Self-Help Strategies for Body Focused Repetitive Behaviours - Trichotilomania and Skin Extortion
Step 1: Learning About Stress and Anxiety
No matter what type of anxiety problem you are struggling with, it is important to understand the facts about both stress and anxiety.
Fact 1: Stress is a normal and routine part of human life in the modern world. One definition of stress is any demand placed upon the body and mind. This “stress” may be both negative and positive. Therefore, dealing with your stress NEVER involves eliminating it but rather managing it.
Fact 2: Stress becomes a problem when we let life’s demands exceed the resources we have to cope. Resources can be both internal, such as our thoughts and feelings, and external, such as our actions, environment, and friends and family.
Fact 3: Anxiety is also a normal and adaptive system in the body that tells us when we are in danger. Therefore, just like stress, dealing with your anxiety NEVER involves eliminating it but rather managing it.
Fact 4: Anxiety becomes a problem when our body tells us that there is danger when there is no real danger.
| To learn more details about anxiety, see What Is Anxiety? |
As an important first step, you can help yourself a lot by understanding that the tension and pressure you may be feeling is Stress, AND, that all of your worries, fears and physical feelings have a name: Anxiety. Once you can identify and name the problem, you can begin dealing with it.
The next important step is recognizing how your anxiety problem is related to.
Step 2: Learning About Trichotillomania and Skin Excoriation
Body-Focused Repetitive Behaviours, or BFRBs, are a cluster of habitual behaviours that include hair pulling (called Trichotillomania), skin picking (called Skin Excoriation), nail biting, nose picking, and lip or cheek biting. In both Trichotillomania (TTM) and Skin Excoriation (SE), the individual experiences ongoing and repetitive urges and actions towards either pulling out of one’s hair or skin picking (dependent on the disorder), resulting in noticeable hair loss, or skin abrasions or lesions. This occurs despite extensive efforts to stop these behaviours. In both disorders there is significant impairment or disruption in routine life functioning for the individual. Women are affected more than men in both disorders. Not surprisingly there are a range of negative outcomes that occur from both TTM and SE than include avoiding routine activities, missed work, problems concentrating, social isolation, and financial strain, among other examples.
It’s important to understand that BFRBs are not simply habits one could stop if s/he tried harder. Rather these are conditions that involve complex brain mechanisms that generate urges and actions of pulling/picking. As a result, specialized help is required to help learn how to manage.
Although these BFRBs can create significant stress, impairment, and interference in the life of the individual, the good news is that there is a treatment that can help. Below we outline a variety of solution-focused, practical steps designed to help you to become aware and notice the triggers that lead to pulling or picking, and engage in alternative behaviours. As a result, this will interrupt and weaken the cycle of trigger --> urge --> pull/pick --> relief --> shame, while strengthening your implementation of alternative behaviors. In addition, this treatment will also help you to challenge unhelpful ways of thinking that can contribute to urges and actions that result in either pulling or picking.
Step 3: Building Your Trichotillomania and Skin Excoriation Management Toolbox
HRT is a behavioural approach that combines awareness training, and use of an alternative and incompatible behaviour, to eliminate hair pulling and skin picking. By bringing into awareness all aspects that precede the pull/pick (triggers), including thoughts, sensations, urges, behaviours, and emotions, the adult is better able to recognize that the pull/pick is about to occur. Yet rather than allow it to occur, as soon as the individual becomes aware, s/he learns to immediately engage in a competing response. A competing response (CR) is a behaviour that is incompatible with the pull or pick, such as clenching one’s fists or sitting on one’s hands. When this combination of increased awareness and use of a CR is done every time the pull/pick would otherwise occur, the cycle weakens. A useful analogy is tending a garden- If you spend a little time every week pulling weeds as they appear, the garden progresses and you’ll prevent a weed infestation. Using the tools as soon as you notice urges and early warning signs, the easier it will be to control or stop your urges, and to reduce and eventually eliminate your pulling/picking. However, it becomes much harder to use your tools effectively if you wait until you have a bald spot or skin lesions. To learn and engage in HRT, follow these steps:
- Collect information about what happens both internally and externally prior to each pull/pick. Take a sheet of paper and record what you were thinking, feeling, doing, any sensations you experienced, and any other important details that occurred right before the pull/pick.
- On the reverse side of the paper write out all the details to a pull/pick incident. Record the sensations you felt as you pulled/picked, emotions you experienced, thoughts, actions (e.g., playing with the hair prior to pulling), and any other important information during the pull/pick incident.
- Based on the above information develop 1-3 warning signs that best predict a pull/pick is imminent. For example, a tingling sensation on the scalp and a lightness in the hand.
- Begin to pay attention to these warning signs. You can use a pad and paper to check off each time you catch a warning sign.
- Develop a competing response you would be willing to do rather than pull/pick. This is an intentional movement that makes it impossible for the pull/pick to occur. Ensure your alternative behaviour is easy to do, subtle, and socially acceptable. Common examples include clenching both hands into a fist, sitting on hands, holding a pen/pencil, or keeping hands in pockets.
- Choose a relaxing action that you can do while engaging in your CR, to shift your focus away from the urge and onto your CR. For example, slow deep breathing, use of a pleasant image like soft rainfall or a gentle ocean current, or a body-scan of your muscles. Pairing a relaxing action with your CR can also help to reduce the tension that usually accompanies urges.
