Tricky, sticky habits: what are body-focused repetitive behaviours?

We’ve all heard the phrase “pulling their hair out” used to describe someone who is particularly stressed, or “splitting hairs” to refer to being overly fussy. But you might not realise that these sayings can be traced back to compulsive hair-pulling disorder and other body-focused repetitive behaviours (BFRBs). Excessive hair-pulling (now called ‘Trichotillomania’) for example, was written about in 410 BCE by Hippocrates, the father of modern scientific medicine.

In this blog, we offer some information about what BFRBs are, what causes them and the negative impact they may have, and how they are treated.

 What are body-focused repetitive behaviours (BFRBs)?

The term BFRBs is used to refer to a category of repetitive behaviours that involve touching our own body in ways that interfere with bodily tissue. Common BFRBs include:

• Hair-pulling (associated with trichotillomania)

• Skin-picking (also called excoriation or dermatillomania)

• Nail-biting 

• Lip and cheek biting

• Nose picking

These behaviours can occur outside of the person’s awareness for some, or even most, of the time. This is one of the reasons why BFRBs are not considered to be a form of deliberate self-harm, and usually require a different treatment approach.

How common are BFRBs?

You may notice that many of these behaviours are common in both children and adults. Many people will recall picking at dry skin, popping a pimple, or removing a grey hair at some point. BFRBs occur on a spectrum, and most people find they can stop before the behaviours reach a problematic level that may be considered a disorder.

BFRB disorders (where the BFRB occurs a problematic level) are thought to affect about 3-5% of people at some point in their lives.

Around 2% of adults experience severe hair-pulling, and slightly more (3%) severe skin-picking, reaching a level that fit with trichotillomania or excoriation. BFRB disorder appears to be more common in children than adults.  

People with obsessive-compulsive disorder (OCD), anxiety, ADHD, and autism may be more likely to struggle with BFRBs.

When do BFRBs become a problem?

BFRBs are usually considered to be a problem when they cause the person who is experiencing them distress or significantly impact daily life. For example:

• Engaging in the BFRB to the point of causing pain (e.g., bleeding) or repeated damage to hair or skin (e.g., leaving scarring or bald patches)

• Excessive time spent doing the BFRBs or covering them up, resulting in being late or missing work, school, or other important activities

• The BFRB is causing or putting the person at increased risk of health problems (e.g., skin infections, gastrointestinal blockages)

• Low self-esteem, feelings of worthlessness, depression, and anxiety

People with BFRBs such as trichotillomania and excoriation often report high levels of shame about their BFRBs and the physical damage these cause. 

Because of this, they will often go to great lengths to hide their BFRBs from others by using make-up or clothing. They may also avoid activities (e.g., swimming, exercise, windy weather, physical intimacy) that may expose their BFRB. While understandable, these coping strategies may negatively impact social and romantic relationships and create further stress in the long run.

What causes BFRBs?

A common misconception is that BFRBs are simply ‘nervous habits’ that are caused by stress or anxiety. While these feelings can trigger BFRB urges, other feelings such as boredom, frustration, and excitement can also be involved. 

BFRBs often feel soothing or pleasant to the person in some way, so they can work to ‘dial down’ or ‘rev up’ an over-stimulated or under-stimulated nervous system, depending on the person and the situation they are in at the time. These can be powerful factors in increasing the urge to pick or pull even more over time, despite the negative long-term consequences of these behaviours. 

There is also some research showing that having an immediate family member who struggles with hair-pulling or skin-picking can make someone more likely to develop this problem. However, it’s not clear why this happens, as no genetic markers have been found to be there for everyone with BFRBs.

How are BFRBs treated?

The current gold-standard treatment is structured psychological therapy that includes Habit Reversal Training (HRT) and Cognitive Behaviour Therapy (CBT) techniques. This involves learning to:

• recognise your unique BFRB patterns and triggers

• notice urges to do the BFRB before the behaviour starts

• prevent the BFRB by practicing suitable, alternative behaviours

Therapy usually starts with you and your therapist working together to develop a detailed understanding of your BFRB triggers and what keeps the behaviours going, so that treatment can be individualised to you.

Other therapy strategies may include learning skills to increase mindful awareness, reducing stress, and dealing with unhelpful BFRB-related thoughts (e.g., “I’ll just pull or pick this one little bit and then I’ll be able to stop”).

Resources

The TLC Foundation for BFRBs has useful resources for individuals with BFRBs, and parents and loved ones.