What are BFRBs?
BFRB is a general term that refers to any repetitive self-grooming behavior (e.g., pulling, picking, biting or scraping of the hair, skin or nails) that results in damage to the body. In addition to hair pulling, common BFRB behaviors include picking or biting of the skin (e.g., scabs, acne or other skin imperfections), cuticles or nails, and lips or cheeks. These behaviors are all considered BFRBs because they share similar characteristics. The difference between normal grooming behaviors and a BFRB arises when the behavior(s) cause substantial personal distress and/or interfere with daily functioning The two most common BFRBs are trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder.
Trichotillomania is characterized by repetitive pulling out of one’s hair (from the scalp, eyebrows, eyelashes or elsewhere on the body). According to the Diagnostic and Statistical Manual of Mental Disorders (5th edition) of the American Psychiatric Association, trichotillomania is defined as meeting the following five criteria:
• Recurrent pulling out of one’s hair, resulting in hair loss.
• Repeated attempts to decrease or stop hair pulling.
• The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
• The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).
Excoriation (Skin Picking) Disorder
Excoriation disorder, also known as skin picking disorder, is characterized by repetitive manipulation of the skin causing tissue damage. According to the Diagnostic and Statistical Manual of Mental Disorders (5th Edition) of the American
Psychiatric Association, excoriation disorder is defined as meeting the following criteria:
• Recurrent picking at the skin resulting in skin lesions.
• Individuals must have made repeated attempts to decrease or stop the excoriation.
• The skin picking causes clinically significant distress or impairment in social, occupation, or other important areas of functioning.
• The skin picking is not attributable to the psychological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies
• The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body-dysmorphic disorder, stereotypes in stereotypic movement disorder, or intention to harm oneself in non-suicidal self-injury).
What causes BFRBs?
It is unclear why some people engage in these behaviors and others do not. 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 than would be expected in the general population. Further evidence from a twin study showed higher concordance, or agreement, in the occurrence of hair pulling in identical vs. fraternal twins. Given the possibility that some or all BFRBs have a genetic origin, researchers are currently studying the genes of people suffering from BFRBs in an effort to isolate gene markers that may clarify the origins of these problems and, it is hoped, lead to more effective treatments. It is important to note that even if a predisposition toward BFRBs is inherited, there are certainly other factors involved, including temperament, environment, age of onset, and family stress factors. Hair pulling and skin picking can be seen in other species such as primates who pick at nits and other insects on their own fur and the fur of others; birds who are stressed will pull out their feathers; mice have been known to pull their own fur and that of their cage mates; and dogs and cats may lick their skin or bite at an area, removing fur until there are bald spots and sometimes damage to the skin. Animal researchers are trying to understand these similar-appearing behaviors in animals to shed light on the complex neurobiology that underlies the human experience of BFRBs.
Recommended treatment for BFRBs
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 outcome. However, some individuals may need medication first or in conjunction with CBT.
Cognitive Behavior Therapy (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.
Habit Reversal Training (HRT)
Habit reversal training (HRT) is an early treatment for BFRBs developed in the 1970s by Nathan Azrin and Gregory Nunn. HRT is the method that has been examined most in research studies. HRT has a varying number of components in its treatment package. The three components that are considered most critical are awareness training, competing response training and social support.
Comprehensive Behavioral Treatment (ComB)
The comprehensive behavioral (ComB) model, developed by Dr. Charles Mansueto and his colleagues, is based on the assumption that a person engages in their BFRB because it meets one or more need in the individual (e.g., helping to relax, to fall asleep, or to feel like a goal was accomplished). This model focuses on understanding why, where and how a person engages in their BFRB so that individualized interventions can be selected to help the person achieve what they want to achieve without engaging in the BFRB. The ComB model consists of four components: Assessment, Identify, and Target Modalities, Identify and Choose Strategies, and Evaluation. It focuses on understanding five domains:
Sensory, Cognitive, Affective, Motor, and Place (SCAMP).
Acceptance and Commitment Therapy (ACT)
A promising treatment approach that may serve to add strength to other cognitive behavior therapies is called acceptance and commitment therapy (ACT), developed by Steven Hayes. This approach differs from others in that it promotes an increased acceptance of, and tolerance for, urges to pick or pull, without acting to reduce or eliminate them. Thus, individuals are asked to experience negative emotions that come before or after pulling as events to be observed without judgment rather than as events that must be acted upon. Understanding, feeling and experiencing that one does not have to respond to an urge or emotion can be quite freeing.
ACT-Enhanced Behavior Therapy
Dr. Douglas Woods and his colleagues developed an ACT-enhanced behavior therapy that combines principles of ACT with other strategies typically used to treat BFRBs, including HRT and stimulus control. These latter strategies are employed only to make the pulling or picking more difficult for the individual (not to eliminate urges) so the individual can engage in more value-driven activity. Early research has documented that the use of ACT-enhanced habit reversal treatment is more effective than a control condition in reducing pulling symptoms. Importantly, short-term treatment benefits were also maintained several months after treatment termination. Additional research is needed to confirm these findings. A large-scale randomized, controlled trial of ACTenhanced behavior therapy is underway.
Dialectical Behavior Therapy (DBT)
DBT, a treatment developed by Marsha Linehan, is another treatment approach that may add to the effectiveness of other learning-based therapies. DBT was researched by Dr. Nancy Keuthen in conjunction with more traditional habit reversal and stimulus control approaches. A pilot and a randomized controlled study demonstrated the superiority of DBT-enhanced behavior therapy to a minimal attention control condition for TTM. Maintenance of treatment benefit months after treatment termination was demonstrated. As with all other approaches discussed earlier, additional research is needed to confirm treatment efficacy and to understand the mechanisms by which they reduce symptoms. This approach has not yet been utilized to treat BFRBs other than hair pulling. DBT has four modules including mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance. In DBT-enhanced behavior therapy, all of the modules were utilized except for interpersonal effectiveness.
The TLC Foundation for Body-Focused Repetitive behaviors offers the following resources for patients, families, and clinicians: www.bfrb.org website offers:
Treatment Provider Referrals
A free directory of local mental health professionals and online treatment resources
Support Group Locator
A searchable database of regional support groups and online forums
Salon and Service Provider Directory
Find a BFRB-aware cosmetologist, a skin care provider, and other providers
Books, Sensory Fiddles and Other Products
A curated selection of clinical books, biographies, fiddles, brochures, and BFRB awareness products