Body-focused repetitive behaviors (BFRB’s) are “complex disorders that cause people to repeatedly touch their hair and body in ways that result in physical damage” (BFRB.org). While BFRB’s are habit-like, they are technically not habits. However, the concept of a habit is used here to help explain what a BFRB is.
Nearly everybody on Earth has learned different habits, at different points in their life, like washing one’s hands after using the bathroom, saying “bless you” when someone sneezes, or possibly, habitually lighting up a cigarette when stepping outside. There are some habits we should hold onto, and others we would love to live without. And for the many who have tried to change a habit, I’m sure you’re aware that it can be quite a tricky task.
Habits basically fall into two categories: healthy and unhealthy. But there is also a gray area which I will explain here. Some habits, like brushing one’s teeth, are usually a healthy habit. However, if the person brushes their teeth so frequently that it is damaging their gums, then is it still a healthy habit? Perhaps not! Habits can be mild (biting one’s nails a couple times a week, or, pulling out a few stray eyebrows) to extreme (repetitive nail-biting to the point of tissue damage, or, spending hours removing every last eyebrow hair).
Sometimes, as in the case of our friendly nail-biter and friendly eyebrow puller just mentioned, habits involve doing something to our body, very often including grooming behavior including hair-pulling, nail-biting, and/or skin-picking. Doing any of these grooming behaviors occasionally is normal. However, when they become habitual and excessive, or negatively impact a person’s life in some way, then is becomes “clinically significant” to doctors and mental healthcare providers – basically meaning that the habit is no longer healthy and needs professional treatment. Today, mental health care professionals are in the process of adopting a new term to best capture these behaviors: body-focused repetitive behavior (or simply BFRB).
BFRB’s include many different conditions, some of which are shown in the list below. When the behaviors (and the impact of the behavior) meet actual diagnostic criteria for the disorder, they may be diagnosed with the name in parentheses:
- Skin-picking (“Excoriation disorder”)
- Hair-pulling (“Trichotillomania,” “Trich,” or “Hair-pulling disorder”)
- Nail-biting (“Onycophagia”)
- Hair nibbling (“Trichophagia”)
- Teeth-grinding (“Bruxism”)
- Cheek biting (“Morsicatio Buccarum”)
- Tongue biting (“Morsicatio Linguarum”)
- Compulsive nose picking (“Rhinotillexomania”) (Wikipedia.com)
Note: The use of “–mania” on some of these terms is not to be confused with “mania” or “hypomania”
To be clear, merely picking a scab or pulling a few hairs does not mean the person has a mental disorder. It’s only when the behavior is repetitive, damages or alters the body in some way, and creates significant distress, may there be diagnosable condition(s) present.
BFRB’s may appear utterly baffling to many – especially to those who have never seen or experienced them up-close. “Can’t you just stop?” Is a common initial reaction that BFRB sufferers hear. The urge behind the repetitive behavior can vary from mild to extreme, and “binges” can quickly result after the first hair is pulled or scab is picked, giving the disorder (in some people’s view) an addiction-like quality. Although BFRB’s are generally not the same thing as “self-harming behavior”, (TLC Foundation, 2017) significant physical damage can result (e.g. extreme nail-biting leading to bleeding; hair-pulling for many hours a day can lead to a repetitive motion injury). In some cases, BFRB’s can actually be life-threatening, for example when ingested hair creates a trichobezoar (hair ball), leading to digestive blockage. BFRB’s vary considerably in severity, and tend to wax and wane over time. The reality is that it is not uncommon for the BFRB to persist for many years, even with treatment attempts. A BFRB disorder, when untreated or not treated properly, can cause considerable shame, loss in time (the behaviors can be very time-consuming), and other interruptions in social life and activities of daily living. Many individuals go to great lengths to hide their disorder, and many clients are very relieved to find that other people have the same or similar behaviors.
There has been a history of placing BFRB’s in different diagnostic categories. A short time ago, the DSM classified BFRB’s as “impulse control disorder not elsewhere classified”, in the same category with “pyromania” and “kleptomania” (American Psychiatric Association, 2000). This was hardly a precise categorization, as BFRB’s are very different from such disorders. In the current DSM-5, BFRB’s are classified as an “other specified obsessive compulsive and related disorder” (American Psychiatric Association, 2013). This may be an improvement, but this is still probably not a precise categorization of BFRB’s, since BFRB’s have at least one substantial difference from obsessive-compulsive disorder (OCD) (TLC Foundation, 2017). In OCD, the compulsive behaviors are rarely described as pleasurable, whereas those with a BFRB commonly report that the action can create a pleasurable feeling (TLC Foundation, 2017). Sometimes, a BFRB has a “tic-like” quality, especially when automatic, but BFRB’s are not tics (BFRB.org). BFRB’s are distinct from stereotypic movement disorder (some common examples would include hand-wringing and arm-flapping) (Stein et al., 2008). However, BFRB’s can be conceptualized as a stereotypic movement disorder (Stein et al., 2008).
