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Body-Focused Repetitive Behaviors

Skin Picking? Hair Pulling? That’s Just the Beginning

Body-focused repetitive behaviors can be serious. Here's what to do about them.

Key points

  • Body-focused repetitive behaviors include nail-biting, hair pulling, skin picking and many other less familiar but potentially serious habits.
  • The etiology of BFRBs is not fully understood, but it may involve somaticized anxiety.
  • Habit reversal training and comprehensive behavioral treatment can help mitigate or reverse these habits if they become serious.

The other night, I sat down to watch a movie with my 11-year-old daughter. The movie—Titanic, if you’d like to know—was absorbing enough, so it took a while for me to notice a tiny, clicking, nibbling sound in the room, audible during quiet moments. It occurred to me then that my daughter was biting her nails, which I’d never seen her do before. As a parent, I felt an instinct to tell her not to do this to herself; as a psychologist, though, I wanted to understand the behavior a little better.

 The TLC Foundation / CC0
Source: The TLC Foundation / CC0

Nail-biting, it turns out, is one of a large number of similar habits focused on the human body—tiny, potentially self-destructive compulsions that seem to gratify a momentary urge but really only succeed in feeding, and refueling, themselves, and forming little behavioral loops. They’re called body-focused repetitive behaviors, and although they do usually originate in childhood, it’s not just 11-year-old girls who give in to impulses like these: they’re relatively common among teenagers and even adults. BFRBs (according to clinical psychologist and Harvard Medical School instructor Roberto Olivardia, Ph.D.) may originate in boredom or anxiety. They result in various levels of physical injury or disfigurement, like scarring or skin infections (more on that here) and they can cause significant emotional distress as well.

There’s no known permanent cure for BFRBs; the Anxiety & Depression Association of America reports that no medication has yet been approved to treat one. Many of the people who struggle with BFRBs do so for their whole lives. For a start, consider these:

Onychophagia: Commonly known as nail-biting, this BFRB can result in a number of negative consequences (according to an article published in Case Reports in Dentistry): fungal infections in the nail bed, chronic inflammation of the fingers, gum disease, or dental problems such as tiny fractures in the teeth. The origins of nail-biting are associated with anxiety, although as of 2016, no clear causal relationship had been found between the two.

Trichotillomania: You’ve likely seen someone on the subway, or another student sitting in class, habitually selecting a strand of hair and twisting or contorting it—or even repeatedly pulling one out. Trichotillomania is not restricted to the scalp, either: some people pull out their facial hair (including eyebrows and eyelashes), arm or leg hair, or even pubic hair. The Anxiety and Depression Association of America indicates that trichotillomania afflicts up to one out of every twenty-five people. It can result in chronic, embarrassing bald patches, infections at the root of the hair, or even permanent hair loss. As noted in a 2012 article in Psychiatry Research, the habit may be connected to other well-known disorders such as those on the obsessive-compulsive spectrum, or others related to impulse control.

Dermatillomania: Also referred to as excoriation disorder, this describes the habit of chronically, repetitively picking at the skin. People who do this often scratch themselves, peel away scabs, or just repeatedly touch or rub certain areas of their skin. According to the Anxiety and Depression Association of America, up to five percent of the American population (75 percent of whom are female) has the habit of picking their skin to the point of noticeable tissue damage.

In addition to these, a number of other, related BFRBs have been noted. They may sound unusual, but the people suffering from these disorders are likely to try to hide them, so they could be more common than you think. Here are a few:

  • Dermatophagia: Biting or eating the skin, or the scabs of healing scratches or scrapes
  • Linguarum: Biting the tongue
  • Morsicatio buccarum: Biting the flesh inside the mouth
  • Morsicatio labiorum: Biting the (inner) lip
  • Onchyotillomania: Picking skin from around the fingernails and toenails
  • Rhinotillexomania: Picking the nose (often enough to cause problems)
  • Trichophagia: Eating head hair. (This is observed in about 20 percent of people who pull out their hair.)
  • Trichodaganomania: Biting the hair on other parts of the body
  • Trichotemnomania: Having a strong urge to remove hair from the body

No matter which of the BFRBs you may suffer from, you’ll know it’s a problem if you’ve made repeated, unsuccessful attempts to stop. If this is your experience, please know that it’s possible to make progress against these seemingly minor but potentially life-affecting afflictions. The primary rule for making changes in your own behavior is to notice yourself doing it. Pay attention to what it feels like, and to the thoughts that go through your mind when you feel the urge to act out a BFRB. If your BFRB is oriented toward biting or chewing, you may want to consider finding ways to keep your mouth occupied. Chewing gum or sucking on mints or candy may work well as distractions. Some people prefer to crack sunflower seeds with their teeth or gnaw on raw pieces of pasta.

As with other anxiety-related behaviors, BFRBs can be associated with thoughts or feelings that you might be trying to suppress or avoid. Psychotherapy (of the psychodynamic variety) may be a good choice if you think this might describe you.

If your BFRB is hard to eliminate, or has begun to cause serious problems, you may want to seek out habit reversal training. As described by Roberto Olivardia, Ph.D., this type of therapy involves three main components: increasing your awareness of the behavior (including anything that triggers it and any personal rituals surrounding it), developing a competing response for these triggers and rituals, and seeking social support for the feelings of shame, irritation or disappointment it engenders. You might also seek Comprehensive Behavioral Treatment, a multi-phase therapy that assesses the BFRB, identifies interventional strategies to target your specific needs, and revises these interventions after evaluating their effectiveness.

If you have been struggling with BFRBs, it’s important to remember that these habits are not necessarily a life sentence. With awareness, attention, insight, and appropriate intervention, many body-focused repetitive behaviors—like the nail-biting habit of an eleven-year-old girl, one hopes—can be brought back under voluntary control.

References

Anxiety & Depression Association of America. (n.d.). Body-Focused Repetitive Behaviors (BFRBs). Retrieved from https://adaa.org/understanding-anxiety/co-occurring-disorders/body-focu…

Bhandari, S. (2020, August 5). Understanding body-focused repetitive behaviors. Retrieved from https://www.webmd.com/mental-health/ss/slideshow-understanding-body-foc…

Flessner, C.A., Knopik, V.S., McGeary, J. (2012). Hair pulling disorder (trichotillomania): Genes, neurobiology, and a model for understanding impulsivity and compulsivity, Psychiatry Research, 199 (3), pp. 151-158

Mansueto, C. S., Golomb, R. G., Thomas, A. M., & Stemberger, R. M. T. (1999). A comprehensive model for behavioral treatment of trichotillomania. Cognitive and Behavioral Practice, 6(1), 23–43.

Marouane, O., Ghorbel, M., Nahdi, M., Necibi, A., & Douki, N. (2016). New Approach to Managing Onychophagia. Case reports in dentistry, 2016, 5475462

Olivardia, R. 2022, March 25). Overview of Body-Focused Repetitive Behaviors: Types, Treatments & ADHD Links. Retrieved from https://www.additudemag.com/body-focused-repetitive-behaviors-adhd-anxi…

Psychology Today. (n.d.). Body-Focused Repetitive Behaviors. Retrieved from https://www.psychologytoday.com/us/basics/body-focused-repetitive-behav…

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