By: Casey Clark
Writer, content Strategist, and BFRB Advocate
You may know someone that bites their nails, pulls their hair, or even picks their skin. All of these behaviors fall under a mental health category known as Body-Focused Repetitive Behaviors (BFRBs).
"Body-Focused Repetitive Behaviors (BFRBs) include any repetitive self-grooming behavior that involves biting, pulling, picking, or scraping one’s own hair, skin, or nails that results in damage to the body and have been met with multiple attempts to stop or decrease the behavior and cause notable distress or impairment to the individual’s daily functioning and is not better accounted for by a medical condition, substance use, or other psychiatric disorder," says Dr. Marla Deibler, PsyD, licensed clinical psychologist and executive director at The Center for Emotional Health.
Ahead, we've broken down information on Body-Focused Repetitive Behaviors from types and causes to treatments and professional insights.
What are BFRBs?
As mentioned above, Body-Focused Repetitive Behaviors are self-grooming behaviors that result in unintentional harm to the body. The most common types of BFRBs include hair pulling (trichotillomania), skin picking (dermatillomania), nail biting (onychophagia), and cheek biting (morsicatio buccarum.)
For people who deal with BFRBs, there usually have been multiple attempts at stopping the behavior with little to no success. In many cases, people who engage in BFRBs also find them to be pleasurable in some regard, otherwise they probably wouldn't do it.
When speaking of Body-Focused Repetitive Behaviors, they generally fall into two categories: automatic and focused.
Automatic refers to the behavior being engaged in on an impulse, is more trance-like or habitual in nature. Many people don't realize they are engaging in the behavior while it's taking place and it usually occurs in frequent, short bursts.
Focused BFRBs involve intentionality or purpose. For example, one may stand in front of a mirror and look at the different hairs to see which one looks like it needs to come out.
What Are The Causes of BFRBs?
There is not one singular cause for BFRBs, however, a few different factors that may come into play. BFRBs may have genetic, hormonal, environmental and stress-related origins.
Are BFRBs Genetic?
If you find yourself with a BFRB, then it may be because you are genetically predisposed. Research has shown that some people may have an inherited predisposition for skin picking or hair pulling. Additionally, those with BFRBs may find that some family members also engage in body focused repetitive behaviors too.
Are BFRBs caused by Stress?
The answer here is maybe. For many individuals, BFRBs are self-soothing and could have been developed during a period of high stress whether that was a negative event, traumatic incident or work-related anxiety. "The emotion regulation model of BFRBs suggests these behaviors serve as a mechanism for immediate emotional self-regulation, initially providing relief but ultimately leading to negative emotions such as frustration, anger, sadness, and anxiety that perpetuate the behavior chain," says Dr. Deibler.
How does the Environment affect BFRB urges?
According to Dr. Deibler, it is widely believed that BFRBs are a neurobiological set of behaviors that involve both biological and environmental factors. "High stress environments or major life changes, such as moving, changing schools, or experiencing trauma, have the potential to act as environmental stressors that lead to or exacerbate BFRBs for those who are biologically vulnerable to the disorder," she says.
Do Hormonal Changes impact BFRBS?
At this time, there isn’t enough research about the link between hormones and BFRB onset. Anecdotally, we do see onset during adolescence (puberty) and another peak in 30s/40s, which potentially aligns with menopause.
What Are The Types of BFRBs?
There is no one-size-fits all when it comes to types of BFRBs, however, there are a few common ones that people tend to experience.
Trichotillomania
Trichotillomania, also known as hair pulling, is one of the most common BFRBs. This could include pulling hair out of one's scalp, eyelashes, eyebrows, and anywhere else on the body where hair grows. According to the Anxiety & Depression Association of America (ADAA), approximately 1 to 2% of people in the United States have Trichotillomania and ADAA also reports that “although women more frequently self-identify as having Trichotillomania than men, at a ratio of 10:1, (DSM-5-TR) there is likely no significant gender difference.”
Dermatillomania
Dermatillomania, also known as skin picking, is another Body Focused Repetitive Behavior that one may experience. Those who have Dermatillomania generally can't stop picking at their skin and in many cases do so to the point where it bleeds. Dermatillomania affects between 1.4 and 5.4% of American adults.
Onychophagia
You probably know someone who bites their nails or have seen someone do it while at work or in school. Onychophagia, or nail biting, is another type of BFRB that affects more than 30% of the population. Common triggers for nail biting include stress and boredom while for others it's simply a habit.
