Imagine that you had an urge to pull out your hair that was so strong it wouldn’t go away. You try and distract yourself but that doesn’t work. The tension continues to build until you pull out the hair. You might say to yourself, “I’ll just pull out this one,” but one turns into two then ten. The next thing you know you have a visible bald spot on your head.
Along similar lines, what if every time you went to the bathroom to wash your hands or wash your face, you couldn’t help but look in the mirror and focus on any small blemishes you see? You can’t stop yourself because the urge to pick at it overwhelms you. As a result there is now a large bleeding sore on your face, or maybe several.
Body-Focused Repetitive Behavior (BFRB)
The above examples illustrate what it is like for those who struggle with Body-Focused Repetitive Behaviors. Some common BFRBs are:
- Hair pulling
- Nail biting
- Skin picking
Body-focused repetitive behaviors are compulsive, repetitive behaviors directed toward one’s body that ultimately alters one’s physical appearance (i.e. thinning hair, bald spots, scabs, missing eyelashes, chewed nails), and may lead to loss of self-esteem, shame, and even social alienation. Despite this, stopping or reducing these behaviors can be very challenging.
Anxiety Worsens Due to Body-Focused Repetitive Behaviors
While anxiety does not cause someone to develop BFRBs, they often occur together, and anxiety plays a large role in exacerbating these conditions. Studies have observed that those with BFRBs experience significantly higher levels of anxiety and depression than those without.1
In my clinical experience, most people who struggle with BFRB’s experience a tremendous amount of shame, distress, and powerlessness over their condition. Hair pulling and skin picking, especially, can substantially alter one’s physical appearance, leading to thinning hair, baldness, no eyebrows or eyelashes, as well as scabs and scars. This may lead to social anxiety, embarrassment, rejection, low self-esteem, and depression.
As these consequences become more significant to the individual, levels of anxiety increase, and a person can begin to feel a complete lack of control. A vicious cycle then ensues, because anxiety and distress then trigger the need to self-soothe by use of the BFRB. It has been my experience that effective BFRB treatment, not only reduces the frequency and severity of the behavior, but must also address issues related to self-esteem, body image, and anxiety management.
Habit Reversal Training
Although there are several treatment options available to sufferers, research suggests that Habit Reversal Training (HRT), a specific type of behavioral intervention, is one of the most effective forms of treatment. HRT involves several components, including:
- Building awareness of one’s urges to pick or pull, etc.
- Identifying situations, places, activities, and urges that typically precipitate the behavior
- Tolerating urges
- Reducing cues that lead to the body-focused repetitive behavior
- Developing a competing response that the person can use instead of the behavior
HRT shows high efficacy rates in reducing BFRBs. Patients who have had difficulties resisting the urge to bite their nails increased their nail lengths by 22 percent after using HRT.
If you or someone you know would like help for a body-focused repetitive disorder, seek help from a mental health professional who specializes in treating BFRBs. Working with a specialist can help you or a loved one reduce anxieties over body image in a nonjudgmental environment.
1Teng, Ellen J., Douglas W. Woods, Brook A. Marcks, and Michael P. Twohig. “Body-focused repetitive behaviors: The proximal and distal effects of affective variables on behavioral expression.” Journal of Psychopathology and Behavioral Assessment 26, no. 1 (2004): 55-64.
Liana Georgoulis, Psy.D., is a clinical psychologist and founder of Coast Psychological Services in California. She holds a Doctorate in Clinical Psychology from Pepperdine University and specializes in Cognitive Behavioral Therapy (CBT) for adults and adolescents. Additionally, Dr. Georgoulis offers group therapy sessions addressing social anxiety, social skills, and assertiveness. She also supervises post-doctoral fellows and psychological assistants in her role as clinical director.