Body-Focused Repetitive Behaviours (BFRBs) is an umbrella term that describe a complex set of behaviours that are driven by a strong urge to perform repetitive actions towards one’s own body. BFRBs include hair-pulling (trichotillomania), skin-picking (excoriation disorder), nail-biting (onychophagia), or cheek-biting resulting in some physical damage or hair loss. The official term for hair-pulling, trichotillomania, comes from the Greek words for “hair” (trich), “pull” (tillo), and “frenzy” (mania). Similarly, dermatillomania, a term previously used to describe skin picking, was formed from the Greek words for “skin” (derma), “pull or pick” (tillo), and “frenzy” (mania). The reference to “mania” simply refers to the feeling of being out of control in the ability to stop picking or pulling. Therefore, by definition, BFRBs are extremely difficult behaviours to stop. In fact, most people have tried to do so many times (!), with little success. BFRBs frequently cause a significant degree of distress and can get in the way of normal life.

BFRBs can have significant impacts on health and wellbeing. The severity of these habits can range from mild (takes up little time, minimal physical damage) to very severe (incredibly time consuming, causing significant physical damage or changes in appearance). Common physical consequences of BFRBs can include permanent hair loss, follicle damage, scalp irritation, repetitive strain injuries, scarring, sores, and infections. While rare, some individuals with hair-pulling disorder may engage in the eating of whole hairs which can lead to the development of trichobezoars (hair balls) that form in the digestive tract and which can be fatal. If you or someone you care about engages in this behaviour it is very, very important to inform a health care professional! Emotional consequences are extremely common and include feeling unattractive, shame, guilt, embarrassment, social difficulties, poor school attendance, and poor academic performance. People with BFRBs might avoid social gatherings, brightly lit areas, swimming, sports, and even being outdoors.

Unfortunately, BFRBs tend to be poorly understood even though these conditions are quite common! Prevalence rates in the general population range from 1 to 15 percent for hair-pulling and from 1.4 to 13 percent for skin-picking. Rates of BFRBs are even higher in individuals with Tourette Syndrome, ADHD, anxiety, and OCD. Overall, experts think that prevalence rates are actually much higher than we think, given that many people may be too ashamed or embarrassed to tell others about their BFRB.

BFRBs tend to be chronic (long-lasting) disorders that fluctuate over time. Symptoms of BFRBs can occur at any time during childhood or adolescence. It is common for skin-picking disorder to first occur in adolescence with the onset or pimples or acne; however, many people may pick at bug bites, dry skin, minor skin imperfections and even healthy skin. Similarly, trichotillomania can occur at any age, but the most common age of onset is also in adolescence. People are most likely to pull hair from their scalp, however, pulling may occur from any body part that has hair (i.e., eyebrows, eyelashes, pubic hair, arms, legs, etc.). In skin-picking disorder, many individuals tend to pick from their face, however, picking can occur anywhere on the body. BFRBs affect boys and girls equally in childhood, with somewhat higher numbers of affected females in adulthood. For hair-pulling in particular, this may be because baldness in men is more socially acceptable and may not draw much attention.

Even though BFRBs are by nature very difficult to manage, that doesn’t mean we can’t do anything about them! It is possible to better manage and even recover completely from a BFRB!

