Nail Biter? Hair Fiddler? You Could Be a Perfectionist.

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STARTING IN MIDDLE SCHOOL study halls until I cut my hair very short in my early 20s, I spent many minutes every day searching for and removing split ends: it was a habit, an addiction, definitely not a successful treatment for split ends.

Although my split-end search qualifies as a “body focused repetitive behavior” (BFRB), the more serious version is trichotillomania: pulling out hair, especially from the scalp, eyebrows and eyelashes – from just a few hairs to large clumps, entire eyebrows and eyelashes. Other BFRBs are dermatillomania – skin-picking, and onychophagia – biting or picking fingernails until they bleed.

Yuk – is what sufferers as well as observers think, but it’s very hard to stop. Repetitive behaviors like these, which most experts place on the OCD (obsessive-compulsive disorder) spectrum, change the brain’s physical structure by creating new neural pathways, which in turn continue to direct these behaviors. BFRBs affect more females than males, and the estimated prevalence is five percent of the population – some 10 million Americans.

They have traditionally been deemed nervous habits, problems with impulse control or signs of anxiety. But recently, researchers at the University of Montreal linked bouts of hair-pulling to personality traits – to both perfectionism and to becoming easily frustrated, bored or stressed.

Twenty-four study subjects with BFRBs, along with 24 control subjects, were placed in situations designed to elicit these three feelings along with a fourth, relaxation. To trigger frustration, participants were asked to complete a task that was supposedly easy and quick, but wasn’t either – just the sort of task I would try to hurry through and then get annoyed when it couldn’t be completed quickly. For boredom, each participant was left in a room alone for six minutes. For stress, a video showed a plane crash; and for relaxation, waves on a beach.

“We believe that individuals with these repetitive behaviors maybe perfectionistic, meaning that they are unable to relax and to perform tasks at a ‘normal’ pace,” explained principal investigator Kieron O’Connor. “They are therefore prone to frustration, impatience and dissatisfaction when they do not reach their goals.”

BFRBs seem to have a genetic component: sufferers can usually point to family members with a related behavior, as well as to those with related personality traits. And perfectionism in turn further explains the repetitive behavior: an effort to perfect the hair or nails by removing hair that feels “different” or repairing cuticles that appear rough or uneven.

The first step in treatment for most sufferers is keeping a diary. Whether the BFRB is focused or unfocused (hair-pulling that occurs unconsciously), the diary helps pinpoint where, when, how and why the behavior begins each time, which can provide clues to work on stopping it. How is important, for example, because barriers can help: if “pulling” – as they refer to it — is done with certain fingers, then band-aids or gloves can impede it.

The most often-prescribed treatment, Cognitive Behavior Therapy (CBT), encourages sufferers to alter their behavior by identifying triggers and then learning skills to interrupt and redirect their responses. “Stimulus control” involves identifying and then altering or avoiding environmental cues that trigger the behavior or make it easier to do. Some common triggers, however, such as reading, watching TV and talking on the phone, are difficult to avoid.

In “habit reversal training,” the sufferer learns to replace the repetitive behavior with a substitute, usually a competing response that makes it hard or impossible to pull or pick – such as making a fist and keeping that fist in your lap. With CBT, new neural pathways can be formed to make the new response more automatic than the old habit.

My friend Deb, who struggled with hair-pulling for years, found the best relief from medication – but she didn’t like the side-effect of sleepiness. Ultimately, cognitive-behavior therapy helped stop the trichotillomania, but she has moved on to skin-picking. According to Deb, the worst part of these disorders is the shame: “Someone should educate hairdressers,” she said. “If it’s compared to [a disease like] cancer and not seen as an issue of willpower, hairdressers might be more sensitive.”

A good local resource is The Behavior Therapy Center of Greater Washington in Silver Spring, which began by treating trichotillomania but now works with all OCD issues. The success rate is best with children, Deb explained, because the longer the disorder lasts, the harder it is to get rid of.

In a new book, “Life is Trichy,” author Lindsey Muller describes her struggle with trichotillomania – both to hide it from others and at the same time to stop doing it — after which she became a psychologist treating people with BFRBs. Muller says her hair-pulling started with efforts to create “the perfect ponytail,” which took longer and longer each morning. But her first repetitive behaviors came earlier, in kindergarten: skin-picking and then nail-biting.

Muller traces her BFRBs to boredom due to sensory deprivation, because she usually did them when obliged to sit still at school, but rarely when eating a meal or listening to music. For her, the behaviors acted as an “internal regulator of attention in the highs and lows of daily life.” In the end, what Muller found most helpful was redefining “normal,” and realizing that “if I were to ever attain the level of perfection I so long desired, I would not be normal.”

Most familiar to me was her contention that “I was identifying my sense of worth and sense of self from my external appearance.” When she mentioned that everyone in her family was a nail-biter — I remembered my mother picking her skin.

I still fiddle with my hair – and my fingers – not very noticeably, though I’m still embarrassed by both. As with anorexia, alcoholism and many other dysfunctional behaviors, “you are never recovered, only in recovery.” I’ve been fiddling for too many years to expect total and permanent cessation, but I recently started trying the fist-in-the-lap maneuver: I seem to be doing a little better.

–Mary Carpenter