Body-Focused Repetitive Behaviors (BFRBs) can feel like an unknown or forgotten mental health experience due to a lack of awareness and education in our society. The prevalence of BFRBs in the general population can range from 0.5% to 4%, but it can be higher depending on the specific type of BFRB. BFRBs are more common in people with certain conditions, such as ADHD, anxiety, OCD, or Tourette Syndrome.
What Types of BFRBs Are There?
While Trichotillomania (hair pulling), skin-picking (Dermatillomania or Excoriation Disorder), or biting and picking at your nails (Onychophagia) are viewed as more “common” types of BFRBs, nose picking (rhinotillexomania), Cheek biting (Cheilophagia), Tongue Chewing, or Hair eating (Trichophagia) are also included in this subset of mental health struggles.
BFRBs ultimately hijack the quality of your life as they interfere with your daily activities. You find yourself avoiding people and places due to feelings of shame or the fear of others noticing your behaviors or the ramifications of them. Even though they may cause harm to the body, BFRBs are not a form of self-harm, and those suffering from BFRBs find it extremely difficult to stop.
Three Ways to Manage Your BFRB
1) Learning more about your BFRB(s):
All behavior change starts with psychoeducation and awareness. Before you try any behavioral methods in therapy, it is important to learn the cycle and symptoms of your BFRBs. A typical cycle involves a time preceding the behavior; usually, stress and anxiety are building up. Eventually, there is either a conscious act, such as pulling out your hair, or an unconscious manifestation, such as pulling at hair or picking at the skin while studying, watching television, or some other activity. Following the incident, feelings of shame and frustration can occur. You may be hard on yourself, wondering why you can’t stop biting your nails, eating your hair, picking at your skin, or whichever body-focused behavior you have partaken in. These negative emotions lead you into the beginning of a new cycle of mounting stress, and it begins again.
Part of learning more about BFRBs means you look honestly at what it has taken from you and what you wish to gain back into your life by challenging yourself. For example, you may have had to adjust how you dress to hide the behavior’s impact on your body. You might avoid certain social events or opportunities due to an increased chance of being found out if you attend or the adverse impact of attending on your stress levels. You may have pulled away from others out of embarrassment, shame, or the fear of someone finding out when you don’t want them to. Reviewing this history and recognizing the toll that has been taken on your life can be overwhelming.
Those who attend therapy for skin picking, therapy for hair pulling, and other manifestations of bodily-focused repetitive behaviors often find themselves trying to sort their BFRBs from other mental health issues. Patients who have anxiety, OCD, and other mental health disorders often find that they aren’t sure where (or even if) their symptoms diverge from their BFRB. The truth is that there is a great deal of overlap, which means that understanding your BFRBs might lead to greater understanding and/or management of your other mental health struggles. Here in our Woodland Hills OCD therapy sessions, we encourage mindfulness as part of the learning process. Mindfulness is about taking note of what is happening without judging it. This can be difficult to do at first, but over time, it is a practice that allows us to be honest with ourselves about what is really going on. When you take away your judgment, you take away avoidance because you’re no longer trying to evade feelings such as shame and frustration. Instead, you are able to face the situation and accept it for what it is; from there, you can take note of what occurs and use it to further your education about your BFRB. All journeys, tasks, and goals start somewhere. Knowing where you are beginning is the only way to start moving forward.
2) Apply Comprehensive Behavioral treatment (ComB):
ComB is a collaborative approach to treatment for body-focused repetitive behaviors, wherein the therapist and patient work together to first identify and then change the reaction to various triggers that are leading to the BFRB. Our approach to therapy is to individualize it, employing a combination of techniques and modalities until we find the one that works best for our patients. ComB requires trust and a feeling of safety so that the patient can identify the established behavioral pattern, and provide honest feedback so that the behavior can be changed. ComB evolves and adapts throughout the process, as new discoveries are made and information is uncovered.
ComB is a relatively new protocol, on the cutting edge of treatment for BFRBs. In order to best identify triggers, multiple angles must be assessed. Sensory, Cognitive, Affective, Motor and Place (SCAMP) triggers and needs are identified.
Sensory analysis looks to identify what the nervous system is looking for, such as certain tactile needs that can be soothed by holding something or playing with something instead of turning that physical energy into the body. Any sense that is stimulated (smell, sight, taste, sound, or touch) can stimulate the need to partake in your BFRB. You might see or feel a bump or a hair, for example. You may taste or smell something you’ve picked, or in the case of hair eating and cheek biting, the taste may already factor into your behavior.
