# Hoarding, Trichotillomania, and Excoriation Disorder in Youth ## Introduction Hoarding disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-picking) disorder are classified under Obsessive-Compulsive and Related Disorders in the DSM-5. Although substantial research exists in adult populations, these conditions are increasingly recognized in children and adolescents. They share features of repetitive behaviors, difficulty resisting urges, and significant functional impairment, yet each has a distinct clinical profile and treatment approach. ## Trichotillomania (Hair-Pulling Disorder) ### Definition and Diagnosis Trichotillomania involves recurrent pulling out of one's hair resulting in hair loss, repeated attempts to decrease or stop the behavior, and clinically significant distress or functional impairment. The behavior must not be attributable to another medical condition or mental disorder. ### Epidemiology The lifetime prevalence is 1-3%. There is a bimodal onset pattern: early childhood between ages two and five, which is often self-limited, and pre-adolescence or adolescence between ages ten and thirteen, which tends to be more persistent. There is a female predominance in clinical samples at a ratio of 3-4:1, though the ratio may be more equal in community samples. The condition is frequently underreported due to shame. ### Clinical Features The most common pulling site is the scalp, followed by eyelashes, eyebrows, and pubic hair. Automatic pulling occurs outside awareness, often during sedentary activities such as reading or watching television. Focused pulling is preceded by tension or an urge, with pulling providing relief or gratification. Many patients exhibit both automatic and focused pulling. Associated behaviors include examining, manipulating, or ingesting the hair, a behavior called trichophagia that carries a risk of trichobezoar formation. Emotional triggers include boredom, anxiety, frustration, and fatigue. ### Treatment Habit reversal training is the behavioral treatment with the strongest evidence base. It combines awareness training, competing response training, and social support. Acceptance-enhanced behavior therapy integrates acceptance and commitment therapy principles with habit reversal training. The Comprehensive Behavioral Treatment model addresses sensory, cognitive, affective, motor, and environmental factors contributing to pulling. Pharmacotherapy evidence is limited; N-acetylcysteine showed benefit in one adult randomized controlled trial, SSRIs have modest evidence, and clomipramine may be considered. In young children under five, parent-directed behavioral strategies are appropriate, and pulling often resolves spontaneously. ## Excoriation (Skin-Picking) Disorder ### Definition and Diagnosis Excoriation disorder involves recurrent skin picking resulting in skin lesions, repeated attempts to decrease or stop the behavior, and clinically significant distress or functional impairment. The behavior must not be attributable to another medical condition or substance effects. ### Epidemiology The prevalence is 1.4-5.4%. Onset is typically in adolescence, often coinciding with or following the onset of acne. There is a female predominance at a ratio of 3:1. The condition commonly co-occurs with depression, anxiety, OCD, and body dysmorphic disorder. ### Clinical Features The most common sites are the face, arms, hands, and legs. Individuals may target real or perceived skin imperfections such as bumps, scabs, and blemishes. Both automatic and focused subtypes exist, similar to trichotillomania. The behavior can result in scarring, infection, and significant disfigurement. Associated shame leads to covering of skin with long sleeves and makeup and to social avoidance. ### Treatment Habit reversal training and CBT are first-line, using approaches similar to those for trichotillomania. Stimulus control strategies such as fidget tools, bandages on fingers, and gloves are helpful adjuncts. N-acetylcysteine has some evidence in adults but limited pediatric data. SSRIs may help, particularly when the condition is comorbid with OCD or depression. Dermatological treatment of skin lesions should be provided as needed. Comorbid body dysmorphic disorder should be addressed if present. ## Hoarding Disorder in Youth ### Definition and Diagnosis Hoarding disorder involves persistent difficulty discarding possessions regardless of actual value, a perceived need to save items with distress associated with discarding, and accumulation of possessions that congest living areas and compromise their intended use. The DSM-5 specifies whether excessive acquisition is also present. ### Epidemiology in Youth The pediatric prevalence is poorly established, with