What are Body Focused Repetitive Behaviors (BFRB)
BFRB, or Body Focused Repetitive Behavior, is the general term that refers to routinized and self-damaging behaviors. The most common manifestations of BFRBs are Trichotillomania and Excoriation, but BFRBs can also come in other forms. Trichotillomania, or compulsive hair pulling, and Excoriation, or compulsive skin picking, cause suffers to ritually and routinely scan, ruminate on, and pull one’s own hair, or pick scabs and pimples. In addition to compulsive skin picking and hair pulling, BFRBs can also present as biting the inside of one’s cheek, finger biting, toe nail pulling, and picking or biting finger cuticles.
Picking and pulling routines can result from a wide variety of emotional, cognitive, or environmental triggers. Some begin their scanning to manage anxiety from work and school, others absent mindedly pick and pull during their down time. Furthermore, others can even “zone out” and spend hours picking or pulling in a bathroom or bedroom mirror as part of their daily routine. Elaborate rituals around the preparation, act, and aftermath of picking or pulling also develop. Similarly, rituals can include biting off the hair’s root bulb, eating fingernails or cuticle skin, saving pulled hair or picked scabs, excessive washing routines after popping pimples, taking pictures to monitor acne and acne scarring, and using specialized tools for “greater precision.” In fact, 5-20% of people who pull their hair also swallow the pulled hair.
These behaviors can be hidden from others for years. Very often, people experiencing BFRBs can resist or hide their behaviors around others at work or school, but can then erupt in their routines when they return home or get to another safe location. For some, this can be their bathroom, shower, car, or bedroom.
Without effective treatment, BFRB sufferers can experience worsening or permanent damage to their body. For example, Trichotillomania sufferers can develop bald spots on their scalp, eyebrows, and other picking locations. In severe cases, hair follicles may become damaged beyond the point where hair can regrow. Similarly, compulsive skin picking can cause pimples to become more noticeable after picking, long term blemishes, and even permanent scarring.
Hiding and Shame in BFRB
Skin pickers and hair pullers usually feel an enormous amount of shame surrounding their routines. Surprisingly, they often are able to resist their picking while around others, but when alone their BFRBs can become all-consuming. They can also go to elaborate lengths to hide evidence of their rituals. Some examples include:
- Wearing wigs or hair extensions
- Wearing their hair in specific styles
- Resisting clothing that reveals their picking locations
- Using excessive make up
- Considering cosmetic procedures or surgeries
- Avoiding social or occupational events.
These issues can be treated using Cognitive Behavioral Therapy, Habit Reversal Training (HRT), and mindfulness. The goal is to develop a reality-based perspective of one’s appearance and the ability to control one’s actions, increase awareness of urges and situations that influence picking/pulling routines, and to develop more adaptive and helpful responses to deal with picking/ pulling urges and life stressors. All this combined builds one’s confidence in their ability to control their actions and tolerate the fleeting and fluctuating urges to pick and pull.
Habit Reversal Training, also commonly called Habit Reversal Techniques, helps clients channel their anxiety, nervous energy, and habitual behaviors into more adaptive directions. The self-damaging behaviors of BFRBs can be reduced through a well-constructed set of alternative behaviors that either block or redirect damaging behaviors towards less- and non-damaging activities. Over time and committed use of these tools, BFRB sufferers can find freedom from their harmful routines.
To learn more about BFRBs, including treatment for Excoriation and Trichotillomania, please contact me.
The California OCD and Anxiety Treatment Center offers specialized therapy for Trichotillomania, Compulsive Skin Picking (Excoriation), and other BFRBs in its Fullerton offices. In addition to serving North Orange County, Los Angeles, and the Inland Empire, CalOCD offers online therapy, group therapy, and Intensive Out-Patient treatment.