Morsicatio Buccarum
Morsicatio buccarum, also known as cheek chewing, refers to the action of one biting the insides of their cheeks. Individuals may engage in this behavior with the intention of creating a smooth inner lining, however, others may do it so much they develop sores and cuts. It's more common in females and a 2013 study found that 750 in 1 million people might have the condition.
What Treatment Options Exist for BFRBs?
Seeing a mental health treatment professional is also a recommended course of action for those individuals with BFRBs. There are various treatment options to help individuals treat BFRBs and manage their related symptoms. The existing treatments focus on the physiological / physical behaviors. For decades, treatment for Body-Focused Repetitive Behaviors was treated almost exclusively with Cognitive Behavioral Therapy, which has led to mixed results, including persistent relapses. Currently, researchers and clinicians are looking at the efficacy of more integrative approaches.
Comprehensive Behavioral Model
The Comprehensive Behavioral Model (ComB) for BFRBs focuses on identifying and modifying different domains that maintain the repetitive behavior:
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Sensory – Similar to SCAMP, this refers to the physical sensation aspect.
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Cognitive – Thoughts that fuel the behavior.
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Affective – Emotional states that lead to engagement in the behavior.
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Motor – The physical execution of the behavior.
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Place – The environmental settings where the behavior occurs.
The SCAMP/ComB models can be used at the jump to help clinicians help clients modify their environment so individuals are more likely to manage the urge to engage in BFRBs. This helps more in terms of symptom management as opposed to determine the underlying triggers causing the behavior in the first place.
Habit Reversal Training
Habit Reversal Training (HRT) is another evidence-based and research-backed first line of treatment for most BFRBs.
Habit Reversal Training is a 3-step practice of undoing - or reversing - unwanted behaviors:
Step 1 is called Awareness Training and focuses on learning to become aware of the BFRB. For individuals with trichotillomania and dermatillomania, there are wearable devices that can help one increase self-awareness of their triggers and track patterns to see when they are most prone to engage in the behavior.
Step 2 is called Competing Response Training and is about learning to do healthier behaviors that compete with the Body-Focused Repetitive Behavior, and
Step 3 is Support Training and leverages ongoing support and encouragement as an integral part of the Habit Reversal Training process.
Integrative BFRB Treatment Approaches
Two common therapy modalities used in the treatment of Body-Focused Repetitive Behaviors are Acceptance and Commitment Therapy (ACT) and Dialectical Behavioral Therapy (DBT).
"Acceptance and Commitment Therapy (ACT) helps improve treatment outcomes for BFRBs by focusing on logical behavior change strategies such as trigger reduction and habit reversal, while also incorporating acceptance, mindfulness, and values-based skills. Our hope is that the ACT skills help individual with BFRBs side-step the urges or related thought about picking or pulling. ACT can also be helpful in creating strong motivation to do hard work in therapy," shared Dr. Michael Twohig, a leading BFRB clinician and one of the researchers pioneering the integration of ACT into traditional HRT treatment models.
As for DBT, Dr. Laura Chackes, Psy.D, licensed psychologist and owner of The Center for Mindfulness & CBT, says the mindfulness component of DBT can be extremely helpful for those with body-focused repetitive behaviors.
"It is the core of my treatment approach because in order to recover from a BFRB, you first have to become aware of when you're doing it," Chackes says. "With practice you learn to pause when you notice you're doing the behavior, or better yet, right before you start, so that you can intervene by meeting the need in another way. For instance, if you've become aware that you tend to pick when you're feeling anxious and that you feel your anxiety building by feeling a tightening sensation in your chest, then as soon as you notice that sensation, you can choose to use a strategy to help manage your anxiety before you start engaging."
Aside from helping individuals manage the physical component of BFRBs, therapy can also be helpful in learning ways to cope with the psychosocial components that tend to accompany the condition including low self esteem, anxiety, and depression. If you're a mental health professional reading this, then you may want to consider signing up for the BFRB Changemakers CE Training Academy which offers continuing education about BFRBs and how to improve outcomes for patients with BFRBs.
About the Author:
Casey Clark is a writer and content strategist from New York City who specializes in mental health, beauty and travel. Her work has appeared in The Wall Street Journal, HuffPost, National Geographic, Daily Beast and more.
