The Role of Trauma in Trichotillomania, Skin Picking Disorder, & Body Focused Repetitive Behaviors
The Role of Trauma in Body Focused Repetitive Behaviors
Here is what I see over and over again in my counseling practice. Someone comes in for their skin picking or hair pulling problem (trichotillomania), collectively known as Body Focused Repetitive Behaviorsor “BFRBs.” As we get to know each other their story quickly reveals a whole person with a full life of struggles and successes. Someone who is so much more than a picker and a puller. My goal is to help that whole person heal their traumas without losing sight of the picking and pulling. I noticed many overlaps between what I learn about trauma and what I learn about trichotillomania and skin picking. Here I hope to share with you how sometimes trauma is related to body focused repetitive behaviors (BFRB) such as skin picking disorder and trichotillomania.
Since I was a kid I have struggled with skin picking, then I started hair pulling, around the time unfortunately trauma became all too much of an issue for me. After over 10 years of psychotherapy many things got much better, even the picking, pulling, and trauma related struggles were less severe, but I was far from the progress I hoped for. A major shift on those issues was not made until I started resolving my trauma at the nervous system level, using Somatic Experiencing (SE). SE is a body-awareness approach to therapy developed specifically to resolve post traumatic stress disorder in a gentle, naturalistic way grounded in neuroscience and ethology. The work done in SE therapy is what freed me to finally be able to use the cognitive behavioral therapy (CBT) interventions which were suggested in the past to address my BFRBs. Prior to Somatic Experiencing I was stuck, helpless, and frustrated. After a few sessions of SE, I realized there is an internal activation that I was previously unaware of, and could now identify. I feel and notice early signs that if not attended to would lead to a picking or pulling episode. Even if I find myself leaning to the mirror, which used to be a point of no return, I can now remain present in my body and back away.
Based on my own journey; geeking out over neuroscience in my post graduate education, and now over 4 years of focusing on these three issues for my clients in my professional counseling practice, I see how intricately these issues are woven together. Helping clients see and escape this web has become my passion. In several cases my clients’ trauma has been tied into or connected to their picking and pulling habits. I also see that they get stuck where I got stuck in my own treatment, until we start to use SE, and finally shifts happen. Now I introduce it from the beginning integrated with CBT.
When a BFRB is present we cannot assume there was a traumatic event that caused it. Unfortunately, many of us (BFRB or not) have survived a trauma at some point in our lives. I am not saying that trauma causes trichotillomania or skin picking disorder. I believe that healing trauma can empower us to fight the behavior and reduce the triggers that lead us to pick or pull in our current lives.
I bring this up after a pattern of unfortunate discussions where trauma was dismissed altogether once the topic of BFRB came up. In our effort to dispel the myth that BFRBs are solely a symptom of a major repressed childhood trauma, I believe our message overcompensated a bit and overshadowed the fact that sometimes trauma is a very important piece of the BFRB puzzle. Again, I am not saying trauma is related to all BFRBs, I am saying it is worth considering on a case by case basis.
What is Trauma?
When I talk about trauma, I refer to our nervous system’s reaction as opposed to a specific event that occurred. Trauma usually impacts people when they perceive their self or a loved one is in danger. Danger may or may not actually be present, but the nervous system is not always that logical. In addition to traumatic events, the nervous system may respond to chronic stress, dramatic change, shame, betrayal, or prolonged chaos as if trauma were present.
Every person’s nervous system is different. Some of us are built with a resilient system, while others may be more vulnerable to stress, chaos, or being startled or shamed. Those with a more sensitive body/nervous system can hold onto that experience for months, years, or even decades. It is not about the event, it is about how that circumstance was internalized by this survival oriented parts of the brain. Some people will have a visceral, nervous system shifting, traumatic reaction to a being yelled at during a vulnerable time or getting into a fender bender. These events are nearly universal. When scars, wounds, and bald spots are visible to people around us, their negative responses and the resulting shame and isolation can be traumatic. Then of course the statistics behind how many people survive sexual assaults, terror attacks, and witnessing acts of violence, are truly overwhelming. The BFRB population is not immune to being a part of those events, events which become major parts of our lives.
Long after situations which lead us to where we are now have passed, our body and nervous system may continue to function as if it is still ongoing. Essentially our body remains on guard for danger, sustaining itself in fight, flight, or freeze mode. People respond to trauma in many ways, so they may be impacted by trauma even if they do not meet diagnostic criteria for PTSD (Post Traumatic Stress Disorder). Trauma-informed therapy help restore the nervous system for real healing. It builds resilience in our nervous system, emotions, and life functioning. Specifically, I use Somatic Experiencing as the modality for treating trauma in therapy.
