Borderline personality disorder in Trichotillomania and skin picking disorder: a survey study

Comorbidity studies in trichotillomania and skin picking disorder (known as Body-Focused Repetitive Behaviors, BFRBs) have traditionally not examined rates of borderline personality disorder. When it co-occurs, borderline personality disorder may necessitate different treatment approaches and if untreated may interfere with the response to the treatment for trichotillomania or skin picking disorder. The objectives of this study were to (1) examine the rate of co-occurring borderline personality disorder in BFRBs; and (2) explore associations between co-occurring borderline personality disorder and relevant clinical characteristics (such as demographic features, BFRB symptom severity, lifetime history of suicide attempt[s], levels of dissociation, and other comorbidities including impulsive conditions that are often unmeasured in studies).

Adults with skin picking disorder, trichotillomania, or both completed an online survey. The survey was comprised of demographic and clinical questions, plus instruments to measure for probable borderline personality disorder, as well as BFRB severity, dissociation, impulse control conditions (including BFRBs), and alcohol use disorder. Each participant also completed questions about previous formal mental health diagnoses.

Of the 281 adults with BFRBs (n = 105 with skin picking disorder; 93 with trichotillomania, and 82 with both disorders), 105 (37.4%) screened positive for a probable diagnosis of borderline personality disorder. Participants screening positive for probable borderline personality disorder reported significantly worse pulling and picking symptoms (p < .001), higher rates of dissociation (p < .001), and were significantly more likely to report lifetime suicide attempts (p < .001) and to endorse co-occurring alcohol problems (p < .001), compulsive buying disorder (p < .001), gambling disorder (p < .001), compulsive sexual behavior (p < 001), and kleptomania (p = .005).

These data suggest relatively high rates of borderline personality disorder in people with BFRBs, in turn linked to more severe psychopathology and elevated lifetime suicide attempt risk. Perhaps the comorbidity with borderline personality disorder reflects a possible subtype of these behaviors that is more impulsive and may necessitate different treatment approaches.