Body-Focused Repetitive Behaviors (BFRBs)

BFRBs are more common than most people realize. While BFRBs are often stigmatized and misunderstood, research suggests that they are actually quite prevalent. For example, trichotillomania affects approximately 1 to 2% of the population (Thomson et al., 2022), while skin-picking disorder affects between 1 to 5% of adults (Grant et al., 2012). Despite their prevalence, many people with BFRBs may feel ashamed or embarrassed about their behavior and may not seek treatment. However, with increased awareness and understanding of these conditions, people may feel more comfortable seeking help and support to better manage their symptoms.

BFRBs can be also classified as either "focused" or "automatic" behaviors. Focused behaviors are intentional and usually occur when a person is feeling anxious or stressed. Automatic behaviors, on the other hand, are done unconsciously and without any awareness of the behavior.

The physical consequences of BFRBs can be severe, including scarring, infections, and even permanent hair loss. The emotional toll can also be significant, including feelings of shame, embarrassment, and low self-esteem. Additionally, BFRBs can interfere with daily activities, such as work or school, and can cause significant distress and impairment.

Fortunately, BFRBs are treatable. The front-line treatment is Habit Reversal Therapy (HRT).

What is Habit Reversal Therapy (HRT)?

Habit Reversal Therapy is a behavioral therapy that aims to identify and replace negative behaviors with positive ones. HRT is based on the principle that habits are learned behaviors and can be changed through the use of behavioral techniques. The steps involved include:

• Awareness training: The first step of HRT involves teaching you to become more aware of the repetitive behavior. This can be done through self-monitoring techniques such as keeping a log or journal of when and where hair pulling, skin-picking, or nail-biting occurs.

• Competing response training: The next step of HRT is to teach you to engage in an alternative behavior when you feel the urge to pull, pick, or bite. This behavior should be incompatible with the BFRB, meaning that it cannot be done at the same time. For example, clenching your fist, playing with a thread, or squeezing a stress ball can be effective alternatives to pulling or picking.

• Stimulus control: Stimulus control means that certain cues in the environment influence when a behavior occurs. For example, you may be more likely to pick, pull, or bite in certain locations (e.g., at your work desk) or situations (e.g., when watching TV or doing homework). By modifying the triggers in the environment, we can help you learn to manage the behavior more effectively.

• Social support: It is important to have a supportive environment as you address TTM. Treatment may involve asking a trusted loved one, friend, roommate, or partner, to subtly and gently let you know when you may be engaging in automatic or mindless hair-pulling, picking, or biting.

• Maintenance and relapse prevention: Once you have learned to identify and replace the behavior with an alternative behavior, it is important to continue practicing these skills to maintain progress.

Habit Reversal Therapy is an effective treatment for BFRBs. It has been shown to be the most effective treatment to reduce the frequency and severity of BFRBs (Skurya et al., 2020), as well as improving quality of life. If you or someone you know is struggling with a BFRB, it is important to seek help from a mental health professional with knowledge of HRT who can provide guidance and support.

One interesting aspect of HRT is that it is a versatile treatment that can address a wide range of behaviors beyond BFRBs like Tourette's syndrome, stuttering, and tic disorders. This highlights the flexibility and adaptability of HRT as a treatment approach and underscores the importance of evidence-based, individualized treatment plans that address the unique needs of each client.

Summary

Body-focused repetitive behaviors (BFRBs) are a group of psychological disorders characterized by repetitive behaviors that result in physical damage to the body. BFRBs can have a significant impact on mental health and well-being, but there are treatments available to manage symptoms and improve quality of life. Habit reversal therapy is a type of cognitive-behavioral therapy and aims to help clients recognize their BFRB behaviors, understand their triggers, and develop alternative behaviors to replace them. It has been shown to be the most effective treatment for BFRBs.

If you or someone you know is struggling with hair pulling, skin picking, or nail biting, finding a therapist who specializes in BFRBs can be a great first step. I am a graduate of The TLC Foundation for BFBRs Virtual Professional Training Institute. I serve Las Vegas, NV, and Nevada statewide as well as Portland, OR, and all of Oregon statewide (California and to 33+ PsyPACT states). You may call me at (702) 530-6134, schedule an initial consultation, or use the contact form to take the first step and to develop a personalized treatment plan.