant professor, Baylor College of Medicine, Houston, Texas

Most people are aware of some impulsive behaviours that afflict young people -- and old, of course. The focus is on critical awareness and dissatisfaction with one's body. Binge-eating might be included in this kind of dysfunction, but most certainly anorexia and bulimia are two conditions that do very well reflect an unhealthy regard of one's appearance and body weight. These are serious enough conditions to make anorexics and bulimics very sick indeed, and even threaten their very lives.

The human condition seems to provoke people to act in unorthodox, self-harming ways as a type of coping mechanism, to relieve stress, to satisfy an urge to be other than what they are, any number of issues that people find disturb their thoughts and their lives. It's unlikely that the general public has even heard of two of these disorders; hair pulling and skin picking, trichotillomania and excoriation/dermatillomania respectively, to give them their scientific names.

Each is known to the scientific medical community as body-focused repetitive behaviours (BFRBs). Repetitive 'self-grooming' habits capable of causing injury through pulling, picking or scraping, or biting the hair, skin and nails. There is a vast difference between most peoples' casual picking or nail biting, and the type of extreme behaviour that these more serious disorders represent. And the cause of that behaviour is linked to a mental state.

Onychophagia or Dermatophagia?

BFRBs were once classified in medical literature along with other impulse-control disorders such a kleptomania and addiction to gambling. The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, however, now categorizes BFRBs as obsessive-compulsive disorders (OCDs). "The  truth is", says Dr. Woods "they probably belong in an in-between category". 

Viewed by the scientific community as being on the same spectrum, the two conditions are quite different as it happens, with classic OCD occurring with uncontrollable, recurring thoughts; revulsive fear of germs as opposed to behaviour compelling the person afflicted to endlessly repeat motions, such as repetitively excessive hand-washing. Whereas impulse-control disorders involve an inability to resist a potentially harmful or self-destructive urge.

Hair or skin eating, lip and cheek biting, tongue chewing and compulsive haircutting, according to a non-profit based in Santa Cruz, California, are typical of other types of BFRBs. Among boys and girls hair pulling occurs equally before age twelve, while at a later age, it occurs mostly in girls, according to Dr. Moutom-Odum at Baylor College. There is a belief by researchers of a genetic component in the disorders since they tend to run in family groups, leading researchers to study genes of affected people in an effort to identify markers to provide clues to their origins.

One study found higher rates of OCD in immediate family members, with people demonstrating extreme cases of hair pulling, than in the general population. As well, a twins study suggested the existence of a higher occurrence of hair pulling in identical as compared to fraternal twins. Add to that, research that has detected differences in the brains of people with these disorders, compared to the brains of others who show no symptoms of like disorders.

Clomipramine, an antidepressant used to treat OCD, has been moderately useful, but the most effective therapy according to experts in the field, is behavioural modification, of which there are two frequently used protocols. Habit-reversal training, teaching patients to be more self-aware when they pull and pick, and recognition of cues trains those affected to make use of a 'competing response' when the urge rises; clenching the fist with the hair-pulling hand and pressing it to the body's side.

The other is called ComB or comprehensive behavioural treatment, explained by Dr. Mouton-Odum as enabling clinicians to design a treatment plan taking into account specifics related to an individual.