Trigger Warning – Suicide, self-harm.
As the name suggests, Body Focused Repetitive Behaviours (BFRB’s) are problematic, non-functional and damaging self-grooming behaviours. We have all at some point engaged in one or some of these behaviours, namely, biting your nails, lips or even your skin. However, most of us are not obsessively reliant on these actions to cope in a situation. If these behaviours are experienced by you only to a certain degree then it is not a cause of worry. But the moment they begin to hinder or limit activity in your daily life, it is best to think about seeking help or support from a professional. These recurrent behaviours and repetitive efforts to stop them creates a web of obsession, anxiety and stress for the individual. The symptoms usually begin to appear in late childhood or early adolescence (9-13years of age). While hearing about the following BFRB’s, you may think that they are not uncommon in nature, but one needs to remember that these behaviours are categorized as such because they cause significant distress and impairment for the individual suffering.
Different kinds of BFRB’s include but are not limited to:
- Trichotillomania – Pulling out one’s hair
- Onychophagia – nail biting
- Onychotillomania – nail picking
- Trichophagia – hair eating
- Dermatophagia – skin eating
- Lip Biting – lip bite keratosis
- Cheek Biting – cheek keratosis
- Tongue Chewing – Chronic chewing on the tongue
- Trichotemnomania – hair cutting
These behaviours can even cause severe medical complications if not treated in time. For example – Eating hair may lead to trichobezoars – hairballs that may form in the stomach or bowel. This can be life-threatening. It can also cause milder symptoms such as constantly feeling sick, vomiting, stomach pain, foul breath, or other symptoms of gastrointestinal problems. Oral problems are also correlated with this condition.
A common misconception occurs when we think about these behaviours. We often confuse it with an obsessive compulsive disorder, an anxiety disorder or an impulse control disorder. Unfortunately, the BFRB’s listed above are not specifically indexed in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5). Some are classified as “other specified obsessive-compulsive and related disorders,” with specification of “body-focused repetitive behaviour.” This is a grave cause of concern since this increases the chances of a misdiagnosis. This mental health condition can occur simultaneously with other disorders but their symptoms and treatment efforts will vary significantly as compared to when the individual only struggles with BFRB.
These behaviours have genetic and neurobiological origins. Several studies have shown the increased likelihood of BFRB’s in an individual who has immediate family members suffering from the same. Other factors include temperament, environment, age of onset, and family stress factors. There is an interesting connection between humans and animals, both exhibiting similar behaviours. Researchers have observed Primates such as the Great Apes or certain types of monkeys, pulling out hair, overgrooming and picking out insects from their own fur or others’. Birds also pull out their feathers, mice do the same with their hair and several dogs and cats get obsessed with licking and biting their skin until they have bald spots. This connection is being used to find further neurobiological implications overlapping between several species (The TLC Foundation for Body-Focused Repetitive Behaviors, n.d.).
Several people who do not understand or are not aware of this condition tend to have an unconcerned attitude towards BFRB’s. They may say things like “Why don’t you just stop, it is not that hard,” or “Just break this habit now.” Such language begins to minimize the sufferer’s experience. This adds to the stigma surrounding these behaviours, causes intense shame and an unwillingness or fear to reach out for help. We must be cautious of using such language without understanding the degree of difficulty faced by others. We have also explored the connection between Language and Mental Health in our previous blog.
A 2018 study, highlights the prevalence of Body Focused Repetitive Behaviours – From a sample of 4,435 college students, 71.81% of participants surveyed stated that they engaged in a BFRB within that past month. 59.55% were considered subclinical (not severe enough for a diagnosis) and the other 12.27% were considered pathological, or appropriate for a diagnosis. Almost three-fourths (73.2%) of people with a pathological BFRB also endorsed at least one subclinical BFRB. In both these categories, the most common form was cheek biting. The research did go no to show that BFRB’s are fairly common and involve normal behaviours taken to an extreme (Hougton et al., 2018).
Treatment of body-focused repetitive behavior disorder could include drugs, such as Selective Serotonin Reuptake Inhibitors, Antidepressants, Inositol and N-acetylcysteine.
Evidence-based treatment for BFRB’s includes Cognitive-Behavioural Therapy. There are various treatments for BFRB’s that fall under the umbrella of CBT: Habit Reversal Training (HRT) which has varied components. The three, regarded most important, are Awareness Training, Competing Response Training (identifying triggers and employing strategies to aid and put a stop to them) and social support. Another is Comprehensive Behavioural Treatment. The Comprehensive Behavioural Model (ComB) emphasizes recognizing why, where and how a person engages in their BFRB in order to assist them to accomplish what they want, without performing it, with the help of individualized interventions.
Acceptance and Commitment Therapy (ACT) is a hopeful procedure that may bolster the effectiveness of other cognitive behaviour therapies. It promotes acceptance of desires to pick or pull, without acting to lessen or terminate them. Dialectical Behaviour Therapy is another treatment approach that may serve to add effectiveness of other cognitive behaviour therapies. It has four facets consisting of mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance.
Some self-help strategies have shown promising results for many with BFRB’s to handle their behaviours by themselves. These could be, using an object to preoccupy the hands when pulling transpires; wearing gloves or mittens to make picking difficult and joining a support group. Treatment can also include Behaviour Modification Therapy and Family Therapy. Another form of treatment that focuses on mindfulness, stimuli and rewards has proven effective in a few people. Yet, no treatment is considered well-established to treat any form of BFRB’s.
As mentioned previously the average person who suffers, typically endures levels of shame, varying from mild to overwhelming, and occasionally even life-threatening. Before awareness regarding these behaviors increased, the ones who could not understand why they were engaging in the same and could find no healthy forms of relief would often contemplate and commit suicide. Although the domain of BFRB’s is in its early days, today there are several treatments, lifestyle changes, and awareness practices that can have a favourable influence in diminishing behaviours and enhancing every-day life.
– Urveez Kakalia, Ferangiz Hozdar & Dhara Mehta.