Body-Focused Repetitive Behavior (BFRB) Treatment in Los Angeles
Written by Dr. Alexis Hershfield
What are Body-Focused Repetitive Behaviors (BFRBs)?
BFRB is an umbrella term used to describe a group of related disorders involving a set of repetitive self-focused grooming behaviors. Common examples of BFRBs include hair pulling (trichotillomania), skin picking (excoriation), and nail biting (onychophagia). For some people, BFRBs are merely a frustration. However, for others, these behaviors can lead to significant interference in daily functioning and physical injury. While BFRBs are not considered a mood or anxiety disorder, various emotional states may provoke pulling/picking behavior (e.g., fatigue, anxiety, tension, boredom and sadness). People with BFRBs often report experiencing unpleasant bodily sensations prior to engaging in the behaviors and report that the behaviors result in temporary reduction of these physical experiences. Along with hair loss and skin lesions, BFRBs can lead to serious physical injuries such as skin infections, gastrointestinal problems, comorbid mental health problems (e.g., depression, anxiety) and significant psychosocial, academic and occupational impairment.
Current research suggests that approximately 2-5% of the population lives with a BFRB.
Yet many researchers and clinicians believe that these figures are an underrepresentation of the full story. BFRBs often go undiagnosed or are untreated due to personal shame and lack of resources and education. BFRBs may develop at any age, and can present as early as one year of age. Average onset typically begins during puberty. Over time, symptoms may wax and wane in severity. Research indicates that the timing and course of symptoms may depend on a number of factors including frequency and intensity of life stressors, temperament, environment, family inheritance, hormone imbalances, and access/engagement in early intervention. Among adults, females outnumber males significantly (9:1).
Early signs of BFRBs:
Searching behaviors (rubbing fingers over hair or skin, twisting/playing with hair)
Intense focus on body irregularities (acne, scabs, thick/coarse hair, bumpy skin, rough cuticles)
Urge to fix irregularities
Increased time spent in the bathroom or in front of the mirror
Loss of hair
New unexplained skin sores/patches
Do BFRBs look the same for everyone?
No, not at all. We find that BFRBs are experienced widely across individuals. Some individuals report that BFRBS are focused behaviors that serve an emotional regulation function, while others state that the majority of their behaviors are automatic and lack awareness. Behaviors can occur during sedentary activities (e.g., lying in bed, sitting in the car, watching television) or during more active periods (e.g., putting on makeup, playing sports). We also know that for some individuals the disorder is closely linked with thoughts and feelings about personal appearance while for others the experience is purely sensory. This is why it is important that individuals receive evidence-based treatment that is individualized to address the personal factors that trigger and maintain behaviors.
Treatment for BFRBs
At this time, there is strong research that supports certain forms of Behavioral Therapy for the treatment of BFRBs. These treatments focus on increasing one’s awareness of their picking/pulling behavior and urges and learning how to engage in competing responses. Treatment also incorporates stimulus control to help identify cognitive, sensory, emotional and environmental triggers, and distress tolerance/emotion regulation skills.
When approaching a child about beginning treatment, providers recommend parents first starting a dialogue at home about observed behaviors, inquiring whether your child is aware of any triggers and asking about their desire to change their behavior at this time. For some children, picking/pulling behaviors may be more distressing for their parents than for themselves as it is challenging to see your child inflict damage on their physical selves. However, for other children, BFRBs may be causing significant social and emotional interference. Each developmental stage may bring unique challenges to treatment and should be addressed in treatment by your clinical provider.
Parents may be asked to play an active role in treatment depending on your child’s age and stage and may be asked to help with monitoring and managing treatment with guidance from the therapist. While psychotherapy continues to be considered the first line of treatment for BFRBs, medications are often used as well. Current data suggests that medications have little impact on the course of the disorder, though some people do benefit, especially those with comorbid mental health concerns.
To learn more about BFRBs, consider viewing the TLC Foundation’s website and resources.
