Body Focused Repetitive Behaviors (BFRBs)
Body-Focused Repetitive Behaviors (BFRBs) can focus on any area of the body, including face, hair, fingernails, mouth, and feet. These behaviors are often very difficult to talk about. Others may perceive the behaviors simply as a habit, or minimize and assume that it is the same as pulling out a hair with split ends or popping a pimple. However, a person who struggles with BRFBs has tried to stop the behavior several times before, but becomes frustrated and discouraged when they find themselves coming back to the behavior. This experience may become a barrier to treatment since the person may feel hopeless about their ability to recover. It can also be challenging to talk to medical, mental health, and other professionals about the symptoms for fear of being judged or misunderstood.
It is crucial to find a specialist who understands evidence-based modalities, including Habit Reversal Training (HRT) and Comprehensive Behavioral Therapy (ComB). When starting treatment, a person can expect to develop more insight and awareness about when the behaviors occur and any pertinent details that allow the client and therapist to create gradual change. It is also important to note that there is no one-size-fits-all approach since people engage in behaviors for different reasons.
Skin-picking can occur on any part of the body and often results in wounds and open sores. These episodes are typically brought on by scanning behaviors, including feeling the texture of skin and looking closely in the mirror. This over-attending to the skin leads to efforts to minimize or correct the perceived flaw. Acne, blemishes, dry skin, bumps, and ingrown hairs are commonly targeted. Some people may use tools, such as needles, tweezers, lancets, extractors, or other objects to aid in removal. Others may engage in skin-picking without any awareness, often due to understimulation or boredom.
Symptoms can be very time-consuming, with some skin-picking episodes lasting for hours at a time or happening on and off throughout the day. The resulting damage to the skin often causes shame, leading a person to spend hours camouflaging it with makeup, or covering it up with clothing or bandages. A person may also avoid leaving their home or socializing altogether, furthering their sense of isolation and shame.
Hair-pulling can also occur anywhere on the body. Common areas include the head, facial hair, genital area, arms, and legs. Scanning behaviors include running fingers through or over the hair and looking for specific texture. Targeted areas may include split ends, hair bulbs, coarse hair, and the hairline. Needles, tweezers, and other tools may be used to remove the hair follicle.
Hair-pulling episodes can occur in single episodes or throughout the day. Some episodes may involve awareness of scanning and pulling, while others may happen automatically as a person is engaging in another activity. Depending on the severity of the symptoms, some may feel the need to hide bald spots or thinning areas with wigs, accessories (i.e. hats or scarves), specific hairstyles, or other products. Similar to Excoriation Disorder, Trichotillomania can cause shame and cause a person to avoid socializing or engaging in activities they once enjoyed.
Evidence-based treatments for Body-Focused Repetitive Behaviors (BFRBs) include Habit Reversal Training (HRT) and Comprehensive Behavioral Therapy (ComB). Both treatments involve developing insight and skills training so that the BFRB becomes less effective over time. Many people report that the BFRB is highly comforting in that it allows them experience a “trance” like state, but of course comes with emotional and physical consequences.
HRT consists of awareness training and developing competing responses to block the BFRB. Awareness training involves logging specific details about BFRB episodes in order to increase insight and gather data. The next step involves teaching competing responses to the person’s BFRB, such as creating fists when experiencing an increased urge to scan and pull. Other skills, such as progressive muscle relaxation and deep breathing, can assist a person in resisting urges. Lastly, behavior blockers (e.g. rubber finger tips) and stimulation substitutes (e.g. sensory rings) equip a person with objects that can be transported easily or placed around their home.
ComB starts by assessing what maintains the BFRB using the SCAMP model:
- Sensory – sensations (e.g. hairs that are unpleasant to touch)
- Cognitive – thoughts (e.g. “I must get rid of this hair”)
- Affective – feelings (e.g. anxiety or boredom)
- Motor – body posture or movements (e.g. placing hand on head when working)
- Place – environment (e.g. at desk)
Using the data gathered through the SCAMP model, a person will start to target specific symptoms using skills including cognitive restructuring, mindfulness, and building tolerance for urges. ComB also makes use of the skills mentioned in the HRT protocol, including awareness and relaxation training, sensory substitution, and behavior blockers.
It is important to discuss self-compassion in treatment, as shame and guilt are common after an episode. Over time, learning to be self-compassionate can make the BFRB less effective at managing emotions.
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