Jamye Shelton Pelosi - Psychologist - 232 X 249Trichotillomania and Excoriation

Dr. Jamye Shelton Pelosi, a licensed psychologist at Union Square Practice, gives an overview of trichotillomania and excoriation, discusses common misconceptions, and provides information about the treatment for trichotillomania and excoriation that are available at Union Square Practice.

 What is trichotillomania (pronounced TRICK–oh-till-oh-MAY-nee-uh)?

Trichotillomania (trich for short) is a hair pulling disorder that is defined by reoccurring pulling of hair. A person with trich might tear hair from their head, face, eyebrows, eyelashes, or even from more concealed places like legs, armpits, and pubic areas. It’s estimated to occur in 0.6-3.4% of adults (Christenson, Pyle, Mitchell, 1991; Woods et al 2006)

What isn’t trichotillomania?

Trich does not include typical grooming for socially normal cosmetic reasons, i.e. plucking and shaping eyebrows. Before giving a person a diagnosis of trich a thorough dermatological assessment is best to rule out any other possible causes.

What are the official diagnostic criteria for trichotillomania?

The Diagnostic and Statistical Manual of Mental Disorders 5th Edition Lists the following criteria for the disorder:

1.Recurrent pulling out of one’s hair, resulting in hair loss.

2. Repeated attempts to decrease or stop hair pulling.

3. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

4. The hair pulling or hair loss is not attributable to another medical condition (e.g. a skin condition).

5. The hair pulling is not better explained by the symptoms of another mental disorder (e.g. body dysmorphic disorder).

What does trich look like?

People with trich might pull hair from one or multiple sites on their bodies and have noticeable spots of baldness, short hairs, or thin hair. The hair can be pulled by fingers, using tweezers, or even with any other tool.

Hair pulling can also be accompanied by playing with the hair, rubbing it across the lips, chewing, or eating the hair or eating the hair follicle if it is attached to the hair (this is known as trichophagia). These behaviors occur in a small number of people with trich, but can result in painful hair splinters or a trichobezoar, or hairball, which can require medical intervention to treat.

How does trichotillomania impact someone in daily life?

People with trich are often distressed by the pulling or the result of pulling (Stemberger, Thomas, Mansueto, & Carter, 2000). It can be a minor nuisance or a consistent bothersome experience—everyone’s experience varies.  It is also not uncommon for someone to try to cover or hide short or missing hair of pulling by wearing hats, scarves, etc. Trichotillomania is not a perfectly understood disorder, and has not been investigated as much as other psychological disorders.

When accompanied by trichophagia, or the compulsive eating of hair, trichotillomania can cause severe health problems. Hair cannot be digested like regular foods and can often get stuck in the gastrointestinal tract as a trichobezoar, more commonly known as a hairball. These can cause abdominal pain, nausea or even life-threatening gastrointestinal issues in some rare cases when left untreated. When hairballs become severe, they must be surgically removed.

What is excoriation?

Excoriation is a skin picking disorder that is defined by picking of skin that results in cuts, abrasions, scabs, and other types of wounds. This is also a disorder that requires assessment for a dermatological problem to diagnose.

What are the diagnostic criteria for excoriation?

The Diagnostic and Statistical Manual of Mental Disorders 5th Edition Lists the following criteria for the disorder:

1. Recurrent skin picking resulting in skin lesions.

2. Repeated attempts to decrease or stop skin picking.

3. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

4. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition.

5. The skin picking is not better explained by symptoms of another mental disorder


What does excoriation typically look like?

People that pick their skin might bite, squeeze, scratch, cut or scrape at irregularities (like pimples, hangnails, or dry skin), at healthy skin, or at scabs that have resulted from previous picking. Picking can occur using fingers, fingernails or with tools like tweezers or cuticle trimmers.

How does excoriation impact someone in daily life?

Similar to trich, people with excoriation usually experience distress about the picking behaviors, and also might try to cover up wounds with makeup, clothing, or jewelry (Penzel, 1995).

However, there are also key differences between the two:

  • Trichotillomania is a hair pulling disorder. The disordered part is when there is noticeable changes in the amount, thickness, or quality of hair AND being upset about these changes. Someone might over groom body occasionally once, but doing so in a consistent and ongoing fashion is when it might be a concern.
  • Excoriation is a skin picking disorder. The criterion for this disorder once again includes ongoing, consistent problems with picking at skin causing wounds on the body.

