ICD-116B25	BODY-FOCUSED REPETITIVE BEHAVIOUR DISORDERS Body-focused repetitive behaviour disorders
ICD-10F63.3	Trichotillomania
DSM-5-TRF63.3 / F42.4	Trichotillomania (Hair-Pulling Disorder)

1. Definition and nosology

Body-focused repetitive behaviors (ICD-11: 6B25 Body-focused Repetitive Behaviour Disorders) — a group of disorders characterized by the patient's repetitive interference with their own body (hair, skin, nails). Main subtypes:

• 6B25.0 Trichotillomania (hair-pulling disorder);
• 6B25.1 — Excoriation / Dermatillomania (skin-picking disorder);
• 6B25.Y Other specified (nail biting — onychophagia, lip biting, cheek biting).

DSM-5-TR — Trichotillomania (F63.3) and Excoriation (L98.1) coded separately, but within the OCD spectrum category.

2. History

• Hallopeau F.H. (1889) — term “trichotillomania”.
• DSM-III-R (1987) — Trichotillomania as an impulse control disorder.
• DSM-5 (2013) — moved to the OCD spectrum category; excoriation added as a separate diagnosis.
• ICD-11 (2019) — as a joint category (6B25 umbrella).

3. Epidemiology

• Lifetime prevalence of trichotillomania: 0.5–2%; in clinical form, females 4:1.
• Excoriation: 1.4–5.4%; higher in females.
• Onset: adolescence (10–13 years).
• Comorbidity: MDD, anxiety, OCD, BDD, ADHD.

4. Aetiology and pathogenesis

• Heritability 30–40%; family history prevalent.
• Genetic — SAPAP3 (SLITRK1) — hypergrooming phenotype in mice.
• Neurobiological — OCD-like cortico-striato-thalamo-cortical dysregulation, but with a different profile.
• Behavioral mechanisms: stress response, ‘automatic’ (unconscious) and ‘focused’ (purposeful, with intense attention) subtypes.

5. Clinical features

Trichotillomania (6B25.0)

• Hair pulling — usually from head, eyebrows, eyelashes; sometimes from other body parts.
• Visible hair loss.
• “Pre-pulling tension” or “post-pulling relief” — may not be present in all patients.
• Trichophagia (eating of pulled hair) — in 10–20% of patients; ‘trichobezoar’ — gastrointestinal obstruction may require surgery.

Excoriation / Dermatillomania (6B25.1)

• Skin picking — face, arm, damaged skin areas (“acne”, insect bite site).
• Injury, crust, scars.
• Infection, scarring, cosmetic outcomes.

General characteristics

• The patient makes repeated unsuccessful attempts to stop the behavior.
• Social isolation due to shame (wearing a wig, covering mouth/hands).

6. Diagnosis

6.1 Unified diagnostic criteria

A. Hair pulling (in trichotillomania) or skin picking (in excoriation) — visible hair loss or skin damage.

B. The patient makes repeated attempts to stop or reduce the behavior.

C. Behavior causes clinically significant distress or functional impairment

D. Medical condition (alopecia areata, dermatological illness) or other mental disorder exception (in BDD appearance motivated; in delusion of psychotic episode; substance induced).

6.2 Source-specific clarifications

• DSM-5-TR — Trichotillomania (F63.3) and Excoriation (L98.1) separate.
• ICD-11 — under the common 6B25 umbrella; subspecifiers.

6.3 Diagnostic algorithm

1. Clinical interview (patient often does not speak openly due to shame).
2. Dermatological examination — exclusion of other causes of hair loss and skin lesions (alopecia areata, tinea capitis, eczema).
3. Scale — Massachusetts General Hospital Hairpulling Scale (MGH-HPS), Skin Picking Scale.
4. Comorbidity screening.
5. Trichophagia screening — if gastrointestinal symptoms present.

6.4 Differential diagnosis

7. Examination and assessment

• MGH-HPS (trichotillomania), Skin Picking Scale-Revised.
• Dermatological examination.
• Abdominal ultrasound in case of trichophagia.

