Sleep Disturbance in Trichotillomania and Dermatillomania

Sleep is a fundamental, vital aspect of our existence. Trust me, I’m lacking a few hours as I’m writing this, and I can feel that lack. Sleep is essential for our physical, mental, and emotional well-being. Sleep allows our body to rest and rejuvenate, it helps consolidate memories and process information. During sleep, our brainwaves and bodily functions undergo specific cycles that run numerous necessary restorative processes. Adequate and restful sleep contributes to improved cognitive function, increased focus, and enhanced creativity.

Moreover, good quality of sleep plays a crucial role in regulating mood and emotions, promoting a sense of balance and stability in our lives. Dreams are, in their own right, equally crucial and often give our unconscious minds a unique opportunity to communicate important issues we need to address but prefer to ignore in our everyday lives. Freud famously called dreams the royal road to the unconscious.

In 2017, a study was published in the Journal of Obsessive-Compulsive and Related Disorders that took a look at how people with hair pulling and excoriation disorders sleep. In my own clinical practice, I often talk about sleeping and dreams with my BFRB clients. Different types of insomnia appear to be common as well as low sleep quality due to unconscious picking or pulling. In addition, with sleep problems, a person’s stress levels, and anxiety levels will go up increasing the likelihood of further picking and pulling.

There isn’t a lot of research into sleep patterns and issues that people with BFRBs face, so coming across this study was a pleasant surprise, especially because, for once, the sample size wasn’t absurdly small. This study included 339 respondents in the trichotillomania group and 285 in the dermatillomania group. There was also a control group consisting of 390 people.

Let’s review the results.

It appears that the control group used medication for sleep far less (13%) than people with trichotillomania (21%) or skin picking (32%). The medications in question were over-the-counter medications, but are nonetheless a good indicator of issues that study participants face. Self-medicating with OTC drugs is usually the first step people take, especially if they don’t have free health insurance and visits to doctors may be quite costly. This also tells us how people with skin picking or hair pulling approach their problems - there are many ways to regulate sleep and using medication is just one of these ways. If this is what a person chooses, it points us to their understanding of their problems and their default approach to solving them.

While there were no significant differences between self-reported sleep issues between trichotillomania and dermatillomania groups, both of these groups of respondents indicated significantly more frequent sleep issues.

Measurements of indications of specific sleep problems further showed significant group differences for sleep quality, sleep disturbances, and daytime dysfunction due to sleepiness. Even after controlling for the significant effects of age, anxiety and depression results remained the same. The study showed a consistent pattern of sleep impairment in persons with body-focused repetitive behaviors. Furthermore, there were no differences between those who have trichotillomania and dermatillomania.

Hair pulling while sleeping is an issue I encounter in my practice, and it was addressed in this study too. 12.9% of participants reported pulling their hair while sleeping in the past month, while only 5 respondents indicated that this is a daily occurrence. Only one person indicated that this is the only way in which they pull. The same was asked of the skin picking group and 26.9% of the participants indicated that they have experienced skin picking in their sleep, only 5.6% indicated that this is a daily occurrence. This result in particular seems interesting to me because in my private practice, the opposite seems to be true: while people struggling with hair pulling relatively often talk about pulling in their sleep and consider it an important issue to address, one that often perplexes and frustrates them, those with skin picking talk about it a lot less. Reading these results was quite revealing and it shows why we can’t rely on clinical experience only and how important studies like these can be. While they may not apply to everyone, they tell us what topics are worth exploring or at least keeping in mind while doing clinical work. The fact that only a few of my clients with skin picking discuss picking in their sleep doesn’t mean that this doesn’t deserve targeted exploration on my part. This seems particularly useful to pay attention to:

When participants were asked how they knew they had engaged in skin picking during sleep, 35 (71.4%) had noticed skin residue/blood under fingernails upon wakening, 23 (46.9%) had woken up with fresh sores, 22 (44.9%) had woken up during a picking episode, and seven (14.3%) had been told by someone else that they had engaged in this behavior (several participants endorsed more than one reason).

This study shows that there are connections between BFRBs and sleep disturbances, but it can’t tell us much more about the nature of those connections. Is it that sleep disturbances cause and/or contribute to skin picking and hair pulling? Or is it the reverse, that picking and/or pulling somehow lead to sleep disturbances? This is where we have to shrug our shoulders and say that more research is needed, while, ultimately, the individual person’s experience determines what’s important and what’s true for them.

Here's how the study authors articulated the possibilities they see:

It is not uncommon for individuals who pull or pick in the evening to complain of significantly shortened sleep duration as a result of prolonged pulling or picking during this time period (Christenson & Mansueto, 1999). It is also possible that insufficient sleep contributes to the development or maintenance of BFRBD symptoms in vulnerable individuals (e.g., through mechanisms of inhibitory control or regulation of internalizing symptoms; Coles, Schubert, & Nota, 2015; Drummond, Paulus, & Tapert, 2006). An alternative explanation is that internalizing symptoms emerge as a function of pulling or picking, contributing to sleep disturbance. Additionally, studies examining diurnal variation in affect indicate depressive and anxiety symptoms often worsen in the evening (Rusting & Larsen, 1998); Wirz-Justice, 2008). It may be the case that BFRBDs, sleep, and internalizing symptoms are complexly interrelated. Furthermore, it is possible that BFRBDs and sleep disturbance are not directly related but reflect a shared underlying vulnerability (e.g., through the serotonergic and dopaminergic systems both implicated in TTM and sleep disturbance; Harvey, Murray, Chandler, & Soehner, 2011; Woods & Houghton, 2014).

I will quote another passage from the study because I feel like it describes a rather common scenario in a clear way:

These findings highlight time in bed before sleep as a high-risk setting in which pulling and picking may commonly occur, and draw attention to several cues (i.e., low awareness, anxiety, boredom, relaxation) which may contribute to symptom exacerbation in this context. Clinicians should specifically ask about such night-time patterns in assessment and treatment of affected individuals.

If we were trying to come up with practically useful solutions based on this, it would perhaps take us in the following directions:

·        Evenings should be an intentionally mindful part of the day

·        Introducing more structure into evenings and hours before sleep my be beneficial

·        Persons with BFRBs would benefit from paying more attention to sleep hygiene

·        Using stimulus control techniques before sleep and during the night might be beneficial (sleeping with gloves or finger covers, for example, a calming bedtime routine, etc.)

As is often the case with BFRB studies, this one poses more questions, but the questions this study poses are, for a change, rather interesting. At least to this psychotherapist. To take something practical for this, perhaps you can take a look at your own picking/pulling habits and see if there are any connections to your sleep.

You can use this to create a few experiments. Here are a few to try:

1.      Sleep with gloves on. You may be surprised to discover that you, indeed, pull your hair in your sleep or pick your skin. This study indicated that roughly every fourth person that picks their skin also has experiences with picking in their sleep. Using stimulus control is not only the solution for this, but also a good experiment to see if the issue occurs from time to time.

2.      Create a journal to track your sleep quality and hours of sleep and see if they correlate in some way with picking/pulling.

3.      Pay attention to your dreams and how they affect sleep quality and picking/pulling during the day.

4.      Try creating a calming evening routine. Instead of doomscrolling before sleep, play relaxing music, sounds of nature or read a book. You may also try a relaxation exercise. And then see how this affects your sleep and your picking/pulling the next day.