Trauma significantly impacts what therapy looks like and its effectiveness for BFRB, but this lens can really help. With some time and focus spent on healing trauma, a client can begin to feel safe enough to be seen, work through shame, develop healthy ways to self soothe, and become ready for change. Therapy, especially for BFRBs, is best when the client is curious and open to the process. Yet the nervous system is only wired to allow for curious and receptive states when it knows it is truly safe. It is not just a logical process of being safe, it is the reptilian, survival mode in the brain that needs to be calm and ready.
Comprehensive cognitive behavioral therapy (ComB) as taught by the Trichotillomania Learning Center to help with BFRBs has been effective in my practice. ComB leads to the exploration of many factors related to the picking and pulling. The thoughts, emotions, sensations, and places brought up in the ComB assessment may be triggers for traumatic memories, implicit or explicit.
Neurons that Fire Together Wire Together
Basic neurobiology shows that “neurons that fire together, wire together.” (Dan Siegel, 2010). BFRBs already appear to be hardwired in our brain, and when BFRB patterns get wired to a trauma response, it can feel powerless to take on one without the other. Somatic Experiencing calls this overcoupling. It is not uncommon for the picking or pulling to start long before any traumas. However, if the BFRB soothes when lonely, helpless, scared, worried, or angry, and you must find a way to cope with a trauma making you feel that way. Then your brain starts to link the BFRB to the a trauma. Now they are overcoupled, tied together in the brain and nervous system.
I see a pattern of clients who come in for BFRB and gradually reveal much unprocessed and un-integrated trauma, complex trauma, and/or so much chaos growing up that their nervous system had to find some way to cope. Ultimately, they found some way to self soothe and picking or pulling did the trick. It is common for clients to be unaware of this link and even deny it in the ComB assessment, but I watch as their nervous system gets activated around a traumatic topic, their hands get busy, start searching, fidgeting, or even start to engage in the BFRB.
“Studies suggest that prevalence of PTSD in trichotillomania may be higher than in general population and that more different type trauma story is related to duration of hair pulling period and location of bald area.” (Aytac, 2017)
How do BFRBs get Uncoupled?
Research distributed through the Trichotillomania Learning Center is already supporting the push to include psychotherapy interventions with CBT, HRT, and ComB. These therapies show some effectiveness in helping clients self soothe, learn to regulate their own emotions, communicate assertively, become more mindful, and resolve major life stressors that make it really hard to focus on or make progress with the BFRB treatment. To this I add trauma-informed treatment approaches grounded in neuroscience. I am trained in Somatic Experiencing (SE), so this is the specific skill set, language, and lens through which I observe my clients and deeply impacted my own journey. When working with trauma using SE, you discover and renegotiate over coupled emotions, thoughts, images, behaviors, and bodily sensations. While it can take time, teasing out what are the past and present issues, doing so can be freeing and bring much clarity. It also takes the “umph” out of the triggers- both BFRB and PTSD.
What I see in my clients’ progress and in my own life, is that once the uncoupling has occurred, and the barriers to feeling safe enough in a helping setting are lifted, we can then use those great CBT assets to take on the picking and pulling head on. Often, I see the need to turn to those techniques dissolve significantly. Therapy can be linear, a matter of getting the trauma out of the way so we can use ComB for the BFRB, but sometimes is a process of oscillating between working with the trauma and BFRB. There have even been cases that with the resolution of the trauma we do not need to continue to use the ComB interventions beyond general coping skills, boundaries, and self care.
Studying Somatic Experiencing (SE) for trauma and ComB for BFRB’s separately yet concurrently has been very eye opening for me. The overlap between the two I find very exciting. Here we have a BFRB disorder that seems to have strong links to the brain, nervous system, body sensations, and an eclectic constellation of emotional and situational triggers unique to each person. At the same time, we have a treatment option grounded in all of those factors that is designed for trauma, an issue few of us fully escape.
Clients recount their experiences of suddenly looking up in the midst of a BFRB and realizing 15 minutes, 45 minutes, 3 hours, or even 10 hours have passed as if it were a in a blink of an eye. When a client loses time while engaging in a BFRB, such as reporting they “go away,” or feel “out of body,” these are signs of some level of dissociation. Dissociation can also be a symptom of trauma and is treatable with SE. What I see is that sensations leading up to this can be caught, felt, tolerated, and settled before reaching this point. If you find yourself already there, the BFRB is happening but you cannot seem to get control over your body, try some of the tips listed later in this article to ground and settle the dissociative episode.
When the survival part of the brain believes it cannot fight off the danger or flee to safety, it defaults to an immobility response. Like the opossum “plays dead,” we have a broad spectrum of dissociated states as a lingering impact of trauma. Dissociation is like a faux death, the stimulation and touch of picking and pulling lets us know we are alive. While not ideal, it is an effective way to soothe. BFRBs stimulates us to get back into our body, soothes us when overwhelmed. It can be done alone; we do not need a safe caregiver to rely on.