So let’s give them a brake

  • It is very important to educate the person with the BFRB and their loved ones about BFRBs. Many people with BFRBs live with a high degree of guilt and shame about their condition – after all they are doing this to themselves, right? Well . . . sort of. While we don’t know the exact cause of BFRBs we know they are inheritable (linked to our genes) and that individuals with these conditions have great difficulty putting the brakes (or inhibiting) these behaviours because of the way their brains work. Most people would just stop if it was that easy!! Helping people with BFRBs understand that there are many others who deal with BFRBs and that they are not alone, goes a long way in reducing shame.
    • The TLC Foundation for Body-Focused Repetitive Behaviours (www.bfrb.org) is the single best comprehensive resource for learning about BFRBs. This organization hosts an annual conference for those with a BFRB (typically in the USA) and the website offers a wide variety of valuable resources for individuals, parents and families, schools and professionals.
  • Remember that BFRB’s are powerful habits that are developed and maintained in complex ways that are unique to each person. It is important to know that for many, BFRBs serve a real and functional purpose. For instance, BFRBs can be positively reinforcing in that they feel good, satisfying, or provide some desirable sensory input. BFRBs can also be negatively reinforcing in that they take away bad feelings like anxiety, stress, boredom, etc. So, before we just take these habits away, we must first understand the purpose they are serving for the individual and find a suitable replacement.
  • BFRBs can be extremely upsetting to parents and loved ones of the individual with the BFRB. This is, of course, a natural and understandable response. It is upsetting to see your loved one damage or alter their appearance or suffer because of their BFRB. It is even harder to accept that your loved one is doing this to themselves. Unfortunately, this can lead to a high degree of tension, conflict, and damage to the relationship. Parents can’t help but proclaim “stop it!” every time they see their child pick or pull. While we encourage those impacted by BFRBs to seek help, we also encourage parents and loved ones to work toward acceptance of their family member’s BFRBs. Try focusing on your child’s strengths, talents, and personality traits that have nothing to do with their picking or pulling. Provide them with unconditional positive regard and send the message that they are loved and valued regardless of their appearance!
  • Whether or not the individual with the BFRB is ready to accept treatment, allow for accommodations that will make their life easier. Many individuals with BFRBs are deeply ashamed of their habit, and some may have been teased or bullied about it. Though this is a personal choice, some individuals may choose to hide evidence of their BFRB when in public settings by wearing wigs, hats, bandanas, band-aids, or certain clothing. This may include gaining special permission to wear head coverings in the school environment if there are rules against this. For some, these articles of clothing may actually act as a barrier to pulling/picking in the first place!

So, what about treatment?

Currently, behavioural interventions are considered the first line treatment for BFRBs as there are no medications that have demonstrated to be consistently safe and effective for use in children. Medications can be very helpful however, in helping with symptoms of depression and anxiety and this should be discussed directly with your pediatrician, family doctor, or psychiatrist.

There are a number of treatments for BFRBs that have proven to be effective. These fall under the broad umbrella of cognitive behavioural therapy (CBT). Broadly, CBT for BFRBs involves examining thoughts and emotions that may trigger or result from BFRBs and developing behavioural strategies to help prevent and replace the habit. Examples of CBT informed treatments that have proven to be effective in managing BFRBs including the comprehensive model for behavioural treatment (CoMB; Manseuto et al., 1997), habit reversal training (HRT; Azrin et al., 1980), and acceptance and commitment therapy for BFRBs (ACT; Woods & Twohig, 2008). In the Brake Shop Clinic, our treatment (‘BFRB Management’) includes elements of all three of these treatments, especially the COMB model.

Psychoeducation is a critical component in treatment of BFRB that is important for the individual with a BFRB and their loved ones. It is important to understand that BFRBs are actually very common and that the person with the BFRB is not alone. Not even close! While there is still much to be learned about the cause of BFRBs we do believe them to be inheritable traits – that means there is a good chance that a family member also has a BFRB. BFRBs are NOT believed to be the result of a traumatic experience; however, some people do recall having had a negative experience around the time that their pulling/picking started. Even so, these are usually fairly common experiences such as parental divorce or changing schools.

One of the most helpful and important parts of improving your BFRB is understanding everything you can about it. This can be done through a functional assessment. Figuring out all you can about your BFRB is half the battle! This involves identifying the body parts that are targeted, what happens before, during, and after a picking/pulling episode, identifying triggers for pulling/picking episodes (i.e., people, places, objects, emotions, etc.), and identifying the consequences of pulling/picking (i.e., pain, infection, avoidance of activities, embarrassment). Many individuals may be unaware of when they are actually pulling or picking and don’t notice that they are doing it until they see the pile of hair beside them or someone else points it out. Others are more aware of their BFRB and may use tools such as mirrors or tweezers to assist in their picking or pulling. Even if you are aware of your pulling, awareness training or self-monitoring of the BFRB can give a whole lot of insight into the behaviour. This can be done by recording details about a pulling/picking episode to better understand the timing and frequency of episodes and potential triggers. This can be written down in a journal or notebook or recorded in an app (SkinPick or TrichStop), depending on your preference.

