The itch that can’t be scratched
Everyone bites their nails, or picks a scab when they shouldn’t, or goes through periods when they just have to wash their hands one… last… time. As humans, we’ve evolved to view grooming as essential to our very survival. But how much is too much?
For millions of Americans, the impulse to keep clean, or, in a more modern sense, look as good as possible, becomes pathological, so that they can’t stop, and it all but takes over their lives. “People really want to stop, and they’re distressed by what they’re doing,” says Marla Deibler, the director of the Center for Emotional Health of Greater Philadelphia, which treats people suffering from pathological grooming disorders. “They become socially isolated, and it becomes very hard to live with.”
Getting that stray gray can be pretty gratifying, but what if you can’t stop there? For people suffering from trichotillomania, the desire — even the need — to keep going is too much to resist. Some will pull until there are bald spots or until they’ve yanked all the hair from their legs or torso. “Anywhere hair grows,” Deibler says. But why?
It’s unclear. For many, hairpulling relieves stress; others are triggered by something sensory or environmental. Such behaviors tend to run in families. And they’re often misunderstood. “For a long time, people thought it was a form of self-mutilation,” she says. “But people aren’t trying to harm themselves. They’re trying to get relief. And a lot of sufferers say they do feel better afterwards.”
For some hairpullers, it’s not enough just to yank a hair and be done. A small percentage also eats it. Researchers haven’t figured out why. For decades, some thought people ate their hair because of an iron deficiency or that it hinted at destructive impulses. Deibler says that it’s likely just another step in the ritual for hairpullers, a wrinkle in that disorder. “Some just bite the split end or the root bulb after they pulled it out,” she says. “They say it’s crunchy or gummy, and kind of satisfying.”
Eating hair is dangerous, though. It can get trapped in the intestines and form giant hairballs that need to be surgically removed. “If they’re not removed, they can prove deadly,” she says.
Hairpulling often can be done without a person even realizing it. They can do it while watching TV or reading a magazine. Hair-cutting, or trichotemnomania, always requires a conscious act, and the results can be startling. Those suffering the disorder feel compelled to cut or shave their hair, whether patches or the whole thing. As with other pathological grooming disorders, what’s done to relieve stress can itself cause more stress. One sufferer who blogs about the disorder anonymously wrote how after compulsively cutting her hair, she’d wear headbands or bandanas — anything — to cover the damage. “I was so ashamed of it.”
Who hasn’t felt that little surge of pleasure from getting your nail under a pesky scab and just tearing it free? Skin-picking is actually extremely common among people. It’s an evolutionary response to mites and other nasty things that can get into our skin. But people suffering from dermatillomania go much further, often resulting in infected sores, scarring and skin discoloration. Deibler says that many who pick are trying to remove what they see as an imperfection. “They tend to pick when anxious, excited or bored,” she says. “They can lose hours in front of a mirror. It affects work; it affects family life.”
Nail-biting is probably the most socially acceptable of the pathological grooming behaviors. People believe it becomes problematic only if they bite down to the cuticle and cause pain or an infection. The most common treatments for onychophagia are aimed at making the fingernails unpleasant to the taste, avoiding the underlying issues entirely. “It’s about relieving stress,” says Dr. Carol Mathews, who runs the Obsessive Compulsive Disorder (OCD) clinic at the University of California, San Francisco. Treatment focuses on “habit reversal training,” a combination of remedies that make patients aware of their disorder and what their triggers are, and then finding ways to resist the urge to pull, pick or bite. Deibler says the awareness part is often a huge step. “People are so isolated, they think they’re the only people who have it.”
While most pathological grooming disorders exist on the OCD scale, some are more OCD than others. The difference might seem minor, but it’s crucial. For those with clear OCD, there is little of the satisfaction that comes from getting at the perfect scab. People who obsessively wash their hands do so out of fear of contamination, and no amount of soap can make all germs go away.
“It gets to be a reinforcing pattern,” says Mathews. “There is the anxiety of contamination, then the compensatory behavior. And you’re fine for the short term. But then you have to do it again, and often more elaborately, because what you did before just isn’t good enough.”
While the impulse that drives obsessive hand-washing and excessive showering is essentially the same, “people do things in ways that doesn’t always makes sense,” as Mathews puts it. People with this expression of OCD can shower three or four times a day, or just once for several hours. There is often an elaborate ritual (which parts of the body get washed first and in what way), as well. If it isn’t followed perfectly, the ritual has to be rebooted. “There is a certain amount of magical thinking at work: If I wash a particular way, I’ll get an A on my math test,” says Mathews, adding that all of us, to a certain extent, exhibit OCD-like behaviors: We knock on wood three times or avoid walking under ladders. The problem is when they spiral out of control. “People can get so impaired that they can essentially get trapped in their home and never come out. It can have real impacts on their health and life.”
Excessive plastic surgery
Sometimes, a blemish is so bad it can’t be picked away. For those with body dysmorphic disorder, the slightest defect can require drastic action. “They become obsessed with camouflaging these perceived defects,” says Dr. David Sack, a Los Angeles-based psychiatrist and CEO of Promises Treatment Centers. “They usually end up in a surgeon’s office years before a psychiatrist’s office.” Before reaching out for help, a person can go through a series of surgeries, altering noses, chins, brows, even arm and back muscles. “I had one patient who was convinced he had a receding hairline,” he says. “He got hair grafts three times, even though there was nothing wrong with his hairline. He became depressed and alcoholic. He was tortured by it.”
Everyone knows by this point that excessive tanning is extremely dangerous. Yet people still do it, turning their skin into a leathery hide and greatly increasing the risk of deadly cancer. When researchers started studying people who obsessively tanned, they assumed the impulse was to cover up some perceived defect. But Sack says what they found was surprisingly different: They’re basically getting high. Part of the chemical reaction to UV light that causes tanning also releases hormones that control stress and produce endorphins. Tanning for these people produces a rush. Take it away and they go through withdrawal. “When forced to go cold turkey, they go through the same symptoms as getting off opiates,” says Sack. “They see no reason to stop because they’re enjoying it. They think the world is trying to interfere with their pleasure. Their behavior is addict behavior.”