- Start implementing your CR every time you notice a warning sign. Instead of pulling/picking, engage in the CRse for two minutes, or until the urge to pull/pick passes.
- Once your awareness is improved, each time you detect your warning sign/s, engage in your CR. Do this each and every time you encounter and urge to pull/pick.
If you find your awareness has lapsed and you catch yourself in the middle of a pull/pick episode, stop immediately. Engage in your CR.
Some adults find HRT doesn’t always work because the urges to pull/pick can feel overpowering at times, and at other times the mix of pleasure, relief, and soothing that comes from a pull/pick incident is hard to resist. Therefore, combining HRT with use of Stimulus Control is optimal. Stimulus Control functions to eliminate temptations and reduce the strength of urges to pull/pick, by modifying the environment. Stimulus control involves changing how you behave and interact in your home, work, and other environments to make pulling/picking harder. The following is a list of ideas, although it is not exhaustive.
- Use Silly Putty, Rubik’s Cube, or other fiddle gadgets to keep hands busy
- Draw, color, paint, clay, or do other crafts that keep hands busy
- Play with a smooth stone
- Use a pot scrubber, sand paper, dried glue, or emery board on the fingers to provide a rough/picking sensation rather than actual skin picking
- Brush a fluffy pet
- Chew gum, raw pasta, toothpick, sunflower seeds, or other items to keep hair out of mouth
- Wear Band Aids on finger tips or gloves to prevent finger grip
- Wear a hat to cover head or forehead
- Use lotion on hands or Vaseline on eyebrows/lashes to make pulling slippery
- Cover mirrors in paper to prevent looking at skin
- Get rid of, or give away for safe keeping, any implements used to aid in the pulling and picking, such as tweezers, needles, cleaning solution, etc.
- Sit in the middle of the couch when watching TV or reading, so elbows are not resting on the arm chair allowing hands to be closer to the head or face
- Study, read, or watch TV with others to prevent being alone when pulling or picking may occur
- Keep the bathroom door open to prevent long, private stays that can lead pulling or picking
- Sleep with hands in gloves or under the pillow
- Drive with both hands on the steering wheel
- Wear a specific scent or a charm bracelet on your wrist to alert you to your hands moving closer to your face/head.
- Using a variety of these ideas, create “kits” to place in rooms where pulling/picking most often occur. Include the car and your office.
- Consider rewarding yourself for using your kit, such as buying a magazine or treating yourself to a nice coffee, for every 10 kit uses.
Once you have chosen a handful of ideas, begin to implement these. Some individuals like to have a partner or friend subtly prompt them to use their skills (e.g., a look or a gentle shoulder tap), while others prefer to do this independently. Consider help when you need it.
When you are working hard to reduce and eliminate pulling or picking from your life, it is important to pay attention to excessive and unwanted stress and anxiety, as this can leave you vulnerable to increased pulling or picking. Learning how to calm your stress and anxiety through breathing and muscle relaxation are two additional and effective tools. Calm breathing involves slowing down your breathing by breathing in deeply through your nose then exhaling slowly through your mouth. It is a quick and easy way to reduce some of the physical feelings of anxiety in the body. Another helpful strategy involves learning to relax your body. This involves tensing various muscles and then relaxing them. This strategy can help to lower your overall tension and stress levels that can contribute to feelings of anxiety.
For more information, see How to do Calm Breathing
For more information, see How to do Progressive Muscle Relaxation
Adults with TTM and SE, like those with other anxiety disorders, tend to fall into thinking traps, which are unhelpful and negative ways of looking at things. These traps are a contributing factor to engaging in pulling and picking, often because unhelpful thinking leads the adult to feel helpless to cope, thus resorting to pulling and picking as a means to self-soothe. Use the Thinking Traps Form to help you identify the traps into which you might have fallen, and use the Challenging Negative Thinking handout to help you with more realistic thinking (For more information, see Realistic Thinking).
Treatments for TTM and SE continue to be modified to incorporate new strategies to optimize outcome. Outlining the strategies and application of all aspects of CBT treatments for TTM and SE is beyond the scope of this section. However, be aware that Acceptance and Commitment Therapy, and Dialectical Behaviour Therapy, are two other efficacious CB treatments that have been developed successfully for TTM and SE.
Step 4: Continuing your successes
A word about success: Learning to manage your TTM or SE takes a lot of hard work. If you are noticing improvements, take some time to give yourself some credit: reward yourself! However, success is sometimes slow in coming, and it may not mean you are not working hard. It’s important to remember that success is in the effort, not the outcome. This means you can cheer for yourself when you practice using the tools, even if at first the pulling or picking persists. But of course, the more you practices, the more likely the tools will begin to work. It is also important to remember that the purpose of these tools is to help control the urges, not to eliminate them. Just because you have an urge does not mean you’re failing. In other words, its what you do with the urge that counts, not the urge itself.
How do you maintain all the progress you’ve made?
PRACTICE, PRACTICE, PRACTICE!!
The BFRB management skills presented here are designed to teach you new and more effective ways of dealing with your BFRB urges and behaviours. If you practice these skills often, you will find that your symptoms will have a weaker and weaker hold over you.
Learning to manage anxiety, stress, and BFRB symptoms is a lot like exercise – you need to “keep in shape” and practice your skills regularly. Make them a habit, even after you are feeling better and you have reached your goals.
For more information on how to maintain your progress and how to cope with relapses in symptoms, see How to Prevent a Relapse.
