Body-focused repetitive behaviors (BFRBs) are continuously engaged in behaviors like hair pulling, nail or lip biting, cheek biting, and skin picking that can cause physical damage and scarring. These behaviors are often accompanied by many attempts to stop. Treatments for BFRB disorders include therapy and medication.1
What Are Body-Focused Repetitive Behaviors?
Body-focused repetitive behaviors disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as “Recurrent body-focused repetitive behaviors and repeated attempts to decrease or stop the behaviors.” These behaviors may result in significant issues (physically, emotionally, and cognitively) that impact one’s ability to meet their needs.
The TLC Foundation for BFRBs identified that BFRBs tend to impact at least 5% of the general population.1,2 While the cause is complex, BFRBs are not preceded by obsessions or intrusive thoughts like obsessive-compulsive disorder (OCD) is. In some cases, BFRBs are preceded by certain emotions that may be relieved or turned into a sense of pleasure by engaging in this behavior.2,1
Although there is limited research, there has also been discussion surrounding the role of attention deficit/hyperactivity disorder (ADHD) with BFRBs. Researchers found that, in adolescents, an initial diagnosis of ADHD was observed with significantly higher reports of BFRBs occurrences, types, and severity. They noted that individuals with ADHD, especially if experiencing increased mental health concerns, may be at increased risk for BFRBs.3
8 Common Types of BFRBS
Individuals who struggle with BFRBs may experience different types, especially if they experience other mental health issues or substance use disorder.4 BFRBs range from evidence-based disorders to general disorders that fall under the umbrella of compulsion-related disorders. For example, hair pulling (trichotillomania) and skin picking (excoriation) are separate disorders, but both are considered BFRBs.
Types of body-focused repetitive behaviors include:
- Skin picking disorder (excoriation): this more common BFRB disorder is observed in people who continually pick, scratch, touch, rub, and/or dig into their skin to the point of scarring, discoloration, or even tissue damage. Studies have found that between 2% to 5% of people were observed to experience these symptoms, specifically to the extent of tissue damage; 75% of these people were females.1,5,6,7,8
- Hair pulling disorder (trichotillomania): this BFRB disorder is observed when people continually pull hair from different areas (e.g., eyelashes, eyebrows, scalp, arms, legs, etc.) causing short-term and long-term hair loss. Trichotillomania generally starts around age 12 and about one to two in 50 people experience this BFRB.1,5,8
- Hair eating disorder (trichophagia): this less common BFRB (5% to 15% of people) is seen in people who eat their hair. This life-threatening issue can cause physical health issues, such as hairballs that form in the bowel or stomach.1,5
- Nail biting disorder (onychophagia): this more common BFRB is observed when people bite their nails (toe or finger) past the quick (the nail bed) or chew their cuticles or hangnails, which can lead to infection, significant pain, and even permanent nail or skin damage. This behavior often begins at a young age. Studies indicate that 20% to 30% of people experience this.1,5,8
- Nail picking disorder (onychotillomania): this BFRB is observed when people pick and manicure their nails so continuously that they destroy the nail and potentially impact the nail bed. Although studies on this topic are less common, people who engage in nail biting may engage in nail picking as well.1,8
- Cheek biting disorder (morsciation buccarum): this BFRB is observed when people continuously chew or bite the inside of their mouth. This can result in sores, sensitivity, and even scarring of the inner lining of people’s mouths. It can also perpetuate continued behaviors to reduce the irregularities inside the mouth. Research indicates that cheek biting occurs in about 3% of people and often starts in childhood.1
- Compulsive nose picking (rhinotillexomania): this BFRB is observed in people who continuously pick at their nose, sometimes even eating the results, to the extent that they cause permanent damage or scarring inside their nostrils. Research has found that nose picking is common when one is not harming their nose, which differentiates this BFRB from common nose picking.6,7
- Skin eating disorder (dermatophagia): this less common BFRB is observed when people bite their cuticles (akin to nail-biting), fingers, lips, or tongues, and ultimately eat the skin or scabs from the biting. This BFRB is less well-known, but it can impair healing from other BFRB behaviors.1
Causes of Body-Focused Repetitive Behavior
At first look, BFRBs may seem like simple bad habits, but they’re much more complex. Part of this complexity can be attributed to limited clarity and research surrounding the cause. Plus, each BFRB is different. Although research is limited, causes have been linked with genetics, family history (especially substance use), feelings of anxiety, tension, and boredom, and lack of emotional regulation.1,4,9,10,11,12
Coping With the Stigma of BFRBs
Individuals who experience body-focused repetitive behaviors and related disorders experience many impacts, including stigma, physical scarring, emotional dysregulation, low self-esteem or anxiety, difficulty connecting with others at work or school, and feelings of isolation and shame.1,2,4,8
Multiple studies observed that shame is a significant and influential emotion with BFRBs, as well as self-criticism.11,12,13 Because these feelings and thought processes can become so ingrained, it is important to know how to handle the stigma and cope with shame.
Creating and sustaining connections with support systems (i.e., trusted family and friends) and connecting with a mental health professional can help decrease loneliness and increase trust.1,8,13 Education about the experience and risks of BFRBs is also important.
Treatments For Body-Focused Repetitive Behaviors
Multiple resources and organizations note the importance of seeking mental health treatment, regardless of if the behaviors just started or you have been engaging in them for years. Most research suggests cognitive behavioral therapy (CBT) and treatments that fall under the CBT umbrella.1,5,8,9
CBT
CBT primarily focuses on being able to identify and challenge unhealthy thoughts, emotions, and behaviors. It helps the client become more self-aware, especially about triggers that influence BFRBs.1,5,8,9 Habit reversal training (HRT), a kind of CBT created in the 1970s, is the second most studied approach for BFRBs. It primarily focuses on awareness training, competing response training, and social support.
Through these main focuses or sections of treatment, HRT increases awareness of triggers and behaviors, challenges the client to distract with other behaviors opposite from the target, and increases social support systems and awareness for the client to feel they can discuss their struggles. Although HRT alone has not been suggested by studies, research notes its significant short-term helpfulness.1,8,9
Other treatment styles that are being explored include an HRT-enhanced acceptance and commitment therapy (ACT) and an HRT and stimulus control-enhanced version of dialectical behavior therapy (DBT); so far, the latter has only been studied with hair pulling.1
It can be helpful to use an online therapist directory to find a therapist that specializes in CBT or HRT in your area.
Medication
At this time, there are no FDA-approved medications to treat BFRBs and related disorders; however, it isn’t uncommon to be prescribed something to manage feelings of anxiety, depression, or other co-occurring mental health concerns or disorders5 Common prescriptions include selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines.8,9 Medications carry a risk of side effects and you should talk with your doctor about the risk and benefits before starting any medication.
There’s also discussion and research on the use of an amino acid supplement called N-acetylsteine to treat BFRBs. So far, studies observe less than a 20% long-term success rate.1,8 More clinical studies are needed to determine if N-acetylsteine is safe and effective to use for BFRBs.
Final Thoughts
Although you may be experiencing something you feel others cannot understand or relate to, you are not alone. There is no shame in reaching out for support, whether from a trustworthy friend, family member, or mental health professional.
