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Have you ever felt frustrated when friends or family members tell you to simply stop repetitively picking at your skin, biting your nails, or pulling out hair when you know it’s just not that simple?
Both skin picking and nail biting, as well as hair pulling, cheek or lip biting, and even nose picking can fall into the category of body-focused repetitive behaviors, or BFRBs. While many people pick at their skin or body, a BFRB is defined as any recurrent, problematic, and destructive behavior that is directed toward the body.
“What distinguishes the condition from a habit versus a disorder is that there’s either repeated attempts to stop picking or pulling and it’s very hard to stop,” said Dr. Lisa Zakhary, medical director of the Massachusetts General Hospital Center for OCD and Related Disorders. “Most importantly, the defining feature is that the condition is really causing distress or impairing social relationships or work in some way. Habits don’t tend to do that.”
About 5% of the population is affected by one of these conditions, according to BFRB.org, an organization that offers support and resources to connect people in the BFRB community and help them manage their symptoms.
How BFRBs are treated
While BFRBs share some characteristics with obsessive-compulsive disorder, they are not the same.
“OCD is considered distinct from OCD-related disorders,” Zakhary said. OCD is characterized by having intrusive thoughts that are difficult to stop or having compulsive behaviors, whereas hair pulling, known as trichotillomania, and skin picking, known as excoriation disorder (or dermatillomania, as it was previously known), are considered to be OCD-related disorders.
“They’re part of the OCD category, but they are not OCD,” she said. “Many people with skin picking or hair pulling don't have any OCD symptoms at all.”
Experts agree that the first step in determining which treatment is best for any given BFRB is to evaluate the severity of symptoms and what other underlying conditions are in play.
People with BFRB disorders tend to have increased rates of anxiety and depression, said John Piacentini, director of the Child OCD, Anxiety, and Tic Disorders Program at UCLA.
“Sometimes we actually want to start with the depression and anxiety first because that will reduce some of the triggers,” said Piacentini, who is also a professor of psychiatry and biobehavioral sciences. “But if I’m depressed because I pick or pull, we’ll start with the picking and pulling because that should help the depression.”
Though it’s always helpful to see a specialist for guidance, Zakhary said there are many roads to recovery outside of ongoing therapy for those who don’t have access to a specialist.
“Determining what way you get that therapy and if you actually need that therapy or can do a component of that therapy completely on your own depends on the severity of your symptoms,” she said. “Should you be in therapy? Should you start a medication? Are your symptoms mild enough that you can just see a dermatologist?”
Since BFRBs are focused on some part of the body like the skin or hair, it’s possible that a dermatologic trigger — such as an itchy scalp or persistent acne — is driving symptoms. In some of those cases, treating the dermatologic trigger may also lessen the BFRB.
However, if you or a specialist determine that therapy is the right move, it will likely consist of habit reversal therapy with a cognitive behavioral therapist.
“You’re basically trying to pair the urge that you feel before you have a tic or habit and re-pair that premonitory urge with new behavior,” said Adam Weissman, a psychologist at the Child & Family Institute. “That can basically work with anything from actual tic disorders to dermatillomania, trichotillomania, and any other common habits like nail biting.”
A premonitory urge is a feeling of discomfort or tension that can be relieved by a particular movement, like a motor tic, pulling hair, or picking at skin. If you don't have a tic disorder or BFRB, the feeling is akin to trying to ignore a mosquito bite. You can’t think about anything but that itch until you scratch it, and after you scratch it and get relief, you only want to do it again.
People with BFRBs undergo awareness training so they understand when their behavior is happening and what triggers it.
Essentially, the goal is to retrain your behavior so that instead of the premonitory urge leading to a body-damaging response, there’s a new behavior that is less harmful. This can include the use of a stress ball or fidget toy to occupy your hands (if your habit involves the hands or fingers) or relaxation techniques that help reduce behavior-exacerbating stress.
Known as stimulus control, changing your environment or distracting your fingers can make it harder for you to pick or pull. Weissman said that social support is also essential. It can be helpful to have someone point out when you’re engaging in these behaviors and hold you accountable. While a therapist can serve as that person in sessions, you need that support to continue from friends and family in your everyday environments.
Weissman also said that challenging yourself to delay even just for 30 seconds or a minute can be hugely helpful.
“If after a minute the urge is still strong, have at it. But if it’s gone down, keep delaying,” he said. Eventually, you keep pushing the first time you engage in the behavior back further and further each day until you potentially get to a place where it’s bedtime and you haven’t thought about doing it at all.
Whatever your trigger or chosen treatment plan may be, below are some products that may help you deal with BFRBs. As Piacentini said, the important thing is that you need to match the specific tool to the person, environment, and needs of the individual. Everyone is going to be different.
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