Once a there is a very clear understanding of your BFRB, individualized strategies can be developed. It’s tempting to jump straight to strategies, but strategies are much more likely to be effective when there is a good understanding of the function of your unique BFRB – in other words – what’s keeping it going! Strategies should address the unique functions and triggers for the individual with the BFRB, which might include addressing sensory needs, thoughts, emotions, and the environment. Strategies could include identifying ways to prevent picking or pulling or figuring out what makes it harder for the individual to pick or pull. This might include strategies such as dimming lights, covering mirrors, wearing gloves/hats, wetting hair, putting lotion on your hands, etc. Other strategies include identifying what to do instead of picking or pulling – for instance, keeping your hands busy with a fidget, drawing, brushing your hair, playing with soft fabric, shelling peanuts, etc. Finally, it is helpful to learn about your unique sensory system and determine ways to provide input to your senses that would reduce the need for picking or pulling. Once you have a target list of strategies, it’s a trial and error process. You really won’t know if a strategy works for you, until you give it a fair shot (at least a week of consistent use). From there, you would evaluate, modify, and replace strategies until you find what works for you.

Trying to change a well-established behaviour like a BFRB takes a whole lot of hard work, commitment, dedication, and practice – but the good news is that it can be done! Treatments that include the elements described above have been found to be very effective in improving symptoms of BFRBs. It is recommended that you work with a mental health clinician who has expertise in treating a BFRB; however, if you are unable to do so there are options for self-help and parent-help (books, websites) that can be found in our resources section.

Finally, here’s some handy “Don’ts” and “Do’s” for family members, friends, and others supporting those with a BFRB borrowed from Dr. Fred Penzel and Priscilla Elliot.

Do’s

  • Do practice self care.Self care is not selfish. When you take good care of yourself, you are able to be a better parent, sibling, or teacher. It can feel so helpless to watch a loved one suffer. Do things that help revive you, help you feel connected, and centered. This may be seeking your own counseling, reaching out to a good friend, eating well, exercising regularly, and/or daily meditation.
  • Do remember the whole person. They are so much more to your child, sibling, student than just being a picker or a puller. Remember all those parts that you love/like about them.  
  • Do be gentle with shame.Many children and adults will deny their picking or pulling, even when it’s obvious. Confronting them on this may be too overwhelming. Stay with compassion.
  • Do be sensitive to body image issues. As beautiful as they are in your eyes, they are likely struggling with aspects of their appearance.  A “flaw” you don’t notice may be consuming their thoughts and flooding their emotions. Try to focus less on appearance and more on the inner qualities that makes them unique.
  • Do refer to a dermatologist if you see signs of infection or irritation. This will not manage the behavior, but will treat the wounds and diagnose any underlying conditions.
  • Do normalize. Most people have picked or pulled at some point in their lives. If as a parent, you have struggled with similar habits (e.g., nail-biting), it’s okay to share this with your child. Most think they are the only one. No one is perfect.
  • Do encourage treatment.There is no quick fix, BUT there is help. A therapist who has specialized, advanced training on this topic can help clients understand BFRBs and reach a point where the BFRB no longer controls their life. Be supportive in their recovery activities. Encourage them to persist with treatment even when recovery feels impossible.

Don’ts

  • Don’t say “Stop it!” “Don’t pick/pull,” “Quit it.”If it were that simple, they would have already stopped. BFRBs are real biological problems and not a rebellion to upset you or signs of weakness.
  • Don’t talk about it loudly where other people may hear about it. Sarcasm, shaming, embarrassing, and blaming your child/student will only make it worse. This is also harmful to your relationship.
  • Don’t take this disorder on as yours to fix. You cannot fix this for them. You can support them on this journey. Recovery happens only when the person with the disorder takes responsibility for their treatment. Readiness for change happens on their timeline, not yours.
  • Don’t be the skin or hair police. This usually backfires on both the behavior and relationship. It usually starts with parents watching their children like a hawk, and then alerting them every time they notice them pulling or picking. They may do this by calling out to them, touching them, making a noise (finger-snapping, throat clearing, etc.), or even throwing things at them (yes, this happens!). They may even go well beyond this by grabbing their arm or hand and trying to physically restrain them. On a different level, some also use sarcasm, guilt, or anger as a way to try to get them to change their behavior. While your child may want your help or support in reminding them to use their strategies, this should be worked out in advance and the child should be ‘on board’ with this kind of reminder.

Finally, parents, be sure you request that any relevant accommodations found on this hand-out are added to a formalized Individualized Education Plan (IEP).  Hair-pulling and skin-picking are mental health disorders that are recognized in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) as trichotillomania and excoriation disorder. They are real conditions that cause real impairments and should be recognized as such. An informal IEP may not be implemented or transitioned, whereas a formal IEP is a legislated process that also includes the Identification Placement and Review Committee (I.P.R.C.) that must be adhered to, under the Education Act, (Education Act, Regulation 181/98).  Any child with identified special needs has access to this process.