Posted April 10th, 2023

What are BFRBs?

Body-focused repetitive behaviors (BFRBs) include any repetitive physical 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" according to the TLC Foundation for BFRBs. Check out their website for more information. 

These behaviors are unfortunately common in the general population (example: nail biting), and amongst the most poorly understood, underdiagnosed, and untreated group of mental health disorders. According to the research, it's suggested that causes of BFRBs include improving/correcting a perceived imperfection in physical appearance, in addition to self-regulation of intense emotions - becoming an unhealthy but habitual method of coping. There may also be genetic and social factors impacting the statistics on BFRB: several studies have shown a higher number of BFRBs in immediate family members of diagnosed individuals with skin picking or hair pulling than would be expected in the general population. ‍There are times when pulling/picking occurs in a goal-directed manner and also in an automatic manner in which the individual is less aware. Many individuals report noticeable sensations before, during, and after repetitive behaviors. A wide range of emotions, spanning from boredom to anxiety, frustration, and depression can affect hair pulling and other behaviors, as can thoughts, beliefs, and values.

Strategies for Skin-Picking:

This section of the article was written by a BFRB community member who participated in a small group of skin pickers that met daily with Charley Mansueto, Ph.D., Suzanne Mouton-Odum, Ph.D., and Sherrie Vavrichek, LCSW during a TLC Conference.

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The COMB model has 5 categories (SCAMP), so my notes are divided into sections:

1. Sensory
2. Cognitive
3. Affective (emotions)
4. Motor
5. Place / environment

Client reports: Writing this out has been really fun! It's also powerful to notice that I've incorporated nearly 50 practices into my daily routine. I'm really making this a priority, and it's good to notice that it's working! My picking is dramatically reduced from 3 years ago, when I was doing only 2 or 3 of the strategies.

SENSORY – Strategies I'm Using (6)

• Exercise
• Face-stimulator
  One of my skin-picking buddies gave me this little skin-stimulator, a flat palm-sized thing with short plastic bristles. When I rub it on my face, it creates a pleasant sensation, stimulating the nerve endings in the face gently.
• Touch-toys / fiddle toys
• Face-care routine
  Having a regular routine of cleaning and caring for my face and skin gives me ways to touch my face, in a loving caring way.
• Weeding instead
  Weeding is SO satisfying! Especially pulling up weeds by the roots, it's a lot like hair-pulling, but good for the world!

SENSORY – Strategies I could try (12)

• Use face-stimulator more often
• Cleansers with abrasiveness
• Remember: fingertips are not my friend!
• Avoid using fingertips
• Hand cream / cuticle cream
• Music
• Drinking water
• Drawing
• Fragrances
• Floss instead
• Bubble wrap!
• Pay attention to sensory experience of other tasks or chores
  Like the Zen practice of washing dishes with focus.

To read more, and learn what strategies are in the other 4 categories (Cognitive, Affective, Motor, and Place/Environment) check out the original article on the TLC website by clicking here!

Strategies for Hair-Pulling:

Hair pulling disorder or trichotillomania, is characterized by repetitively pulling out one's hair, and this can be hair from anywhere on the body where hair grows. Hair pulling disorder usually begins in late childhood/early puberty, and occurs about equally in boys and girls. By adulthood, 80-90% of reported cases are women. Hair pulling varies greatly in its severity, location on the body, and response to treatment. Without treatment, hair pulling disorder tends to be a chronic condition; that may come and go throughout a lifetime. Those who ingest the pulled hair or parts thereof may experience gastrointestinal distress or develop a trichobezoar (hairball in the intestines or stomach), which could lead to gastrointestinal blockage and require surgical removal. Although trichobezoars are rare, they are a serious risk for those who ingest hair.

The following list is from an article written by an anonymous individual who experienced hair-pulling and accomplished 9 weeks "pull-free." 50 strategies to prevent and stop pulling:

Many of these have helped me achieve my 9 weeks pull free.‍

*  = I have tried these methods.

