Question 1

What are BFRBs?

Accepted Answer

Body-focused repetitive behaviors (BFRBs) include any repetitive self-grooming behavior that involves biting, pulling, picking, or scraping one’s own hair, skin, lips, cheeks, or nails that can lead to physical damage to the body and have been met with multiple attempts to stop or decrease the behavior.

Common BFRBs include hair pulling, skin picking, nail biting, and cheek biting. Other body-focused repetitive behaviors include hair eating, nail picking, skin biting, lip biting, tongue chewing, and hair cutting.

Question 2

What causes BFRBs?

Accepted Answer

Research indicates that some people may have an inherited predisposition for skin picking or hair pulling. Several studies have shown a higher number of BFRBs in immediate family members of persons with skin picking or hair pulling disorders than would be expected in the general population.

In addition, a recent study examined hair pulling in both identical and fraternal twins and produced results consistent with a significant inherited component in hair pulling disorder. So we can safely say that BFRBs are more than likely inherited, at least to some degree.

However, even if a predisposition toward BFRBs is inherited, there are other factors involved as well, including temperament, age of onset, and environmental stress factors. More than likely BFRBs are caused by a variety of factors that interact with each other, resulting in the behavior. It is possible that a person has a predisposition to pull or pick, and the right stressor does not happen at the right time, so the behavior never manifests. Conversely, when a person starts experiencing a BFRB, it is not helpful to blame any one aspect of that person’s life that is happening at that time, but one might assume that the behavior most likely would have come to light at some point in the person’s life.

One interesting point is that other species engage in similar behaviors. Primates such as the great apes or certain types of monkeys will pull hair, over-groom, and pick at nits and insects on their own fur and the fur of others. Birds will pull out their feathers; mice will pull fur or “barber” themselves and their cage mates; dogs and cats may lick their skin or bite at an area, removing fur until there are bald spots. Researchers interested in animal models of BFRBs are trying to understand these behaviors in animals in order to shed some light on the complex neurobiology that underlies the human experience of BFRBs. What these animal studies tell us is that BFRBs are likely, in part, hard-wired behaviors that are not solely the result of environmental factors.

Question 3

What treatment options are available for BFRBs?

Accepted Answer

Research into treatments for BFRBs, particularly hair pulling disorder and skin picking disorder, has grown steadily over the past decade. Although no one treatment has been found to be effective for everyone, a number of evidence-based treatment options have shown promise for many people.

Psychotherapy
A psychotherapy approach called Cognitive Behavior Therapy (CBT) is the treatment of choice for BFRBs. Existing studies suggest that CBT is superior to medication in treatment outcomes. However, some individuals may need medication first or in conjunction with CBT. CBT is a therapeutic approach that focuses on identifying thoughts, feelings, and behaviors that are problematic and teaches individuals how to change these elements to lead to reduced stress and more productive functioning. An emphasis is placed on matching the treatment to the unique symptoms of the individual.

There are a number of different treatment approaches for BFRBs that fall under the umbrella of CBT: Habit Reversal Training (HRT) and Comprehensive Behavioral treatment (ComB). Acceptance and Commitment Therapy (ACT), and Dialectical Behavior Therapy (DBT) are two treatment approaches that may bolster the effectiveness of other cognitive behavior therapies.

Question 4

What other behaviors are associated with BFRBs?

Accepted Answer

Body-focused repetitive behaviors include any repetitive self-grooming behavior that involves biting, pulling, picking, or scraping one’s own hair, skin, or nails that results in damage to the body.
Some of the BFRBs listed below are not specifically indexed in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5).  They are classified as “other specified obsessive-compulsive and related disorders", with specification of “body-focused repetitive behavior.”

Trichotemnomania (hair cutting)
Is characterized by the compulsive cutting of one's own hair to achieve some visual goal (evenness, visual improvement).
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‍Trichophagia (hair eating)
Occurs in approximately 15% of patients with hair pulling disorder. Eating hair may cause serious medical complications in the form of trichobezoars – hairballs that may form in the stomach or bowel. Bezoars can be life-threatening. If you or your child experiences the following symptoms, it is recommended you seek advice from a medical doctor: feeling sick, vomiting, stomach pain, foul breath, or other symptoms of gastrointestinal problems.
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Lip Bite Keratosis (lip biting)
Involves the repetitive biting of the skin of one’s own lips.
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Onychotillomania (nail picking)
Involves damage to the fingernails or toenails by means of chronic picking of the nails.
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Dermatophagia (skin biting)
Often occurs among patients with onychophagia. Dermatophagia behaviors include biting the cuticles or fingers, and digesting scabs or skin (usually as a result of skin picking disorder). Oftentimes, lip, cheek, and tongue biting are also considered dermatophagia.
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Tongue Chewing
Chronic chewing on the tongue, most frequently the sides of the tongue, to the point of damage is a common oral problem and is considered to be a BFRB.

Question 5

Are BFRBs lifelong disorders?

Accepted Answer

For some, the BFRB journey can last a lifetime. For others, their BFRBs wax and wane, with periods of no picking, pulling, or biting. For some, they are able to regulate and stop their behaviors completely.
It's important to remember that this is a very personal, individual journey. No two BFRB journeys are alike. It's up to you to decide how to best manage your BFRBs. Finding space and grace to make good choices for yourself will help you gain clarity on what you want.

Getting connected to community and meeting others on the BFRB journey gives you a variety of perspectives from which to grow. Strive for progress over perfection. You've got this and we've got you!

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