BFRB’s might be somewhat more common than one may think. Estimates on BFRB prevalence rates (for hair-pulling, nail-biting, and skin-picking) reveal the following: about 1 or 2 out of 50 people experience hair-pulling disorder in their lifetime; about 20-30% of people engage in chronic nail-biting; and about 2-5% of the population picks their skin in a repetitive way that leads to noticeable damage. Also, according to Renae Reinardy, as many as 1 in 25 children may have a BFRB (TLC Foundation, 2017).
Some people will outgrow the BFRB behaviors after childhood, while in others the BFRB will persist beyond adolescence into adulthood. It is not uncommon for a BFRB to begin around the time of puberty, and BFRB’s are commonly associated with depression and other psychological struggles. BFRB’s affect all genders, though it is most commonly diagnosed in women (TLC Foundation, 2017).
Unfortunately, the exact causes of BFRB’s are not known at this time. Despite these unknowns, there are different theories available to help explain what may cause BFRB’s. One such model is the “Stimulus Regulation Model” (Penzel, 1997), which posits that those with a BFRB have, compared to others, a relatively narrow band of tolerance for optimum stimulation of their nervous system. Pulling a hair, for example, can provide needed stimulation (e.g. when feeling bored) or needed distraction (e.g. when feeling overwhelmed). Therefore, the BFRB behaviors demonstrate an external solution to regulating internal feeling-states and stress levels. Thus, BFRB’s demonstrate the mind-body connection’s natural (and creatively resourceful) efforts to achieve homeostasis or balance.
If you are a researcher or a student of psychology, much research remains to be done to better understand BFRB behaviors (e.g. the neurobiology behind the urges), thus making it a much-needed area of study.
If your BFRB is interfering with daily activities, causing bodily damage, increasing psychological distress, or is contributing to conditions such as depression, it is time to seek professional help. BFRB’s should be assessed and treated by mental health practitioners who have undergone training to treat BFRB’s. Unfortunately, the current situation in the mental healthcare field is that there is a shortage of clinicians who have been specifically trained to treat BFRB’s. Fortunately, the TLC Foundation has created a directory of therapists with this specific training.
It is important to note, especially to those trying to help their child or teen (or a loved one of any age): It is counterproductive to force or coerce others into changing their BFRB behaviors. (Doing so would only increase the stress the person is likely experiencing, thus worsening the BFRB.) Please watch the following short and inspiring video if you are trying to help someone who has a BFRB, which should help illuminate the experience of the BFRB sufferer:
Although behavioral treatment of BFRB’s can be effective, treatment can and does present challenges, and not all people will get better right away. Some may opt to return to therapy at a later date when they feel ready for change. Since multiple attempts to change these behaviors can be challenging and frustrating to the person with a BFRB, effort should be made by clinicians to minimize “treatment failures” (TLC Foundation, 2017).
Although many people do benefit from taking a medication to help treat a BFRB, medication is not likely to create change unless used in conjunction with behavioral treatment (bfrb.org). According to Jon Grant, MD, “…no drug is currently approved by the Food and Drug Administration for these behaviors, that there is limited research on the use of medications for these behaviors, and that the medications often have side effects” (bfrb.org). The use of medications to treat BFRB’s have had some modest as well as mixed results. For example, stimulants used to treat ADHD tend to increase BFRB behaviors (TLC Foundation, 2017).
Interestingly, all psychodynamic theories about these disorders, including ‘deeper problems’ and trauma, have been discarded, according to Charles Mansueto (TLC Foundation, 2017). Psychodynamic approaches are very unlikely to have any positive effect on the client’s BFRB (TLC Foundation, 2017). A behavioral approach is preferable in general.
Professional help from a mental health care provider who has been specifically trained to treat BFRB’s will probably make the difference between a helpful treatment and one that has little to no impact. It is necessary that the mental health care professional is well-versed in using behavioral science and behavioral interventions. Other therapy models and techniques such as psychodynamic therapy, EMDR, and many others are not likely to help the BFRB, as they are not specific enough to the person’s unique manifestation of BFRB-related thoughts and behaviors (TLC Foundation, 2017).