estimates of 2-6% based on extrapolation from adult data. Symptom onset often occurs in childhood or early adolescence, with a mean age of onset between 11 and 15 years. The disorder is often not recognized until adulthood when the individual lives independently. Family studies show high heritability and familial aggregation. ### Clinical Features in Children and Adolescents Children may have difficulty discarding schoolwork, toys, broken items, or packaging. Excessive acquisition manifests as collecting free items or requesting purchases beyond need. Bedroom clutter may impair function, preventing use of the desk or bed. Distress occurs when parents attempt to discard items. Children may hoard unusual items such as food wrappers, sticks, rocks, or scraps of paper. There is overlap with ADHD through disorganization and inattention and with ASD through restricted interests and sensory attachment to objects. ### Distinguishing Features Normative childhood collecting, which is organized and not distressing, must be differentiated from hoarding disorder. OCD-related hoarding, which is driven by specific obsessional fears such as contamination, is distinct from primary hoarding disorder. Whether hoarding is primary or secondary to another condition such as ASD, ADHD, or depression should be assessed. ### Treatment CBT adapted for hoarding is the primary evidence-based treatment. It involves cognitive restructuring of beliefs about possessions, including beliefs about usefulness, emotional attachment, and waste. Graded exposure to discarding and non-acquiring is a core component. Organizational skills training addresses practical deficits. Family involvement is critical in pediatric hoarding, with parents serving as coaches and collaborators. SSRIs may help when hoarding is comorbid with OCD or depression, though hoarding-specific pharmacotherapy evidence is limited. Home-based interventions may be necessary to address the living environment directly. ## Comparison of the Three Disorders | Feature | Trichotillomania | Excoriation Disorder | Hoarding Disorder | |---------|-----------------|---------------------|-------------------| | Prevalence | 1-3% | 1.4-5.4% | 2-6% (estimated) | | Typical onset | Bimodal: ages 2-5 and 10-13 | Adolescence (often with acne) | Ages 11-15 | | Sex ratio (F:M) | 3-4:1 in clinical samples | 3:1 | Approximately equal | | Core behavior | Hair pulling (scalp, lashes, brows) | Skin picking (face, arms, hands, legs) | Difficulty discarding; excessive acquisition | | Subtypes | Automatic and focused | Automatic and focused | With or without excessive acquisition | | First-line treatment | Habit reversal training | Habit reversal training / CBT | CBT adapted for hoarding | | Pharmacotherapy | N-acetylcysteine, SSRIs, clomipramine (limited evidence) | N-acetylcysteine, SSRIs (limited evidence) | SSRIs (limited evidence; mainly for comorbid OCD/depression) | | Medical complications | Hair loss, trichobezoar (from trichophagia) | Scarring, infection, disfigurement | Impaired living conditions, fire/health hazards | ## Shared Features and Transdiagnostic Considerations All three conditions involve repetitive behaviors with difficulty inhibiting urges. High rates of psychiatric comorbidity, including depression, anxiety, OCD, and ADHD, are seen across all three. Shame and secrecy are common barriers to disclosure and treatment-seeking. Functional impairment may be social, academic, or physical, including infections and scarring. Behavioral treatments, specifically habit reversal training and CBT, are first-line across all three conditions. ## Clinical Pearls Clinicians should ask directly about hair pulling, skin picking, and hoarding, as patients rarely volunteer these symptoms due to shame. Habit reversal training is the gold standard behavioral treatment for both trichotillomania and excoriation disorder. In prepubertal children, hair pulling is often self-limited and may not require intensive intervention; parental guidance and monitoring are usually sufficient. Hoarding in youth is often masked by parental management of the home environment, and symptoms become apparent only when the young person gains independence. ## References 1. Franklin ME, et al. "Trichotillomania and Its Treatment: A Review and Recommendations." *Expert Review of Neurotherapeutics*. 2011;11(8):1165-1174. 2. Grant JE, et al. "Skin Picking Disorder." *American Journal of Psychiatry*. 2012;169(11):1143-1149. 3. Storch EA, et al. "Hoarding in Youth: A Review of Phenomenology, Assessment, and Treatment." *Child Psychiatry and Human Development*. 2011;42(5):549-565. 4. Tolin DF, et al. *Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding.* 2nd ed. New York: Oxford University Press; 2014.