Updated: Sep 29
Body-Focused Repetitive Behaviour, or BFRB for short, is an umbrella term used to represent a range of repetitive self-grooming behaviours, such as hair pulling, skin picking, and nail-biting, that end up damaging the body and causing distress or impairment in a person's life. It's a condition more prevalent than you may think, affecting 1 in 20 individuals. In this blog, I will share the main types of BFRBs and science-based resources to explore if you or someone you know needs help.
What are the most common types of BFRBs?
According to the Expert Consensus Treatment Guidelines Body-Focused Repetitive Behaviors Hair Pulling, Skin Picking, and Related Disorders, there are different types of BFRBs which involve picking or biting (a) the skin (like acne, scabs, or skin imperfections), (b) cuticles or nails, and (c) lips or cheeks. Some people may also engage in repetitive joint cracking and even nose-picking. These behaviours share similar characteristics and can be considered a mental health condition when they result in two negative outcomes. One is damage to the body despite the individuals' many attempts to decrease or stop such behaviour. The other is causing significant distress or impairment in the person's life, such as socially, at work or school.
Here are the most common types of BFRBs:
Hair Pulling or Trichotillomania is when a person repetitively pulls their hair from the scalp, eyelashes, eyebrows, or other body parts. It usually begins in late childhood/early puberty, around age 13. Having little or no body hair can cause a lot of distress for individuals, especially in social contexts where others may notice and comment on it.
Skin Picking or Excoriation Disorder is when one repetitively picks their skin, causing tissue damage. They may pick their faces, arms, legs and other body parts. Sometimes picking may be initiated due to acne or skin imperfections. Other times, dry skin, mosquito bites or scabs can trigger the picking.
Cuticle or Nail Biting involves repetitively biting their cuticle or nails and damaging the skin. This behaviour often begins in childhood, and 20-30% of the general population has been shown to engage in chronic and severe nail biting that may result in permanent damage to the nail and skin.
Cheek, Tongue or Lip Biting is also characterized by recurrent and damaging biting of the cheek, tongue or lips.
Joint Cracking involves repetitively cracking body parts such as the knuckles or neck, frequently resulting in negative feedback from other people because of the sounds cracking joints make.
BFRBs usually occur during sedentary activities, such as when people are watching tv, playing a game, scrolling on their phones, reading, listening to lectures, talking on the phone, lying in bed, riding in a car, or sitting at a desk. However, it can also occur during active activities.
There are two types of pulling or picking: one called "focused," which means that the person is aware of performing such a behaviour (like looking in the mirror while picking a pimple), and the other is called "unfocused," or when they are not aware of doing such a thing (e.g., scratching the skin until it bleeds) or the behaviour is automatic.
Many individuals report noticeable sensations before, during, and after pulling.
Some people may have an urge or sensation that makes them use their fingers to pick or pull from a specific area. These sensations may feel like itching, tingling, or pain. Other people may have no urge or sensation before picking or pulling. Instead, they may seek a sensation by using their fingers to feel certain body parts or searching for a specific characteristic of the hair or skin to remove or fix if perceived as imperfect or problematic.
BFRBs can also be triggered by a wide range of emotions ranging from boredom to anxiety, frustration, or depression. Thoughts, beliefs, and values can also affect these behaviours.
As you can see, BFRBs can cause more significant problems than you think. Below are key ones that you should know about:
1. People who pull their hair may also swallow them in excess. As a result, they may experience gastrointestinal distress or have digestive blockage called trichobezoar or hairball. If this occurs, surgical removal may be required. Therefore, please see a medical practitioner if you (or your child) eat hair.
2. Skin picking can cause infections which sometimes can be severe. Consequently, keeping wounds clean and treating them with antibiotic cream will likely prevent infections.
3. Repetitive motion with the same body part may result in body/motion injuries. Therefore, you (or your child) may need to see a professional to help with the injuries.
4. Secrecy about one's condition due to shame and embarrassment may result in isolation and resistance to seek treatment. Thus, secrecy can contribute to a general misperception of BFRBs as being less common than they are and interfere with relationships, work, and school.
5. Avoiding activities and social situations that make people feel vulnerable to being "discovered" is common. Some examples are not going to the beach, swimming, doctor's visits, hair salon appointments, childhood sleepovers, hanging out in a lighted area, and having intimate encounters.
What to do if you or your child have BFRB?
According to experts in the field, cognitive behaviour therapy (CBT) is the treatment of choice for BFRBs as it is more effective than medication. However, some individuals may need medication before CBT or both medication and CBT. CBT is the umbrella approach to various treatment modalities for BFRB, including habit reversal training (HRT), comprehensive behavioural treatment (ComB), acceptance and commitment therapy (ACT), and dialectical behaviour therapy (DBT).
At Beacon Psychology, we have successfully treated many young clients with diverse types of BFRBs. In our experience, being motivated to change such behaviour and having a support system are crucial factors for positive outcomes. For more information about BFRB, please visit the TLC Foundation for Body-Focused Repetitive Behaviors, read its treatment guidelines, or watch helpful and educational webinars. Finally, if you want to access hands-on free self-help resources to help you cope with BFRB, check out the following website.
I hope you find this information helpful!
NOTE about the author: Dr. Juliana Negreiros is a registered psychologist and director of Beacon Psychology Clinic. She has many years of experience treating young people with OCD and other related disorders such as BFRB. For more information about her, check out her page on our website.