Body-Focused Repetitive Behaviors

What Are BFRBs?

Body-focused repetitive behaviors, or BFRBs, are an interrelated set of disorders categorized by “self-grooming” behaviors that include pulling, picking, biting, or scraping one's hair, skin, or nails. Though 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, most experts agree that they differ significantly from all three. Though certain BFRBs are currently categorized as “impulse disorders” in the DSM-V, debate remains as to whether these grooming behaviors are undertaken impulsively or compulsively.

Regardless of how the behaviors are categorized, they are difficult for individuals with BFRBs to control, and can result in physical injury like scarring, skin infections, or bald spots. They also frequently cause serious emotional distress and high levels of shame for the afflicted person—particularly if the disorder is undiagnosed or kept secret. While many people think of hair pulling, skin picking, or nail biting as merely "bad habits" that can be controlled with effort, many people with BFRBs find that the behaviors defy explanation and resist treatment, and may even impair their ability to socialize or function occupationally.

The prevalence of BFRBs is estimated to be at least 3 percent of the population, affecting both children and adults, but current treatment strategies have a long-term success rate of less than 20 percent. Treatment recommendations presently include cognitive behavioral therapymedication, and select supplements, but their low rate of success is likely due to the fact that almost no large-scale studies have been conducted on the disorders or their ideal treatment methods.

precision medicine initiative, launched by The TLC Foundation for Body-Focused Repetitive Behaviors (formally the Trichotillomania Learning Center), is currently underway, and is the largest effort ever attempted to better understand the genetics and neurobiology of these disorders. Ideally, researchers hope to determine more effective treatments; one goal of the initiative, its director says, is to identify distinct subtypes of both skin pickers and hair pullers so as to offer tailored treatments, specifically formulated for each person’s unique symptoms and picking (or pulling) patterns.

Misconceptions and an Emerging Consensus

The question of how to classify individuals who engage in body-focused repetitive behaviors has long challenged psychologists. Many people with BFRBs report picking or pulling when they’re anxious—often finding that engaging in these behaviors provides temporary relief—leading 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. Further, one person may pick and pull for multiple different reasons. A better understanding of BFRBs is critical for adequate treatment: Someone who pulls due to anxiety may require different treatment than someone who picks when bored.

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