Habitual Behavior or BFRB Disorder?

Recognizing when habitual behaviors become problematic

Posted May 07, 2018

by Emily Ricketts, Ph.D.

At some point in time nearly everyone engages in behaviors such as biting their nails, chewing on their cheeks or lips, twirling their hair, and even picking their nose. Such behaviors, however, may become more habitual for some than others, with varying consequences. Habitual behaviors like these may result in minimal to no impairment or may occur in a problematic pattern consistent with a mental health disorder.

The TLC Foundation for BFRBs/Abby Mahler
Source: The TLC Foundation for BFRBs/Abby Mahler

Body-focused repetitive behaviors, or BFRBs, are not habits in the casual sense of the word. Nevertheless, the science of habit formation may still be relevant to the study of how BFRBs develop and persist over time. In “The Power of Habit” by Charles Duhigg, a journalist and author, he describes habit formation as a three-stage process involving a cue which triggers a given routine (i.e., a particular automatic behavioral, emotional or mental response). This routine is followed by a reward, which may increase the likelihood that this behavior occurs in the future (Duhigg, 2012). The role of habit formation in mental health conditions has been a growing area of interest in recent years. There is much debate in science as to how to precisely define habit. However, there is some consensus that habits emerge through the strengthening of associations between environmental cues and actions in stable contexts through reward. This leads to the automatic occurrence of the behavior with minimal thought, awareness or attention required (Lally, van Jaarsveld, Potts, & Wardle, 2010; Wood, Quinn, & Kashy, 2002). Doing certain things automatically (e.g., driving, riding a bike, etc.) is very helpful in a variety of contexts as it reduces the amount of mental resources needed to complete actions freeing up resources to engage in multi-tasking. However, because habit learning is based on actions that were previously rewarded in stable contexts, it is not helpful to rely on when aspects of a given situation have changed (Gillan, Robbins, Sahakian, van den Heuvel, & Wingen, 2016). Therefore, in these instances, the brain typically uses a goal-directed system which allows one to weigh the consequences of different choices to decide the choice that will result in a positive outcome (Dezfouli & Balleine, 2013).

Generally, those with Obsessive Compulsive Disorder (Gillan et al., 2011) and milder obsessive-compulsive symptoms have shown an overreliance on habits (Snorrason, Lee, Wit, & Woods, 2016). It is also possible that there are a subset of individuals with body-focused repetitive behaviors who share this overreliance on the habit learning system. Understanding if those with BFRBs differ from the general population with respect to habit learning will help researchers to identify and develop treatments to address symptoms.

Ultimately, body-focused behaviors are considered problematic when they occur repeatedly over time and result in adverse physical, social, and/or emotional consequences. Research shows that 14 to 22% of adults report having at least one body-focused repetitive behavior occurring on a frequent basis and resulting in impairment (Siddiqui, Naeem, Naqvi, & Ahmed, 2012; Teng, Woods, Twohig, & Marcks, 2002) so they are not uncommon when considered broadly. Impairment may include physical damage to one’s skin, tissue, nails, teeth or hair, including bleeding, sores, scabs, infections, hair breakage or thinning. Additionally, these behaviors may result in unwanted comments or teasing from others, or feelings of self-consciousness, embarrassment, shame, anxiety or depression due to difficulty controlling the behavior or the resulting physical damage.

Individuals may go to great lengths to hide the physical damage by wearing certain clothing (e.g., long sleeves, pants, hats, scarves) or following elaborate and lengthy make-up routines. Some individuals may also make repeated visits to the dermatologist or dentist to address the physical damage. This may result in only short-term improvement for some as the source of the physical damage persists. Individuals may also find themselves avoiding certain recreational activities like swimming or sports and shying away from close relationships with others or intimacy for fear of others finding out about their behaviors. Further, some individuals with BFRBs report zoning out and losing track of time while engaged in these behaviors. Individuals may engage in BFRBs at inconvenient times, for example, when engaged in tasks at one’s job, school, or home, resulting in difficulty concentrating and loss of productivity. Despite these consequences, individuals who have body-focused repetitive behavior disorders will have difficulty decreasing or permanently discontinuing the behaviors despite repeated efforts to do so (Bohne, Keuthen, & Wilhem, 2005).

Making the distinction between harmless behavior and disorder is important for ensuring individuals obtain access to appropriate treatment when needed. If you believe you or someone you know may have a body-focused repetitive behavior disorder it is important to see a trained doctor or clinician for a thorough evaluation of symptoms. Oftentimes people do not realize all the sneaky ways in which body-focused repetitive behaviors interfere in their lives. A health professional will work with individuals to help them identify the degree to which these behaviors cause problems. Treatments based on principles of cognitive behavioral therapy are the most well-tested and have been shown to be helpful. However, there is still a lack of therapists trained in treatment for BFRBs. For a list of treatment providers, be sure to view The TLC Foundation for Body-Focused Repetitive Behaviors Online Directory (http://bfrb.org/find-help-support/find-a-therapist).

Source: Ricketts

Emily Ricketts, Ph.D. is a Clinical Specialist in the Division of Child and Adolescent Psychiatry at University of California, Los Angeles. She works in the Child OCD, Anxiety, and Tic Disorders Program in the Semel Institute for Neuroscience and Human Behavior. She also serves as Project Manager for the TLC Foundation for Body-Focused Repetitive Behaviors’ BFRB Precision Medicine Initiative. Her research and clinical interests center on the understanding and treatment of sleep and circadian disturbance in children and adults with tic disorders, and obsessive-compulsive spectrum disorders, including hair pulling (trichotillomania) disorder and skin picking (excoriation) disorder.


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