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Thinking Man on Couch

OCD, Hair and Skin Picking

by Dr. Pam Dorsett

Obsessive-compulsive Disorder or OCD is a term that found its way into everyday language. It’s not unusual to hear people refer to themselves or a friend as “OCD” because they like order, cleanliness or routine. However, the truth is these personal preferences do not constitute OCD, a disorder associated with distress and anxiety.


Obsessions are intrusive, persistent thoughts, images or impulses that cause significant anxiety. Persons experience the obsessions as inappropriate and beyond their control. Attempts to reduce or neutralize the anxiety result in compulsions, which are repetitive and excessive mental or behavioral rituals, such as checking, seeking reassurance, washing, praying and counting. The compulsions are neither pleasurable nor realistically connected to the fear. People with OCD often avoid situations, objects or people that they fear will trigger obsessions and compulsions. For example, a person who has an obsession that he or she may be a pedophile will try to avoid contact with children. Most people with OCD recognize that their obsessions are irrational and untrue and see their compulsions as silly and embarrassing. For a diagnosis of OCD, symptoms must result in significant distress or anxiety and impair functioning.


Obsessive-compulsive disorder occurs in many different forms, and some people experience different symptoms over time. The following is a non-exhaustive list of categories of obsessions and compulsions with a few examples of each from “The OCD Handbook” by Bruce Hyman and Cherry Pedrick. Occurrences and preoccupations must be excessive and distressing to be OCD.



  • Contamination (e.g., bodily secretions, dirt, germs, insects, diseases)

  • Hoarding, Saving, Collecting

  • Ordering (e.g., symmetry, order, excessive concern with perfect handwriting)

  • Religious Obsessions, Scrupulosity (e.g., blasphemous thoughts, morality, religious beliefs)

  • Body/Health (e.g., illness, appearance)

  • Sexual Obsessions (e.g., sexual thoughts or images, homosexuality, pedophilia)

  • Fear of saying something wrong or certain words

  • Worry about making mistakes

  • Lucky and unlucky numbers



  • Cleaning and Washing (e.g., handwashing, bathing, housecleaning, grooming)

  • Checking (e.g., harm to self or others, mistakes, health, doors)

  • Hoarding, Saving and Collecting

  • Repeating, Counting, Ordering (e.g., rereading, worry didn’t understand read material, rewriting, counting)

  • Seeking Reassurance

  • Prayers

  • Touch or Tap

  • Eating according to rules

  • Confess wrong behavior


OCD affects children, adolescents and adults, with most people diagnosed by age 19. Causes of the disorder are unknown but genetics research indicates a higher risk for people with first-degree relatives with OCD, especially if the relative developed the disorder as a child or teen. There are differences in brain structure and functioning among people with OCD, but research is ongoing. In some cases, children may develop OCD symptoms after a streptococcal infection. (See


The first-line option for treatment of obsessive-compulsive disorder is cognitive behavior therapy, specifically exposure and response prevention, and sometimes in combination with medication.  Antidepressants such as the serotonin reuptake inhibitors and selective serotonin reuptake inhibitors are the medication most often prescribed. Research indicates a very high relapse rate with discontinuation of medications without behavior therapy.


Exposure and response prevention is the most effective psychological treatment for OCD. This therapy consists of exposure of obsessions and prevention of compulsive rituals. The fear-provoking cues are arranged in a hierarchy from least to most distressed and exposure begins with items lower in the hierarchy.  Each exposure is prolonged, so anxiety dissipates to that cue.



Hair-pulling (Trichotillomania), Skin-picking (Excoriation) and Other Body-focused Repetitive Behaviors


Hair-pulling, skin-picking, cuticle or nail biting and lip or cheek biting are repetitive behaviors which share common characteristics and are consequently considered body-focused repetitive behaviors or BFRBs. According to the Trichotillomania Learning Center Foundation for Body-Focused Repetitive Behaviors (see, BFRBs are “repetitive self-grooming behaviors in which pulling, picking, biting or scraping of the hair, skin, or nails result in damage to the body.”


Estimates are that 2-5 percent of the general public suffer from hair-pulling and 5 percent from skin-picking. Most people start the behaviors around puberty between 11 and 13 years but can begin at any age. Some parents have reported observations of hair pulling by their babies or pre-school age children, which is frequently accompanied by thumb sucking.


BFRBs are not a form of obsessive-compulsive disorder; nor are these behaviors generally symptomatic of deep emotional issues or trauma or associated with self-mutilation or eating disorders. However, individuals may experience anxiety or depression.


The treatment of choice for hair-pulling and skin-picking and other BFRBs is cognitive behavior therapy, which includes habit reversal training and comprehensive behavioral treatment and possibly acceptance and commitment therapy and dialectic behavior therapy. Self-monitoring is an important part of treatment to identify triggers, increase awareness and assess effectiveness of tools used. Although there is no single medication or combination of medications approved by the FDA for the treatment of hair-pulling or skin-picking, SSRIs may help some people with skin-picking. For people with hair-pulling who are anxious or depressed, SSRIs may be helpful. N-acetylcysteine is a nutrition supplement that may help some.

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