We are so happy to have University of Oxford professor Clare E. Mackay as a guest writer for this blog post.
Clare is an amazing advocate for the Trichotillomania communtiy. She's had trich for 40+ years, and is now using her position as a professor of Imagining Neuroscience in the Department of Psychiatry as a way to create BFRB Awareness.
The following blog is written by Clare herself.
I recently published a perspective article in the British Medical Journal: Mental Health entitled: Trichotillomania: a perspective synthesised from neuroscience and lived experience (https://mentalhealth.bmj.com/content/26/1/e300795.full). This is the beginning of my journey to pull together 30 years of studying neuroscience/psychology and 40 years of living with hair-pulling as part of my daily life.
Here are the main points from the paper:
- BFRB’s can be thought of as a motor response to distress
When you start trying to understand BFRB’s through reading the scientific literature, it quickly becomes clear that we have a problem in relation to other disorders. Many people with BFRB’s experience also other psychological problems, but it is hugely variable. For example, is a BFRB part of an anxiety disorder? A form of OCD? A form of self-harm? A response to trauma? A form of stimming in relation to autism or ADHD? Etc etc. I think it’s sort of all and none of these things. My way of thinking about it is that BFRB’s start off as a motor – i.e. movement – response to emotional or psychological distress. You could think of anxiety or depression as emotional responses to distress, and BFRB’s as a motor response. There is something special about the motor system in the brain - it is specifically designed to learn patterns then execute them without going via the decision-making areas of the brain. For example, we know that when we learn to walk, ride a bike or drive a car it takes a lot of effort at first, then after a while we do it without thinking. It’s the same when picking/pulling/biting – our motor system ‘overlearns’ the pattern of movement that it associates with self-soothing, then initiates the movement pattern without any conscious thought.
2. Picking/pulling/biting behaviours are normal
Everyone picks/pulls or bites at themselves to a certain extent. For most people it’s a normal part of self-care, but for those of us with BFRB’s the problem is that we can’t stop. Indeed, it’s not just humans that pick/pull/bite at themselves… in animals this behaviour is called grooming and you can find examples in all sorts of mammals and birds. Primates are particularly interesting because they groom both themselves and each other, partly as a way of keeping each other free from parasites, and partly to create and maintain social bonds. Interestingly, some individual animals (again both mammals and birds) pull out their hair or feathers or scratch at themselves excessively when in captivity. In the wild, excessive self-grooming behaviours are associated with having lower social status (literally being further down the pecking order), which could be thought of as an example of distress. In other words, this motor response to distress is hard-wired… it’s part of our ancient animal brain. The key questions are: what brain circuits are involved in these behaviours? Why do some individuals get stuck in a feedback loop that means they can’t stop? And is there something we can do to intervene?
3. Shame causes distress, and therefore keeps us trapped in the cycle
I think of BFRB episodes – when you can’t stop picking/pulling/biting as being stuck in a feedback loop, and I think the thing that keeps us trapped is shame. If you think of a simple cycle – distress leads to the urge, which causes the pick/pull/bite behaviour, which gives a very brief relief, but then is followed by a wave of shame, which causes distress, and around we go. Shame is a very interesting emotion – it exists because we’re social animals, but in BFRB’s (and indeed many psychological disorders) it becomes part of the problem. In other words, the shame we feel actually maintains the disorder. And of course the stigma we experience from society (including our families, friends, healthcare providers etc), which is caused by a lack of awareness and understanding, massively amplifies our shame. My personal experience is that by directly targeting shame, the BFRB urges can be made more manageable. The antidotes to shame are two-fold – first is connection, and so the work that Aneela and others are doing to create community is vitally important. I spent nearly 40 years locked in my own shame-filled silence, so I know just how hard it is to speak out, but I also know that having spoken up and found community I have never felt better. The second antidote to shame is compassion. Learning to have self-compassion is hard and takes time, but it is the very best thing we can do for ourselves.
So in summary, the paper highlights the confusion between BFRB’s and other disorders, the lessons we can learn from self-grooming in other animals, and the important role that shame plays in maintaining the behaviours. I’m always up for learning more and connecting, so please find me @thetrichprof if you have any thoughts or comments.
Thank you Clare, for doing such amazing work to spread Trichotillomania Awareness in a space that could do great things to progress research further. We so appreciate you for what you do, and are grateful that you took the time to write a blog post for HabitAware!
The header used for this blog post is a painting done by Clare, herself. It's part of a pair that represent her feelings about Trichotillomania. It's currently her twitter header and is also featured in this University of Oxford article featuring her.
The painting used in the header represents what it feels like for Clare to break out of a Trichotillomania episode. The following one represents what it feels like to be trapped by it.