Currently, the treatment philosophy of choice for a BFRB is the general branch of psychotherapy known as cognitive behavioral therapy (CBT). More specifically, the current treatment of choice is a model known as the Comprehensive Behavioral Model (ComB). Essentially, ComB (Mansueto et al., 2000) uses an antecedent-behavior-consequence framework (also known to behavior therapists as “ABC”) to assess and intervene with the following:
★Sensory: Visual and tactile cues and urges (e.g. feeling a thick or knotted hair with one’s fingertips)
★Cognitive: “Triggering” and facilitative thoughts that enable the behavior (e.g. displeasure with appearance, rationalizations like “I’ll just pull one”)
★Affective/emotional states: The behavior can be associated with current mood. Many people perform the BFRB when feeling stressed or bored.
★Motor habit awareness: This concerns whether the person performs the BFRB automatically (e.g. without even being aware they are doing it), with focused and intentional awareness (e.g. concerted efforts to pluck out all visible gray hairs), or with a combination of both.
★Environmental factors: The influence of time of day, locations, activities, presence of certain people, and availability of implements on the BFRB. For example, many people perform their BFRB while driving, reading, or working on a computer.
The huge advantage to the ComB model is that the treatment strategies are both highly individualized and highly specific. There is no “one size fits all” treatment, and it is not a ‘cookbook’ or protocol (step-by-step) approach. ComB is a practical and transparent model, and a large part of the therapy will involve monitoring what works and what does not, and making appropriate changes. Sometimes supporting sensory tools are used, such as a Koosh Ball, to provide needed tactile stimulation (e.g. rolling the “hair” on the Koosh Ball rather than rolling one’s actual hair, which has for that individual usually leads to pulling). Granted, due to human differences, using a Koosh Ball will not be helpful for everyone (TLC Foundation, 2017).
Some behavioral healthcare providers still use or incorporate Habit Reversal Training (HRT) , which can certainly be helpful in treatment, although using HRT alone might not be sufficient (TLC Foundation, 2017). Interestingly, HRT has most formal empirical support for the treatment of BFRB’s, yet, the American Psychological Association currently classifies HRT as “probably efficacious” (TLC Foundation, 2017). Briefly, the essence of HRT is increasing awareness of the undesirable behavior and performing a new behavior that is not compatible with the undesirable behavior (TLC Foundation, 2017). For example, in HRT, the client/patient may be trained to clench their fists and hold their hands away from the body every time they catch themselves beginning the BFRB behavior – a response not compatible with pulling (or picking, etc.).
Although treatment can take much motivation and won’t necessarily be easy, fortunately treatment can be successfully supported with existing therapies, including mindfulness and awareness training, DBT, ACT, and self-compassion training, each of which can help treatments be more helpful. People of all ages have been successfully treated (TLC Foundation, 2017). While full abstinence is sometimes reported (TLC Foundation, 2017), there is no known cure or method that will always be effective (TLC Foundation, 2017).
Despite the lack of a universally effective treatment, it is essential to find a practitioner who has been specifically trained to treat BFRB’s and has current knowledge about them.
The TLC Learning Center has a wealth of information on BFRB’s, including a nationwide (USA) list of practitioners who are experienced in treating BFRB’s. Support groups can be very helpful in addition to therapy. There are also international conferences on BFRB’s that both sufferers and/or clinicians can attend. The TLC Learning Center includes a wealth of information on all of these, and much more.
American Psychiatric Association, & American Psychiatric Association. (2000). DSM-IV-TR: Diagnostic and statistical manual of mental disorders, text revision. Washington, DC: American Psychiatric Association, 75.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
Body-focused repetitive behavior. (last modified January 29, 2017). Retrieved from https://en.wikipedia.org/wiki/Body-focused_repetitive_behavior
Grant, J.E. (n.d.). Medications for Body-Focused Repetitive Behaviors.
Mansueto, C. S., Golomb, R. G., Thomas, A. M., & Stemberger, R. M. T. (2000). A comprehensive model for behavioral treatment of trichotillomania.Cognitive and Behavioral Practice, 6(1), 23-43.
Mansueto, C., Reinardy, R., & Welch, S.S. (February 17-19, 2017) The TLC Foundation for Body-Focused Repetitive Behaviors. Professional Training Institute (series of lectures)
Nail Biting (Onychophagia). (n.d.). Retrieved from http://www.bfrb.org/learn-about-bfrbs/nail-biting
Penzel, F. (1997). A Stimulus Regulation Model of Trichotillomania. Retrieved from https://www.bfrb.org/component/content/article/3/102
Stein, D. J., Flessner, C. A., Franklin, M., Keuthen, N. J., Lochner, C., & Woods, D. W. (2008). Is trichotillomania a stereotypic movement disorder? An analysis of body-focused repetitive behaviors in people with hair-pulling. Annals of Clinical Psychiatry, 20(4), 194-198.
What is Trichotillomania? (n.d.). Retrieved from http://www.bfrb.org/learn-about-bfrbs/trichotillomania