Both disorders can be problematic, and both can be treated.

What treatments are offered at Union Square Practice for trichotillomania and excoriation?

At Union Square Practice, our clinicians use Habit Reversal Training (HRT) as a primary method of treating trich and excoriation (pulling and picking). It is one of the CBT (Cognitive-Behavioral Therapy)  based treatments that has research indicating its effectiveness for treating these disorders.

HRT is a flexible therapeutic approach: always modified for each person’s individual needs, but it has some basic components that stay the same.

What are some basic components of Habit Reversal Training?

–Understand the symptoms. This means we get a good idea of what the person has trouble with (picking, pulling, or both), and get a good understanding of when, why, and how it happens.

–Plan and practice behavioral intervention. The first step in actively addressing picking and pulling involves working on skills to reduce the behaviors. The behaviors create physical, mental, and emotional problems, and this is why we jump right in to trying to reduce them.

–Address the thoughts and emotions associated with picking and pulling. Here is where the cognitive component of therapy becomes important. Different approaches are used here to address the way people think and feel about their experience of picking and pulling.

–Provide support and relapse prevention. After we have discussed, practiced, and mastered strategies for reducing picking and pulling, it is important to make sure that the client is able to maintain progress. This stage of treatment definitely looks different for different people, but the primary goal is to plan for any bumps in the road that could lead to an increase in picking or pulling again.

What are other treatment options provided at USP?

Psychiatric treatment (including medication management and psychopharmacology) for these disorders can sometimes be effective (Grant, 2007). However, the physiological components of trich and excoriation are not quite clear, so it is not always guaranteed that medication will “cure” the problem. There is still research being conducted about the usefulness about different medications and dietary supplements.

Many of the clinicians at Union Square Practice rely upon CBT interventions, but patients have found hypnosis, dietary supplements, etc. helpful at times as well.

What are some concerns patients have at the beginning of treatment?

Change is hard. Changing something that you have been doing for years can be even harder. Sometimes these changes can be difficult, and sometimes they have to be modified many times to be a good fit.

The therapeutic approach used at Union Square Practice relies upon working with the client to set goals that are realistic and attainable for treatment. We often think about how we can work together to reduce how often, how long, and how much hair and/or skin is being picked or pulled first – not necessarily focusing on immediate and complete stoppage of the pulling or picking.


Because “just stopping” is not usually sustainable, and it does not allow my clients to learn how to address the many aspects of these disorders in a way that is actually obtainable. We start with a focus on “better” instead of “fixed,” and then build upon success as it comes. As I discussed in my blog post on what makes therapy work, CBT involves collaboration and work between the therapist and the client. We are committed to working with each patient to develop an individualized treatment plan that works best for them.



Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry 1991;52:415–417.

Grant, J. (2009) N-Acetylcysteine for Trichotillomania, Skin Picking, and Nail Biting. Trichotillomania Learning Center. InTouch 55.

Grant, J. (2007) Medications for Trichotillomania & Skin Picking. Trichotillomania Learning Center. InTouch 47.

Mansueto, C. S. Trichotillomania Focus. OCD Newsletter, Issue 11, 10-1.1Obsessive Compulsive Foundation.

Penzel, F. (2006) What Cognitive Therapy Can do for TTM. Trichotillomania Learning Center. InTouch 45.

Penzel, F. (1995). Skin Picking and Nail Biting: Related Habits. In Touch, 11. Retrieved from http://www.trich.org/treatment/article-related-habits-penzel.html

Stemberger, R.M.T., Thomas, A.M., Mansueto, C.S., Carter, J.G. (2000) Personal Toll of Trichotillomania: Behavioral and Interpersonal Sequelae. Journal of Anxiety Disorders, Vol. 14, No. 1, 97-104

Woods, D.W., Flessner, C.A., Franklin, M.E., Keuthen, N.J., Goodwin, R., Stein, D.J. Walther, M., & Trichotillomania Scientific Advisory Board (2006) The Trichotillomania Impact Project (TIP): Exploring phenomenology, functional impairment, and treatment utilization. Journal of Clinical Psychiatry, 67, 1877-1888.