**  = These tips have helped me the most.

• Wear a bandana to bed. *
• Make a sticker chart. Every day that you go without pulling add a sticker. Hang this sticker chart in a room where you pull the most.**
• Reward yourself after several days (or hours) of being pull free.*
• Be patient with yourself.*
• Join a support group.*
• Talk to another person with hair pulling.*
• Wet down your hair. This will make it really hard to pull out your hair since it will be slippery.*
• Learn what your body needs instead of pulling. Is your body tired, hungry, sleepy, and excited, etc? Then tell yourself out loud what you need and go do it.**
• Stimulate your senses. Many of us that pull like the sensation that comes with it. Instead of pulling do other things to stimulate these such as washing your hair, brushing your lips on dental floss or string (if you rub the hair on your lips), and massaging your scalp.*
• Avoid caffeine right before bed. Often bedtime is a time when a lot of people pull. By using caffeine you keep yourself up longer and it heightens anxiety.*
• Buy a fidget toy.*
• Find other things to do with your hands such as knitting, crocheting, or cross stitch. *
• Wear a hoodie to bed as a barrier to pulling. *
• Go see a psychologist that performs cognitive behavioral therapy

See the rest of this list in the original article on the TLC Foundation website here. 

Strategies for Nail Biting:

To support you in ending nail biting, dermatologists and mental health professionals recommend the following tips:

1. Keep your nails trimmed short. Having less nail provides less to bite and is less tempting.
2. Apply bitter-tasting nail polish to your nails. Available over-the-counter, this safe, but awful-tasting formula discourages many people from biting their nails.
3. Get regular manicures. Spending money to keep your nails looking attractive may make you less likely to bite them. Alternatively, you can also cover your nails with tape or stickers or wear gloves to prevent biting.
4. Replace the nail-biting habit with a good habit. When you feel like biting your nails, try playing with a stress ball or silly putty instead. This will help keep your hands busy and away from your mouth.
5. Identify your triggers. These could be physical triggers, such as the presence of hangnails, or other triggers, such as boredom, stress, or anxiety. By figuring out what causes you to bite your nails, you can figure out how to avoid these situations and develop a plan to stop. Just knowing when you’re inclined to bite may help solve the problem.
6. Try to gradually stop biting your nails. Some doctors recommend taking a gradual approach to break the habit. Try to stop biting one set of nails, such as your thumb nails, first. When that’s successful, eliminate your pinky nails, pointer nails, or even an entire hand. The goal is to get to the point where you no longer bite any of your nails.

For some people, nail biting may be a sign of a more serious psychological or emotional problem. If you’ve repeatedly tried to quit and the problem persists, consult a doctor or mental health professional. Click here to check out this article from the American Academy of Dermatology Association.

How to Support a Loved One

Body-focused repetitive behaviors can be a difficult issue to navigate, especially when it affects someone close to you. Knowing that most cases of BFRP are not considered intentional self-harm can be reassuring for loved ones. If you have a loved one struggling with skin-picking, hair pulling, or other BFRP, it's important to have patience, and offer support and understanding if the individual chooses to talk with you about what they're going through. Different individuals may have different desires and hopes and from their support systems. Many individuals with BFRB concerns report feeling guilt, embarrassment and/or shame in relation to their symptoms. Supporting a loved one can involve listening without judgment, validating their emotions, and encouraging your loved one to seek the help of a licensed mental health professional when needed. At Annette's Mindful Therapy Practice, I work with individuals, children, and couples to address a wide variety of issues.

Get in Touch with Annette's Mindful Therapy Practice

At Annette's Mindful Therapy Practice, Annette understands the challenges that come with managing body-focused repetitive behaviors such as skin-picking, nail-biting, and hair-pulling. Mental health providers are here to provide support and guidance to help you navigate these difficult issues. If you're interested in learning more about our services, please don't hesitate to reach out. You can contact us at +1 360-818-4091 or [email protected]. We look forward to hearing from you!