Even Colleen's hair stylist noticed the little scars and was afraid to put bleach on Colleen's scalp to highlight her hair. 'I could tell on her face, she was really concerned," she said.
Amy Morin, a licensed clinical social worker at the Health Access Network in Lincoln, Maine, provides outpatient therapy to adults and children.
Morin, who writes a marriage counseling blog, said treatment often involves the whole family.
"It's most often women with the problems, and husbands have difficulty understanding why they can't just stop," she said. "If we can get spouses involved in treatment we have a better success rate."
Pathological grooming issues are difficult to treat and require the patient to "be very motivated," she said.
"Treatment usually involves some motivational interviewing to help assess their motivation to stop," said Morin. "Then, it requires discovering what they get out of doing it."
Often patients pick, bite and scratch when they are in the comfort of home, watching TV, and may not even be aware of the habit. "Sitting on the couch may just trigger their muscle memory to begin skin picking in the evenings," she said.
Morin encourages them to be more conscious of their behavior.
"This may involve a paradoxical approach such as having them pick their skin in front of a mirror for 15 minutes every morning and evening," she said. "This teaches them to be more aware of what their hands are doing."
Knowing habits like hair pulling and scab picking are stress relievers, she teaches new relaxation techniques.
"Often, the shame and embarrassment that accompanies these habits lead people to feel very isolated, which perpetuates the cycle of hair pulling or skin picking," said Morin.
Such was the case with Colleen. "I am more frustrated with me than others trying to help," she said. "I never realize when I am doing it. And it's horrifying and embarrassing when they notice before I do."
Neurologist Shah reassures that every person who bites their nails or picks their scalp shouldn't think they have a serious disorder -- only if it interferes with their daily lives.
"Don't run to the doctor right away," he said. "If it causes concern, pay attention, but for the great majority of people it's not a problem and it's too easy to get swept up in the diagnosis. People have to decide for themselves if they need help or not."
In Nicole's case, she has other issues, including anxiety and some depression.
"A combination of cognitive behavior therapy and keeping my hands busy or being distracted helps," she said. "I look at my whole lifestyle -- my thought process and my sleep patterns and nutrition."
"I still have moments of anxiety that gets bad," she said. "Looking at colleges has been a stressful time. But the pulling isn't worse and I don't have any bald spots now."