The Basics of BFRBs

Source: Nick Karvounis/Unsplash

Every day, each of us must recognize and inhibit countless urges. To the best of our ability, we decide whether to stop (once again) at the candy dish in the office, whether to chew on that pen cap, or whether to check our phone (yet again). We each have varying degrees of success making the “right” decision. Urges can also be directed at our own bodies, such as when we experience that strong drive to scratch an itch. For some people, bodily urges take a very specific form, manifesting in body-focused repetitive behavior (BFRB). BFRBs encompass a range of behaviors, including nail biting, skin picking, and hair pulling, and they occur commonly in the general population. Yet many people do not know that they can be signs of a mental health condition. Even fewer know that evidence-based treatments are available for BFRBs. In this new blog, we’ll be collaborating with our colleagues in the scientific community to shed light on these conditions, where they come from, and what people might do to overcome them.

BFRBs are recurrent behaviors that persist despite repeated attempts to stop or reduce them. Although many people engage in BFRBs—we’ve all popped a pimple at some point, for example—BFRBs become disorders when they cause distress and interfere with a person’s work, family, or quality of life. These distinguishing features—distress and impairment—help to separate them from normal grooming behavior.

Researchers and clinicians have historically had a hard time determining whether BFRBs constitute habits, compulsions, or difficulty with impulse control. Although they were previously classified as an Impulse Control Disorder, in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM V), two specific BFRBs, hair pulling and skin picking (excoriation disorder), are listed under the category of Obsessive Compulsive and Related Disorders. This places them alongside conditions like Obsessive Compulsive Disorder (OCD), Body Dysmorphic Disorder (BDD), and Hoarding. Importantly, this does not mean that BFRBs are the same thing as OCD, only that they are related.

Importantly, BFRBs encompass widely varying types of behaviors, often fueling misconceptions about what they are and are not. Take, for example, hair-pulling disorder (aka trichotillomania). Some people pull their hair in a very intentional manner, carefully searching for a strand that looks or feels a particular way and then reporting some sense of pleasure, satisfaction, or relief in removing it. Others describe having little awareness of their pulling at all. They may be in a distracted or trance-like state. Some people pull when they’re anxious, other people pull because it feels good, and still others describe doing it only when they are bored. This heterogeneity can make it hard to characterize BFRBs and equally hard to treat them.

Research suggests that around 0.6 to 3.6 percent of people suffer from Hair Pulling Disorder (Woods and Houghton, 2014), and 1.4 to 5.4 percent suffer from Skin Picking Disorder (Grant et al., 2012). Although these numbers may sound low, it’s important to recognize that they are roughly the same statistics reported for other better-known conditions, like OCD (1-3 percent; Grant, 2014) and Generalized Anxiety Disorder (4.3 percent; Kessler et al., 2012). Moreover, when viewed more broadly (how many people report having a BFRB versus a full clinical condition), the rate of occurrence goes up to around 13 percent (nail biting is most common). Importantly, it can be hard to accurately gauge how frequently BFRBs occur, because there has been relatively little research on them compared to other mental health conditions. This challenge is amplified by the fact that many people don’t know their repetitive behaviors have a name, or, if they do, feel a sense of shame or embarrassment that keeps them from seeking help. Together, these features make it plausible that these behaviors may be more common than we think.

In the posts that follow, we’ll be sharing the perspectives of researchers, clinicians, and affected individuals about the causes of BFRBs and the best treatments for them. We’ll explore how research into BFRBs can provide valuable insights into the role of things like urge suppression, habit learning, and willpower/response inhibition in all our lives, and how we might work toward better treatments for people affected by BFRBs.