With bodily awareness that comes from this approach to trauma, the client develops more awareness of the picking and pulling behaviors. Even the unconscious, automatic BFRBs are more accessible. Those micro movements, thoughts, emotions, and seemingly irrelevant sensations that precede and build up to the pick or pull become a wealth of information. They serve as cues to self soothe, grab a fidget, or find a way to prevent the next pick or pull. As we know from habit reversal training, the sooner in the chain of events we intervene, the more effective we will be at stopping the next pick or pull before it happens.
Self Help Tips
Here are some ways to integrate healing your nervous system into your own BFRB journey:
◦ Orienting to 5 senses. This is a meditation practice that involves slowly and mindfully noticing each of your five senses. Spend about a minute each observing what you see, hear, feel, taste, and smell. Move your neck slowly as you look all the way around you. Notice what bodily sensations come up as you become more present in the moment and environment. This process communicates to your nervous system that you are safe now, grounding you in the present moment.
◦ Sensory tracking. Non-judgmentally notice various sensations in your body: tightness, softness, textures, temperatures, urges to move, breath, stomach, pressure, etc. Observe how the sensations evolve as you name them. Try this in joyous time and when relaxed just as much as the hard times. If noticing sensations becomes disturbing, please bring these concerns to a trauma-informed therapist.
◦ Resourcing. Self care is essential, so engaging in both our internal and external resources regularly is a lifelong intervention that makes you more resilient. When you are in difficult moments, struggling with an urge or simply stressed out, bringing these resources to mind can help settle your nervous system and help you cope.
◦ Log Sensations when tracking your BFRB. If you keep a log of your picking and pulling patterns, make a note of the bodily sensations that came up before, during, and after the pull as well as thoughts and emotions.
Trauma First Aid. These are simple, structured exercises that you can do to integrate your nervous system. Sit in a calm and safe space with both feet on the floor. Start noticing the sensations in your feet and really feel the contact with the ground. Body part by part, work your way up scanning your body and trying to put words to describe the sensations you feel. Feel the support of the chair under you. Feel the air in your lungs. Imagine a color that represents your current state.
◦ Breathing with a Fidget. Each breath serves our body the way it needs to in that moment. Paying close attention to your breath can help your nervous system settle and calm down when activated. Trying holding a stretchy fidget to represent your airways and lungs. Stretch it with each inhale and relax it with each exhale. Try to keep it in sync with the rate and depth of your breath, and watch how your breath naturally slows down and gets so very deep. Spontaneous breath comes on its own, and washes over you with an indescribable calmness.
What I ask both clients and treatment providers to hold in their awareness is that trauma may not have “caused” the BFRB, but it may very well be a vital part of recovery. I want to stress the importance of helping the whole person including their picking and pulling struggles. Somatic Experiencing is designed to be integrated into other comprehensive treatment modalities. This lens can be overlaid with the ComB model quite neatly to support our clients and their nervous systems.
Siek, A., Makarewicz, A., Lobejko, L., Gralewska, A., Tomaka, J., Szymanska-Piekarczyk, J., …& Juchnowicz, H. K. (2017). “Pulling hair out of the head” -the importance of traumatic family events in the development and maintenance of trichotillomania symptoms-case report. Current Problems of Psychiatry, 18 (4), 367-377.
Aytac, H. M. (2017). History of Trauma adn Current Posttraumatic Stress Disorder in Trichotillomania: A Case Report. Klinik Psikofarmakoloji Bulteni, 27, 133.
Siegel, Daniel J., 1957-. (2010). Mindsight : the new science of personal transformation. New York :Bantam Books.
Stacy Nakell, A Healing Herd: Benefits of a Psychodynamic Group Approach in Treating Body-Focused Repetitive Behaviors, International Journal of Group Psychotherapy, 65, 2, (295), (2015).
Peter J. Taylor Ph.D., SEP, CGP, FAGPA, & Roger Saint-Laurent Psy.D., SEP, CGP (2017). Group Psychotherapy Informed by the Principles of Somatic Experiencing: Moving Beyond Trauma to Embodied Relationship, International Journal of Group Psychotherapy, 67:sup1, S171-S181.
Heller, L., & LaPierre, A. (2012). Healing developmental trauma: How early trauma affects self-regulation, self-image, and the capacity for relationship. Berkeley, CA: North Atlantic Books.
Click Here for a peer reviewed, scientific article about Somatic Experiencing. :
Front. Psychol., 04 February 2015 | doi: 10.3389/fpsyg.2015.00093
Somatic experiencing: using interoception and proprioception as core elements of trauma therapy
Peter Payne1, Peter A. Levine2 and Mardi A. Crane-Godreau1*
About Priscilla Elliott, MA, LPC, SEP
Owner and Psychotherapist at Courage Counseling in Austin, Texas specializing in helping clients with BFRBs. Courage-Counseling.com
Graduate of TLC’s Virtual Professional Training Institute
Completed full certificate program of Somatic Experiencing Training Institute. http://www.traumahealing.com/
Dedicates much time to community outreach for BFRB education