Body-Focused Repetitive Behaviors

What Are BFRBs?

Body-focused repetitive behaviors, or BFRBs, are an interrelated set of disorders categorized by “self-grooming” routines that include pulling, picking, biting, or scraping one's hair, skin, or nails. The prevalence of BFRBs is estimated to be at least 3 percent of the population, affecting both children and adults.

BFRBs—which include trichotillomania (compulsive hair pulling), dermatillomania (compulsive skin picking, also called excoriation disorder), and onychophagia (compulsive nail biting)—have been theorized to be related to anxiety disorders, impulse control disorders, and obsessive compulsive disorder. But most experts agree that they differ significantly from all three. Certain BFRBs are currently categorized as “impulse disorders” in the DSM-5.

Regardless of how the behaviors are categorized, they are difficult for individuals to control, and can result in physical injury like scarring, skin infections, or bald spots. They frequently cause extreme emotional distress, particularly if the disorder is undiagnosed or kept secret. BFRBs may also, unfortunately, resist treatment, and can even impair someone's ability to socialize or function at work.

Why Do I Pull My Hair or Pick at My Skin?

The question of why individuals engage in BFRBs has long challenged psychologists, particularly because most individuals report more than one trigger. 

Many people report picking or pulling when they’re anxious, for instance—often finding that engaging in these behaviors provides temporary relief. This has led some to theorize that the behaviors may be related to anxiety disorders.

But others report that they pick, pull, or scratch without noticing, or while engrossed in another activity like reading or watching TV. This subtype has been viewed as more closely related to people living with impulse control challenges like eating disorders or substance abuse.

A better understanding of the disorders' roots is critical for adequate treatment—especially because someone who pulls due to anxiety may require different treatment than someone who picks when bored.

How to Manage Hair-Pulling and Skin-Picking

Treatment recommendations for BFRBs include cognitive behavioral therapy, medication, and select supplements—most notably N-acetylcysteine, an amino acid. While for some, these options are highly effective, overall, they have a long-term success rate of less than 20 percent. 

The low rate of success is likely due to the small amount of research that's been conducted on the disorders. However, a precision medicine initiative recently launched by The TLC Foundation for Body-Focused Repetitive Behaviors is the largest effort yet to understand the neurobiology of BFRBs and find more effective treatments.

In the meantime, self-help strategies may also provide relief. These include: using an object to occupy the hands during times when pulling or picking often occurs; wearing gloves or mittens to make picking or pulling harder; and joining a support group to connect with others with BFRBs.

Find a therapist who specializes in body-focused repetitive behaviors.

Why BFRBs Can Be So Shameful

Although BFRBs affect millions, they are not well-understood and are rarely portrayed in media. As a result, the behaviors are often seen as little more than “bad habits” that could be stopped using willpower. 

Because of this misconception, many who live with BFRBs report debilitating shame surrounding the disorder. They may beat themselves up for their seeming inability to stop, or go to great lengths to hide the evidence of their hair pulling or skin picking—often using wigs or makeup, or refusing to let people see the parts of their body where they pick or pull. The intense shame can interfere with relationships, intimacy, and daily functioning. 

While sharing these feelings with a loved one or therapist can be extremely helpful, many with BFRBs find comfort simply in learning that they are not alone. For this reason, support groups and online resources can be especially useful in reducing the shame of living with BRFBs.


Embarrassment, Habit Formation

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