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Body-Focused Repetitive Behaviours (BFRB) are, as the name implies, repetitive and unwanted actions a person performs on their body as part of an anxious cycle they become stuck in. The most common ones are skin picking and hair pulling, but other behaviours such as nail biting or eating hair can also become compulsive in response to anxiety.
Also known as habit disorders, they can be very debilitating and distressing, and people who struggle with them might hide their condition for years due to embarrassment and lack of understanding. Even though these seem to be very prevalent – around 5% of the population or more – many professionals are unaware of the conditions and of the fact that there is successful treatment and support available for people struggling with them.
Compulsive Skin Picking (CSP) is also referred to as Excoriation or Dermatillomania. People with CSP pick at imperfections, spots, moles, or scabs on their skin to the point of damage. This is most common around the face but can occur anywhere on the body.
If you struggle with CSP you might feel an ‘itching’ in your fingers or skin that you feel can only be relieved by picking, making the urge too strong to ignore. It might also bring a sense of pleasure to finally pick. Afterward, though, you might feel frustrated or disappointed because of the physical damage or due to feeling like you’ve failed to hold back from picking.
For many people who struggle with CSP, the picking is performed in order to achieve a smooth feeling on the skin, sometimes in a perfectionistic way. In this case, the cycle becomes vicious and entrenched because the damage to the skin will then trigger further anxiety and picking.
Compulsive hair pulling is referred to as Trichotillomania (TTM or ‘Trich’). People with TTM will pull at or break their hair in response to anxiety, which can cause visible bald patches or even damage to the skin depending on how the pulling is being done. The most common places to pull from are the head, eyebrows, and eyelashes, but people do pick from anywhere on the body.
If you live with TTM, you might experience a build-up of tension before pulling, which is then relieved by taking part in it. Sometimes the brain’s association between pulling hair and anxiety relief might cause you to take part in it when you are not anxious, as a self-soothing behaviour. In any case, the feelings after pulling are often depression, shame, and disappointment because of not being able to hold back or due to the visible effects.
People who struggle with TTM can also develop problems in their wrists due to the repeated movements or gut issues if they also ingest or chew on the hair.
The cycle
The behaviours the person takes part in are different from standard grooming behaviours because of the damage and distress they cause, and because they are part of an automatic loop driven by anxiety. You might experience this in different ways. Some people feel a physical sensation such as a tingling in their fingers or on their skin, which becomes more intense with time and feels like it can only be resolved through the behaviour. Others might pick, pull, or bite when they feel anxious. The compulsions can be intentional and ritualised, like picking at bumps in the skin while looking in the mirror, or on the other end of the spectrum can happen without someone noticing. You might only realise you’ve picked or pulled once you notice visibly, like finding a pile of hair next to you. Most commonly, people tend to use their own fingers, lips, or teeth to perform the behaviour, but items like tweezers can also become a part of it.
While everyone’s individual cycle and experience of a BFRB will be different, in all cases the compulsion will be a response to anxiety, bringing a mental and/or physical feeling of relief. The relief or even pleasure you feel causes the brain to view it as a good way of managing anxious feelings, which makes the response quicker and more automatic. The results of the behaviour, though, might then cause more anxiety and upset. Bald patches, damaged skin, and torn nailbeds can be embarrassing in and of themselves, and further to this you might feel ashamed of not being able to stop. You might find yourself avoiding social situations or camouflaging the damage caused, which can increase the pressure and anxiety you feel around the BFRB.
Common responses from loved ones or professionals are to view the behaviours as a bad habit or to only acknowledge the external and visible results. BFRB are complex yet treatable conditions that can have a huge effect on someone’s quality of life, so should be treated as such. Many people find that the pressure they feel from themselves or others to ‘just stop’ actually increase their anxiety and can make their condition worse. Like other obsessive-compulsive conditions, the BFRB cycle is driven by trying to manage anxiety. It takes time, patience, and practice to learn a new response, but it is possible with the right support.
Causes
There has been limited research into BFRB and their causes. Like many mental health conditions, it seems to be a mix of genetic tendency, psychological factors, and experiences. The behaviours most commonly start in adolescence, but can develop at any stage in life. CSP is more common in women than men. TTM has similar prevalence in girls and boys as children, but from adolescence is more frequent in women.
Genetic – Body-Focused Repetitive Behaviours tend to run in families. Family members of people with a BFRB might struggle with one themselves, or with other anxiety-based struggles
Psychological – Individual tendencies like being vulnerable to stress and anxiety, low self-esteem, or a tendency to respond to emotions with physical action could be tied into why a person gets so ‘stuck’ in the cycle
Environmental – The experiences and societal values someone is exposed to in their life can inform assumptions or pressures that become a part of the person’s symptoms. For example, perfectionism could be part of the reason a person becomes so distressed by the results of their compulsions
Body-Focused Repetitive Behaviours are conditions in their own right, which can be treated. The grooming behaviours can also be symptoms of a different condition, though, such as BDD, a processing disorder, or a dermatological issue. Knowing what condition is bringing on the symptoms is important, because it will determine the appropriate treatment. For example, the focus of therapy will be different between a person living with CSP and someone who picks because of their BDD.
If you are taking part in repetitive, body-focused behaviours, you should be assessed by a mental health practitioner who has expertise in obsessive-compulsive conditions. The key focus of an assessment should be what the driver of the behaviours is – what brings you to feel the urge – and how it makes you feel.
