Understanding Why People Pick and Pull
A Closer Look at Body-Focused Repetitive Behaviors
Body-focused repetitive behaviors (BFRBs) are a classification of disorders where a person’s actions are directed towards one’s own body often focused on removing or grooming parts of the body. These behaviors can become habitual and disordered when they happen frequently enough to lead to significant distress or impairment in school, work, or social functioning or cause damage to the body.
Who is Afflicted?
There are no reliable statistics on BFRB prevalence. However, smaller studies on individual BFRBs suggest that up to 4% of the population is afflicted by one of them throughout the lifespan (Chamberlain & Odlaug, 2014). Evidence also suggests that a majority of those afflicted with BFRBs are women with symptoms staring during adolescence at the onset of puberty.
Where Do BFRBs Originate?
More research is needed to provide an accurate explanation of why people have BFRBs. There is evidence that BFRBs are more likely to occur in families where first-degree family members have obsessive-compulsive disorder compared to the general population (American Psychiatric Association, 2013). Neurological causes are harder to determine. The presentation of symptoms of these disorders vary widely from person to person, but the theory is that response inhibition is a likely culprit (Grant, Leppink, & Chamberlain, 2015). Most people pick at their skin or pull out hair at some point in their lives, however, those who do so in a disordered manner may have a malfunction in the part of the brain that inhibits specific behaviors or the part which can interrupt behaviors once they begin (Grant et al., 2015).
What Are They?
There are several behaviors considered as BFRB’s but the most common include trichotillomania, excoriation disorder, and nail-biting. Trichotillomania is the recurrent compulsion to pull one’s hair. Hair is pulled from any part of the body, but the most common areas are the scalp, eyebrows, and eyelashes. Excoriation disorder is repeatedly picking at the skin. It could be healthy skin or unhealthy skin, targeted to scabs, lesions, pimples or other blemishes and some people use tools to poke, squeeze, or lance the skin.
The compulsion to pull hair, pick at the skin, or bite nails can be focused or automatic. Those who engage in the behaviors in a focused way do so as a way to regulate emotions or soothe themselves. It can be in response to a physical sensation such as an itch or tingle, or it can be in response to a perceived physical defect such as a blemish or a hair out of place. Sometimes the behavior results in a feeling of gratification or pleasure, while for others it is a focused method of experiencing a sensation. For those who engage in BFRBs without full awareness, they may pick, pull or bite while “zoned out” and only notice they are doing it when they start to bleed or experience pain.
Bad Habit or Disorder?
Diagnosis of BFRBs is challenging. First, disordered behaviors need to be distinguished from bad habits. Second, as part of the obsessive-compulsive spectrum of disorders, a clinician also needs to differentiate when the compulsion to engage in these behaviors is part of a broader obsessive-compulsive disorder or whether it occurs on its own. Similar symptoms can also occur in patients with a stereotypic movement disorder, which is a neurodevelopmental disorder that starts in childhood (Chamberlain & Odlaug, 2014). Therefore, careful assessment is the first step toward treatment.
Several conditions need to exist to meet the diagnostic criteria of disordered. The existence of a Body-Focused Repetitive Behavior needs to be accompanied by significant impairment and distress which usually looks like spending a considerable amount of time, several hours per day, on the behavior or covering up the behavior. The person also isolates, withdraws socially, and misses school or work by either engaging in the behavior, covering it up or avoiding judgment. Also, there is a pattern of unsuccessful attempts to stop the behavior. Finally, the behavior results in physical damage. For example, people with trichotillomania will get to the point where there are patches of hair missing and may not grow back, scabs where hair is pulled out, or inflammation such as in the condition of blepharitis which results from pulling out eyelashes. People with excoriation disorder will have lesions, skin infections, or scars.
Not Just Physical
The mental and emotional toll of behaviors that do not fit into society’s concept of “normal” is significant, and a lot of work goes into hiding them. A majority of people who have BFRBs are aware of what people think, and they are very sensitive to the reactions of others. The behaviors are usually done in private, and as the consequences become visible such as bald spots or sores, the person spends a lot of time covering it up or withdrawing completely. A person with a BFRB feels unattractive, ashamed of what they do and how hard they have to work to cover it up to blend in. On a social level, sometimes it is better to avoid people and not go out in public. Constantly barraged by the paranoia of someone seeing or detecting the cover-up, the person internalizes subtle nonverbal cues that further separate them from what is “normal.” The person is left to deal with their disorder alone, often accompanied by depression and anxiety. Increased depression and anxiety often feed back into the compulsion cycle by making symptoms worse.
Recovery and Treatment
As a chronic, compulsive disorder, BFRBs are not “cured,” but there is treatment. The first step is recognizing that BFRBs are treatable disorders and support is available. Treatment is designed to meet the needs of each person’s experience. Providers who specialize in BFRBs are equipped to discern what is going on diagnostically as well as to help with the unique combination of co-occurring disorders such as anxiety and depression. There are several evidence-based therapies available including cognitive behavioral therapy, habit reversal training, acceptance and commitment therapy, and dialectical behavioral therapy. Whichever is chosen, expect a combination of learning to increase self-awareness, identify triggers, regulate emotions, manage stress and anxiety as well as learning to create routines that focus on reclaiming the power to choose to engage in the BFRB or not.
Many people who suffer from BFRBs do not seek treatment because of the stigma involved or because of previous negative experiences. While these disorders last a lifetime, there are many success stories of people in recovery who learn to manage their behaviors and symptoms, so they do not interfere with life anymore. The good news is that even if there are no BFRB specialists in your area, there are online resources that offer therapy and social support. If you or someone you love is dealing with BFRBs, encourage them to explore their options until something works.
Trudi Griffin is a Licensed Professional Counselor putting her clinical knowledge, experience, and passion for research to write about mental health, She’s part of the trichstop.com team.
-American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, Fifth edition. Arlington, VA: American Psychiatric Association.
-Chamberlain, S. R. & Odlaug, B. L. (2014). Body-focused repetitive behaviors (BFRBs) and personality features. Current Behavioral Neuroscience Report, 1, 27-32. doi: 10.1007/s40473-013-0003-9
-Grant, J. E., Leppink, E., & Chamberlain, S. (2015). Body-focused repetitive behavior disorders and perceived stress: Clinical and cognitive associations. Journal of Obsessive-Compulsive and Related Disorders, 5, 82-86. doi: 10.1016/j.jocrd.2015.02.001