Body-focused repetitive behaviors (BFRBs)

Body-focused repetitive behaviors (BFRBs) refer to a group of related disorders that include compulsive hair pulling, skin picking and nail biting. BFRBs involve repetitive touching one’s hair or body, resulting in physical damage. For a diagnosis to be made there are repeated attempts to decrease or stop the behavior and the behavior must cause distress or impairment in one or more aspects of life, such as social, occupational or academic. BFRBs affect millions of people in the US alone. These disorders are complex and are not just habits or tics.

Trichotillomania

Also known as compulsive hair pulling, this disorder is characterized by the repetitive pulling out of one’s hair. Those struggling with this disorder pull out the hair from their head, eyelashes, eyebrows, and other parts of the body. Common experiences leading to pulling include unpleasant emotions, a physical tension or urge or an attempt to fix an area that is asymmetrical or “not right” in some way.

Compulsive hair pulling can become a coping mechanism to reduce or control unwanted emotions or other uncomfortable internal experiences.

Following a pulling session which can last for an extended period of time, sufferers may experience a sense of relief or pleasure, a reduction in the urge to pull as well as regret, embarrassment or shame. Those struggling can engage in the behavior can be fully aware of what they are doing or in a trance like state, unaware of the damage they may be causing. Depending on the severity of the disorder those struggling may attempt to camouflage the affected areas.

Excoriation Disorder

Also known as compulsive skin picking and dermatillomania, this disorder is characterized by recurrent picking of the skin, which often causes lesions, discoloration or scarring. Common experiences leading to picking include unpleasant emotions, a physical tension or urge or an attempt to fix perceived skin imperfections. Compulsive skin picking can become a coping mechanism to reduce or control a variety of unwanted emotions and other uncomfortable internal experiences.

Following a picking session sufferers may experience a sense of relief or pleasure, a reduction in the urge to pick as well as regret, embarrassment or shame. Those struggling can engage in the behavior fully aware of what they are doing and also while in a trance-like state unaware of the damage they may be causing. Depending on the severity of the disorder those struggling may attempt to camouflage affected skin with make-up or clothes.

Treatment

Cognitive Therapy – Clients learn to identify unhelpful, distorted thoughts that lead to pulling or picking and restructure them to be more rational and reasonable.

Comprehensive Behavioral Treatment (ComB) – This approach begins with a structured, in-depth assessment to identify the unique pattern of sensory (sensations), cognitive (thoughts), affective (feelings), motor (movements), and place (environmental) factors or domains that trigger and maintain the BFRB.

Following the assessment the therapist and client develop an individual treatment plan with the goal of providing self-management techniques matched to the individual’s needs which allows for the client to have more control over their problem. The program is designed to interrupt problem behaviors and to provide effective alternative ways to help address the habits, emotions, thoughts and beliefs that drive individuals to damage their hair or skin.

Habit Reversal Training (HRT) – A behavioral intervention for BFRBs involving several components, including building awareness of one’s urges to pick or pull, identifying situations, places and activities that trigger the behavior and developing a competing response one can use in place of the BFRB.

Common competing responses are using fidgets or touch toys that are interesting or soothing to touch like silly putty or cush balls. Rather than pick or pull, clients can learn to get creative using their hands by doing art work, learning how to knit, crochet, embroidery, sew, make jewelry or play a musical instrument.

With practice and discovery of what competing responses work best, clients begin to feel more in control and have more choice as to how to respond when an urge arises. When competing responses are used consistently, the urges to pull or pick lessen and they begin to feel the freedom that comes with recovery.

Mindfulness Training – Increases awareness of thoughts, feelings, sensations and urges that lead to skin picking or hair pulling. Clients learn how to tolerate uncomfortable urges by “riding the wave of discomfort” without engaging in the BFRB.

Acceptance and Commitment Therapy (ACT) – A treatment approach using mindfulness tools to manage uncomfortable urges along with a focus on taking action on activities one finds meaningful or important without giving in to the urge to pick or pull.