Have you ever bitten your nails or cuticles when you were stressed? Or found yourself pulling on your hair while reading a book or watching TV? For many people, these behaviors come and go. But for others, they persist and are hard to control, often evolving into ongoing repetitive behaviors that are hard to control and can be emotionally distressing and physically harmful.
Chrissy was a teenager who came to see me because she was pulling out her hair and her eyebrows. She had a bald spot at the back of her head that had gotten so big it was difficult to cover. She was upset about this habit but could not stop it, feeling emotionally distressed and becoming isolated because she was embarrassed to be with her friends. Despite being a good student, even going to school was challenging, because she had difficulty controlling her hair-pulling during the long school day with other people around.
Behaviors like Chrissy’s are called Body-Focused Repetitive Behaviors or BFRBs and they are far more than bad habits. BFRBs are behaviors where a person repeatedly touches, picks, pulls, or bites their own body in a way that causes physical damage and emotional distress. They include:
- Hair pulling anywhere on the body (Trichotillomania)
- Skin picking leading to scabs or sores (Excoriation)
- Cheek or lip biting
- Nail biting
It is easy for an observer to ask why anyone would continue to engage in these “bad habits” but for the BFRB sufferer, these behaviors are because of an underlying emotional reason that can follow one of the following patterns.
- A feeling such as being overwhelmed or anxious builds up, or there may be a sense that something just isn’t right and the person focuses on some small imperfection in their body
- The BFRB happens
- It leads to a brief sense of relief or satisfaction
- Feelings of guilt, frustration or embarrassment follow
This pattern can be deliberate, such as when a person notices a small skin imperfection, or can be done so automatically while reading or scrolling, that the person is unaware that they are doing it. In other words, BFRBs can have a mix of emotion, sensory experience, and automatic habit.
Treatment for BFRBs can utilize Cognitive Behavior Therapy techniques, Acceptance and Commitment Therapy, medication, or strategies such as mindfulness, sensory control (such as fidget devices), and psychoeducation.
The most common treatment technique is called Habit Reversal Training (HRT) which focuses on the motor behaviors of BFRBs because it is believed that these motoric behaviors reduce tension, which is reinforcing to the individual, and therefor leads to more BFRB activity. Steps in HRT include Awareness Training, Competing Response Training, Motivation Training which examines the emotional components of BFRBs and Generalization Training which focuses using new skills in a variety of situations. Relaxation training may also be used in HRT.
In general, it helps to learn the following:
- Become more aware, notice that early urge to perform a BFRB
- Replace the behavior with something physically incompatible, such as using a stress ball, a fidget toy, knitting, etc.
- Change the environment, such as wearing gloves during high-risk times
- Build better coping strategies to deal with emotional triggers
It is important to remember that BFRBs are not a failure of willpower. They are learned patterns of behavior that, with appropriate help, can be unlearned. If you or someone you know struggles with a BFRB, it is most important to be compassionate. These behaviors can be changed over time. They are treatable and with the right support and techniques, they can be changed. Please call my office if you have questions or concerns about Body-Focused Repetitive Behaviors.