What are body-focused repetitive behaviors?
Body-focused repetitive behaviors (BFRBs) are difficult to control and characterized by strong, repetitive, and impulsive urges to manipulate one’s own body.
Examples of BFRBs include:
- Hair pulling
- Skin picking
- Nail biting
- Nail picking
- Lip/cheek/tongue biting
Two of these have distinct diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychological Association, 2013): hair-pulling disorder, also known as trichotillomania, and skin-picking disorder, also known as excoriation disorder.
While many people engage in these behaviors from time to time, they become a more serious mental health challenge when they:
- Are excessive to the point of causing bodily harm
- Interfere with daily life
- Cause significant distress
There are two “styles” of engaging in BFRBs. People may do one or both:
Automatic style: The behavior happens without a person’s conscious awareness. For example, someone may begin pulling their hair when they watch TV or in other settings without even realizing they’re doing it because they’re paying attention to the show or whatever else is going on.
Focused style: The behavior is intentional and may involve preparation. For example, someone may gather tweezers, wash their face, and sit in front of a mirror before beginning to skin pick.
Whether engaging in one or both styles, each person may handle the results of their behavior in a unique way. For example, with hair pulling, some people will quickly dispose of the hairs, while others may play with them, eat the hair or hair root, or chew on the hair or hair root.
How common are BFRBs?
In one study, about 59% of participants reported occasionally engaging in one of the body-focused repetitive behaviors.
Researchers have also found that about 24% of people may be experiencing a BFRB disorder, with skin-picking disorder affecting about 8%.
What causes BFRBs?
Just like with any other mental health challenge, a combination of factors contributes to BFRBs, including biological, environmental, and psychological. Many people who experience BFRBs also have an OCD diagnosis, and some have suggested they have similar genetic causes. More research is needed to gain a clearer understanding of why some people experience serious BFRBs.
What are common myths?
Three popular myths are:
- People can “just stop it.” As with any mental health challenge, it’s not that simple. People need the help of a mental health professional who is knowledgeable about BFRBs and can provide coping tools and strategies.
- BFRBs are untreatable. Some people think there’s no way to stop the behaviors because, in the past, our knowledge was limited. With more research focused on BFRBs, we’re learning better ways to help.
- People with BFRBs are “weird.” Most people will engage in some kind of BFRB at some point in their lifetime. People with BFRB disorders experience the urge to engage in it more, leading to increased severity. Many people who experience BFRBs have a lot of shame. It’s important to fight stigma around these behaviors so they feel more comfortable reaching out for help.
How do they impact a person’s life?
BFRBs impact a person physically and emotionally. The most obvious impact is physical. For example, severe skin-picking can lead to scarring or frequent infections. The emotional toll, though unseen, can be just as significant. As the behavior worsens, feelings of shame often intensify. Some don’t leave their homes so that others won’t see the physical effects. This isolation increases the emotional distress, creating a cycle of shame and loneliness.
How can BFRB treatment help?
While we’re still not sure what causes BFRBs, we’ve learned more about why people continue to engage in these behaviors. Factors include how they think, how they feel emotionally and physically, and what’s happening in their environment.
We treat BFRBs by looking at why each person engages in the behavior. If it’s about sensory stimulation, we support them in finding an alternative behavior that gives the same feeling without causing harm. For others, BFRBs might be a way to cope with difficult emotions. For example, if they’re feeling stressed, they might engage in BFRBs to “zone out” and reduce stress. We might help with this by teaching skills or strategies to manage or tolerate their stress. For others, the behavior is automatic. We focus on strategies that help them become aware of when it’s happening so they can choose to stop or switch to a different action. Addressing all of these factors is key to helping people struggling with BFRBs.
By Johanna Wood, PhD, clinical supervisor, OCD, Anxiety, and Depression Residential Care for adults at Rogers Behavioral Health
Rogers provides mental health treatment
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