Hair pulling, skin picking, nail biting—living with body-focused repetitive behaviors (BFRB) can be very distressing and lead to a long list of undesired consequences. But what exactly is happening here?
Body-focused repetitive behaviors, or BFRBs, are a set of disorders categorized by self-grooming behaviors that become too frequent or extreme to be helpful, resulting in damage to the skin, nail beds, or hair follicles. These grooming behaviors most often include pulling, picking, biting, or scraping. The disorders include but are not exclusive to:
- Onychophagia (compulsive nail biting)
- Trichotillomania (compulsive hair pulling)
- Excoriation/Dermatillomania (skin-picking disorder)
- Dermatophagia (skin biting)
- Rhinotillexomania (nose picking)
- Bruxism (teeth grinding)
In the DSM-5, BFRBs fall under the “other specified obsessive-compulsive and related disorders” category. Body-focused repetitive behaviors are considered to have a significant genetic component and often run in families. Development of BFRBs may also be influenced by early environment, stress, and temperament.
BFRBs typically develop during late childhood or adolescence; however, onset in early childhood and adulthood is possible. It is estimated that a minimum of 3 percent of the population will experience BFRBs during their lifetime. Recent studies have found no significant differences between the sexes for risk of developing BFRBs.
BFRBs can be tricky to interrupt because individuals often mindlessly or impulsively partake in them. These behaviors can also be compulsive, wherein individuals are aware of what they’re doing and often want to stop the behavior, but feel unable to. Those who have BFRBs report physically feeling pleasure and/or pain from these behaviors coupled with emotionally experiencing satisfaction and/or dismay. Most often, people affected by BFRBs dislike the consequences of their behaviors and experience distress..
While BFRBs are typically categorized within the OCD framework, there is a growing body of evidence pointing to other disorders such as anxiety and attention-deficit/hyperactivity disorder (ADHD) being strongly correlated with BFRBs. Despite these disorders having nuanced presentations, their relationship with BFRBs seem to have a commonality: an attempt to self-soothe gone awry.
For example, a person who is anxious may focus on their face and attempt to eliminate any imperfections. While they are picking, they experience pain, which releases feel-good endorphins that provide a boost to our mood, and a sense of achieving a goal, which releases dopamine, a neurotransmitter that prompts us to continue a behavior to achieve goals. The problem with this pattern is that while the satisfaction of a small achieved goal feels good, it often contributes to larger issues. Negative consequences to excessive BFRBs can include damaging the skin and causing injuries, altering our appearance in unwanted ways (e.g., if you were not intending to pluck out all your eyebrow hairs today), or taking up hours of the day time that were intended for other activities. These examples show that despite a person knowing that their behaviors are in fact making the problem worse, they feel compelled to keep doing it.
It is important to remember that BFRBs are often a symptomatic behavior of a dysregulated nervous system, often prompted or exacerbated by stress or boredom. Understanding that sometimes BFRBs are our brain’s best attempt (however misguided) at calming, stimulating, or otherwise regulating our emotional states allows both patients and clinicians to address the underlying distress maintaining the compulsive behavior.
How to help manage BFRBs
Therapy with a clinician who is experienced with treating BFRBs can be extremely helpful to those struggling with this disorder. Below are some of the modalities found to be the most effective treatment options:
- Habit Reversal Training (HRT)
HRT can be an effective treatment for a variety of BFRBs. The three core facets comprising HRT are:
- Awareness training around the BFRB, including the triggers, rituals, and time spent on it. Full awareness is the first step toward change.
- Competing response training to replace the behavior. The options are endless. For example, someone who experiences skin picking may use squeeze balls to keep hands occupied and away from the scalp or face. Wearing gloves or using fidget spinner rings could also help with nail-biting or cuticle-chewing.
- Social support. Individuals with BFRBs often experience shame and frustration surrounding their disorder, which makes seeking treatment difficult. Social support is crucial to reducing distress and improving outcomes.
- Cognitive behavioral therapy (CBT) can reduce the problem behavior by helping individuals identify and challenge negative self-talk and mitigate shame around BFRBs.
- Dialectical behavioral therapy (DBT) may help curb unwanted behaviors by improving distress tolerance, stress management, and identifying healthy coping skills for self-soothing.
Medication is generally considered less effective than behavioral treatments for treating BFRBs. But some medications have shown promise, particularly for individuals with co-occurring anxiety, ADHD, depression, or OCD.
There are currently no FDA-approved medications to treat BFRBs. Prescribers often use the following medications, off-label, to target BFRBs and to complement behavior therapies (many of these medications are also used to treat OCD):
- SSRIs, which may reduce anxiety
- Clomipramine, which may reduce hair pulling
- Fluoxetine, which may reduce skin picking
- N-Acetylcysteine, an anti-inflammatory antioxidant that can be prescribed by a physician or purchased OTC
- Stimulants and other medications (to treat co-occurring ADHD) may reduce BFRBs for some individuals while possibly exacerbating them in others
Medications are not without risk of side effects, so they must be prescribed only by a skilled health practitioner who has experience working with BFRBs and its comorbidities.
As described, social support is essential for individuals struggling with BFRBs. Support groups can help individuals with BFRBs learn more about their condition, seek help for it, and stick with treatments. You can find support groups and additional help through The TLC Foundation for BFRBs and the International OCD Foundation