Body-Focused Repetitive Behavior (BFRB) Disorders

What are body-focused repetitive behavior (BFRB) disorders?

Body-focused repetitive behavior disorders, also known as BFRBs, are a group of conditions that cause you to perform self-grooming actions that unintentionally harm your body.

Many people recognize BFRBs as nervous habits, like picking the skin around your nails or cracking your knuckles when you’re bored. But these behaviors are more than just something to do to pass the time. Research suggests your genetics, brain structure and emotions play a role in why these behaviors happen.

You may try to reduce how often you perform these behaviors but find it difficult to stop them. BFRBs come on with an intense, uncontrollable urge and may bring feelings of pleasure or satisfaction when you do them. Treatment options are available to help you if you need it.

What are the types of body-focused repetitive behavior disorders?

The two most common types of body-focused repetitive behavior disorders include:

• Excoriation or dermatillomania (skin picking).
• Trichotillomania (hair pulling).

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) identifies these two types in their current edition.

There are other types of BFRBs, including:

• Bruxism (teeth grinding).
• Crepitus (finger joint cracking).
• Dermatophagia (skin biting).
• Finger sucking.
• Lip bite keratosis (lip biting).
• Morsicatio buccarum (cheek biting).
• Onychophagia (nail biting).
• Onychotillomania (nail picking).
• Rhinotillexomania (nose picking).
• Trichophagnia (hair eating).

While these aren’t specified in the DSM-5-TR, a healthcare provider can still diagnose these types as a related BFRB disorder.

How common are body-focused repetitive behavior disorders?

Several studies found that between 0.5% and 4.4% of people have a clinical BFRB diagnosis. However, the rate of occurrence is actually much higher because many people don’t reach out to a healthcare provider for help with these conditions.

What are the symptoms of body-focused repetitive behavior disorders?

Common body-focused repetitive behaviors include:

• Picking or pulling your hair, nails or skin.
• Biting or chewing your nails, lips or cheeks.
• Cracking your finger joints or knuckles.
• Grinding your teeth.

You may feel:

• Anxious before the behavior starts and relief after the behavior stops.
• Out of control (unable to stop) during the behavior.
• Aware of what you’re doing (conscious action) or unaware of what you’re doing.

What causes body-focused repetitive behaviors?

Healthcare providers aren’t sure why BFRB disorders happen. Research suggests the following may contribute:

• Brain structure and genetics: The structure of parts of your brain involved in reward processing and emotion may cause BFRBs. Your genetic makeup determines how these parts of your brain develop and function. Genetics may also affect the chemical regulation within your brain of serotonin and dopamine (mood and impulse control).
• Emotional regulation: These behaviors may be your body’s way of handling or avoiding negative emotions like discomfort, embarrassment, boredom and unhappiness.
• Distraction: BFRBs may be a distraction technique used when you feel understimulated or overstimulated. These behaviors may help you through a stressful or uncomfortable situation by taking your mind off what’s going on around you.

While there are some mental health conditions where factors like vanity or a desire to change your appearance drive your behavior, these don’t cause BFRBs.

What are the risk factors for body-focused repetitive behavior disorders?

You may be more at risk of BFRBs if you:

• Are assigned female at birth.
• Experienced abuse or trauma.
• Have a biological family history of BFRBs.
• Have low self-esteem.
• Have obsessive-compulsive disorder.
• Have substance use disorder.

What are the complications of body-focused repetitive behavior disorders?

Repeatedly biting, picking or pulling at different parts of your body can lead to the following complications:

• Bacterial infections.
• Bleeding (open wounds).
• Hair loss.
• Scarring.

You may experience a range of emotions that affect your mood, self-esteem and confidence due to how these self-modifying behaviors unintentionally change your appearance. A mental health professional can help you manage these.

How are body-focused repetitive behavior disorders diagnosed?

A primary care physician, dermatologist or dentist may be the first to recognize the signs of BFRBs. A provider may ask you about your symptoms and how you feel. They may then refer you to see a mental health provider, such as a psychologist or psychiatrist.

A mental health provider will offer an evaluation to see if your symptoms match the following criteria to make a BFRB diagnosis:

• You perform a repetitive behavior on your body that causes damage.
• You try to stop (or lessen) this behavior but can’t.
• This behavior causes you stress or affects how you’re able to function.

How is BFRB treated?

BFRB treatment may include one or a combination of the following:

• Therapy: A mental health professional will teach you habit-reversal training techniques during cognitive behavioral therapy (CBT). You’ll gain more awareness about what could trigger these behaviors and find alternative ways to respond to them.
• Medications: There isn’t a medication approved by the U.S. Food and Drug Administration (FDA) for BFRB disorders. However, medications are available to help you manage symptoms. A provider may recommend taking selective serotonin reuptake inhibitors or antidepressants. The supplement NAC (N-acetylcysteine) may be helpful as well.

It’s important to stick to your treatment plan even if you’re feeling better. You should continue to take the medications prescribed to you as directed unless your provider approves any changes made to your routine.

What can I expect if I have a body-focused repetitive behavior disorder?

BFRBs look and feel different for each person. You may feel anxious, comforted or distressed. It’s difficult to know when the urge to perform a behavior will happen because sometimes, you aren’t aware that you’re doing it unless someone points it out. Over time, these behaviors may damage your body or lead to complications like scars or infections.

Treatment options, usually a combination of therapy and medications, help manage BFRB symptoms. It takes time and practice to get there — you won’t stop these behaviors overnight. If you have any questions about what you can expect from your treatment plan, talk to your provider.

When should I see a healthcare provider?

Visit a healthcare provider if you have body-focused repetitive behaviors that you want to stop but have trouble managing on your own. This may include skin picking, teeth grinding or hair pulling, among others.

Let a healthcare provider know if you have symptoms of an infection like pain, swelling or pus leaking from a wound.

What questions should I ask my healthcare provider?

• How do I stop BFRBs?
• Should I talk to a mental health professional?
• Do you recommend I take medications?
• Are there side effects to taking medications?