8. Treatment

1. Habit Reversal Training (HRT) first-line — awareness training, competing response (e.g., fist clenching), motivation, social support. Evidence: Bloch M.H. et al. Biol Psychiatry 2007 meta-analysis.
2. ACT (Acceptance and Commitment Therapy) — targets emotional component.
3. Comprehensive Behavioral Treatment (ComB, Mansueto) — HRT + multimodal behavioral intervention.
4. N-acetylcysteine (NAC) — evidence base developing; Grant J.E. et al. Arch Gen Psychiatry 2009 RCT — efficacy in trichotillomania.
5. SSRI — evidence base is limited; SSRIs effective in OCD give a weak response in trichotillomania; clomipramine is relatively superior.
6. Atypical antipsychotic adjunct — in refractory cases.
7. Dermatological care — management of injuries and infections.

Source-specific specifications

• Bloch M.H. Biol Psychiatry 2007 meta-analysis — HRT most evidence-based for trichotillomania.
• Grant J.E. Arch Gen Psychiatry 2009 — NAC 1200–2400 mg/day efficacy.

Treatment methods

1. Habit Reversal Training (HRT — Habit Reversal Training) — Azrin (Azrin N.H.), Nunn (Nunn R.G.) — Five core components — awareness training, competing response, motivation, social support, generalization. Gold standard in body-focused repetitive behaviors.
2. Comprehensive Behavioral Treatment (ComB) — Mansueto (Mansueto C.S.) — SCAMP model — individualized approach based on Sensor, Cognitive, Affective, Motor, Place modalities.
3. Acceptance and Commitment Therapy (ACT) — Focus on the emotional component; Woods D.W. et al. Behav Res Ther 2006 RCT.
4. NAC — N-acetylcysteine — Glutamatergic modulator; 1200–2400 mg/day; Grant J.E. Arch Gen Psychiatry 2009.
5. Massachusetts General Hospital Hairpulling Scale (MGH-HPS) — 7 items; frequency, intensity.

9. Prognosis

• Chronic course, “waxing and waning”.
• Significant improvement with HRT; treatment of comorbidity is essential.

10. Myths and misconceptions

Myth 1: “Hair pulling and skin picking are ‘bad habits’, not serious disorders”

Evidence: Clinical impairment; risks of functional impairment, social isolation, infection, and trichobezoar (surgical).

Myth 2: “The patient can stop voluntarily”

Evidence: The patient repeatedly tries and fails — this is the main symptom of the disorder; HRT or pharmacotherapy is required.

Myth 3: “SSRIs are effective for trichotillomania (like OCD)”

Evidence: Response to SSRIs is weaker than in OCD; HRT is first-line; NAC adjunct; clomipramine relatively superior over SSRIs.

Myth 4: “Hiding hair (wig, makeup) is the solution”

Evidence: Cosmetic camouflage short-term; primary behavioral intervention required.

Myth 5: “Only hypnosis or deep psychoanalytic therapy resolves the underlying behavioral cause”

Evidence: Evidence base is limited; HRT-based behavioral approaches are superior.

Myth 6: “Skin picking is a response to ‘acne’ or a cosmetic problem”

Evidence: Clinical impairment — patient cannot prevent behavior, creates scar and infection on skin; clinical intervention required.

11. Sources

1. WHO. ICD-11. 6B25 Body-focused repetitive behaviour disorders. 2024.
2. APA. DSM-5-TR. 2022.
3. Bloch M.H. et al. Systematic review: pharmacological and behavioral treatment for trichotillomania. Biol Psychiatry 2007;62(8):839–846.
4. Grant J.E. et al. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry 2009;66(7):756–763.
5. Woods D.W., Wetterneck C.T., Flessner C.A. A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behav Res Ther 2006;44(5):639–656.
6. Mansueto C.S., Goldfinger Golomb R., Thomas A.M., Stemberger R.M.T. A comprehensive model for behavioral treatment of trichotillomania. Cogn Behav Pract 1999;6(1):23–43.
7. Azrin N.H., Nunn R.G. Habit-reversal: a method of eliminating nervous habits and tics. Behav Res Ther 1973;11(4):619–628.