Guide to Body-Focused Repetitive Behaviors

Do you pick your skin until it bleeds, bite your nails down to the quick, or pull your hair until you leave bald spots? These are examples of body-focused repetitive behaviors (BFRBs) that can cause physical damage to the body. In some cases, they are related to mental health disorders, such as obsessive-compulsive disorder (OCD). Individuals who engage in BFRBs often feel shame and guilt about their habits and are at increased risk for isolation, anxiety disorders, and clinical depression. They may try multiple times to put a stop to the behaviors without success. In this blog, you’ll learn more: what are BFRBs, common types of BFRBs, what causes them, brain abnormalities in BFRBs, and treatments to help manage them. Individuals who engage in body-focused repetitive behaviors (BFRBs) often feel shame and guilt about their habits and are at increased risk for anxiety disorders and clinical depression.

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WHAT ARE BFRBs?

BFRBs are compulsive behaviors and pathological grooming, such as skin picking, hair pulling, nail biting, and cheek biting. People continue to engage in these behaviors even when they cause injury. And in many cases, they persist even after repeated attempts to stop.

COMMON TYPES OF BFRBs

1. Skin Picking Disorder

It’s very common for people to pick occasionally at scabs, pimples, cuticles, and other skin imperfections. However, when someone repeatedly picks at, scratches, rubs, touches, or digs into their skin, it is called excoriation disorder. An estimated 2% of Americans have skin picking disorder. Over time, this repetitive habit can lead to:

• Scars
• Skin infections
• Lesions
• Changes in skin color
• Tissue damage
• Disfigurement

Individuals with this disorder may target areas of skin that have already been damaged, or they may seek out healthy areas. In many cases, they may target several different parts of the body. When compulsive skin picking leads to noticeable damage, people often attempt to mask it by using concealer makeup or wearing long-sleeved clothing and long pants even when it is hot. In some cases, they avoid certain situations to reduce the chances of others discovering the problem. They may shy away from intimacy, which negatively impacts relationships. These individuals may also forego medical treatment, which can exacerbate damaged skin.

2. Hair Pulling Disorder

When people habitually pluck the hair from their scalp, eyebrows, eyelashes, arms, legs, pubic area, or other parts of the body, it’s called trichotillomania. Compulsive hair pulling can result in visible bald patches on the head, face, or body. An estimated 2% of U.S. adults have a hair-pulling disorder. Approximately 80%-90% of them are female. Some individuals also eat the hair that they pull out. Consequences of trichotillomania include:

• Patchy baldness
• Itchy skin (pruritis)
• Infections
• Damaged tissues
• Repetitive motion injuries
• Gastrointestinal issues (in those who eat the hair)

Embarrassment about these issues may lead people to cover up with wigs, hats, combovers, scarves, makeup, and other accessories. Additionally, they may avoid situations like windy weather, swimming in a pool or the ocean, going to a hair stylist, medical appointments, and more.

3. Nail Biting Disorder

Nail biting is common in childhood, but in some people it becomes problematic. Chronic nail biting, known as onycophagia, occurs in approximately 12%-44% of the general population. It involves excessively biting the nails, eventually causing damage to them. Consequences of nail biting disorder go beyond the undesirable cosmetic appearance to include:

• Damaged nails and cuticles
• Infections, cellulitis, and absesses
• Injuries to the mouth
• Dental problems
• Temporomandibular disorders (such as TMJ)

Chronic nail biters may feel so ashamed and embarrassed by the appearance of their nails that they go to great lengths to hide them from others. They may isolate themselves from family and friends in their efforts to conceal the habit. This can have dramatic impacts on relationships and overall well-being.

4. Cheek Biting

Also known as cheek chewing, this disorder is associated with excessive biting of the inside of the mouth. Some people may bite other areas of the mouth, such as the lips. Research shows that approximately one out of every million people engages in this oral habit, and it is more common among females. Compulsive cheek biting can result in:

• Sores
• Changes in coloration (redness or paleness)
• Scarring
• Inflamed tissues
• Tears in lining of the mouth

Following chronic cheek biting, the area may begin to feel irregular. This can drive the person to further bite the area in an effort to make it more smooth. To prevent people from noticing this behavior, cheek biters may self-isolate and avoid going to the dentist.

WHAT CAUSES BFRBs?

Body-focused repetitive behaviors may be related to other mental health issues, such as obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), substance use disorders or withdrawal, psychosis, or autism spectrum disorder. One study in Plos One found that pathological grooming—including hair pulling, skin picking, and nail biting—is related to:

• Impulsivity
• Psychiatric distress
• Low-self-esteem

People who struggle with these behaviors often experience certain feelings, thoughts, or urges that compel them to pick, bite, or pull at parts of their body. For example, the following may trigger episodes of BFRB:

• Uncomfortable emotions
• Obsessive thoughts
• Physical tension
• Unpleasant physical sensations
• Seeing a blemish or perceived imperfection

Finding better ways to cope with these triggers is one of the keys to managing these unwanted behaviors.

BFRBs AND THE BRAIN

Brain-imaging research on people with BFRBs, such as one on trichotillomania, have shown abnormal activity levels in some areas of the brain. In a trichotillomania study, the affected brain regions include those that play a role in emotional processing, regulating impulses and habits, and reward processing. Similarly, a brain-imaging study on skin picking found abnormal activity in regions involved in habit formation, inhibition, and action monitoring. Neuroimaging studies also indicate abnormal brain activity in people with OCD. At Amen Clinics, SPECT scans of OCD patients reveal abnormal blood flow and activity in the following areas:

• Anterior cingulate gyrus (ACG): When there is healthy activity in this brain region, it acts like a gear shifter. It’s what helps you shift from one thought to the next or to go from one activity to another. Excessive activity in the ACG is associated with looping thoughts and repetitive behaviors.
• Basal ganglia: This critical brain region plays a role in setting the body’s anxiety level and in habit formation. Too much activity in this region is associated with heightened levels of fear and anxiety.

HOW TO MANAGE BFRBs

The first step to overcoming BFRBs is admitting that you have a problem. If repeated efforts to stop the behavior have failed, it’s critical to seek help from a mental health professional. Treating BFRBs requires a comprehensive approach. First, it’s important to understand if you have underlying mental health issues—such as OCD, anxiety, or depression—that are driving your compulsive behaviors. SPECT scans that measure blood flow and activity in the brain can be very helpful in identifying co-occurring disorders. Investigating all the important aspects of your life—biological, psychological, social, and spiritual—can also provide insight into what’s causing the unwanted behavior. Blood work may also be beneficial in finding infections that may be impacting your thinking and behavior. Treatment recommendations for BFRBs may include:

• Cognitive behavioral therapy (CBT)
• Acceptance and commitment therapy (ACT)
• Dialectical behavior therapy (DBT)
• Habit reversal training
• Stress-management strategies
• Techniques to stop obsessive thoughts
• Nutritional supplements, such as saffron, 5-HTP, and N-acetylcysteine
• Medications (if needed)

Finding the most effective treatment depends on your individual needs. A one-size-fits-all approach will never work for everyone with BFRBs. Make sure you find a mental health professional who will provide a targeted treatment plan that is personalized for your situation. Body-focused repetitive behaviors, OCD, anxiety, and other mental health issues can’t wait. At Amen Clinics, we’re here for you. We offer in-clinic brain scanning and appointments, as well as mental telehealth, clinical evaluations, and therapy for adults, teens, children, and couples. Find out more by speaking to a specialist today at 888-288-9834 or visit our contact page here.