Cognitive analysis looks at the thoughts and beliefs associated with the body-focused behavior, such as those that contribute to the need to pick, or the “negotiating” that can lead to a slippery slope, such as telling yourself you’ll just do it one more time, or for a certain amount of time. Combating these thoughts happens when you are able to replace them with proactive affirmations about how you’re going to respond to your urge to pick.
How your emotions and moods impact your mindset and point of view are explored when considering your Affective situation. Patterns may become apparent, such as certain situations being stressful or certain times of the week/month/year. Once these patterns are known, compensatory behaviors can be implemented to avoid the BFRB that you struggle with. Both the emotions leading up to the behavior as well as those that follow should be addressed in order to give you a more thorough understanding of why you are doing what you are doing, and how you can adjust your response.
Motor analysis can uncover physical “tells” and triggers that can lead to picking, and how to combat them. For example, covering a pimple with a patch because you notice your hand keeps drifting back to feel the bump. Practicing keeping your hands busy, or wearing something that requires conscious effort if you want to engage in your BFRB. For example, if you are wearing mittens, it will be very hard to bite your nails. Where before you might have bitten them without thinking about it, you will now realize every time you go to do it, no matter how unconscious that action is, because your mouth will be met with a piece of fabric instead of your fingers.
The last aspect that we look at when we are establishing the factors that lead to your BFRB is Place – where are you more likely to participate? How does that environment aid your efforts to stop picking, or combat them? You might be more likely to pick when you are alone, or find that you still participate in the behavior when you are with others. To adjust the place, you might choose to cover mirrors, leave yourself notes where you’re likely to see and need them, or dim the lights to reduce your ability to zero in on small details.
3) Share with trusted friends and family about your struggle:
To fight the shame and the embarrassment, it is important to reach out to those you trust and have a safe relationship with and open up about your struggles. This is the case no matter what issue you are facing, whether it’s a mental illness or any other circumstance in your life that is giving you a hard time. Human beings are social creatures who build communities, and everyone is deserving of support. Remember that sometimes it will be your turn to lean on your loved ones, and sometimes it will be their turn to lean on you.
If you feel nervous or burdensome when you think about sharing, consider how you would feel if a close friend or family member was going through something similar and needed help. Imagine they came to you and shared their fears and frustrations; how would you speak to them? Now imagine they didn’t come to you because they didn’t want to trouble you; how would you feel about that? Treat yourself the way you would treat a beloved friend. Give yourself the permission that you would give to a beloved friend. Reach out for help and support the way you would want a beloved friend to feel comfortable reaching out to you.
It can feel difficult at first to open up about something that is seen as a “bad habit” but not necessarily a serious one. You might worry about being taken seriously for struggling to manage your nail biting. Many of the patients we see for OCD therapy in Woodland Hills speak about how intrusive their compulsions and behaviors are and how demoralizing it feels to be told that there should be simple solutions for these “small tics.” In actuality, it doesn’t matter if behavior is only enacted on a small part of your body, if the results don’t “appear that bad,” or if other people participate in the behavior without feeling overwhelmed by it. What matters is the impact it has on you and your life. A major component of therapy for OCD and therapy for BFRBs is making space to process the impact, the pain of being minimized, and the most productive way to seek support from those around you.
When deciding to share with trusted friends and family, it is best to set both yourself and whoever you’re talking to up for success. For example, asking to set aside time to talk to them about something is going to be a great place to start. Very rarely do thoughtful and safe conversations happen when people are in a rush, caught off guard, and/or distracted. Letting your loved one know that you’ve been struggling and that you’d like to share with them and include them in what’s going on, then asking when a good time for them might be, means that you are committing to the conversation and giving them an opportunity to show up for you as well. When the time comes to get together and talk, you may choose to preface your conversation with guidance, such as, “Something has been impacting my life every day, and it’s been hard. It’s actually a medical condition, and it would help me to be able to share it with you.” Right off the bat, this lets the other person know that you are dealing with something serious, even if it seems like “it’s only nail-biting” to an outsider. Sometimes, all it takes to have a productive conversation is to let the other person know why you’re talking to them. In this case, if your goal is to be able to talk about how you feel and have someone you trust to confide in, tell them that. Then they know that you’re not asking them to solve a problem for you, that you’re not looking for solutions or ideas about what to do. This allows them to show up how you need them, the same way you would want to be able to do if the roles were reversed.
Lesser-known types of BFRBs, including lip biting, cheek biting, and hair eating, may not be talked about as much as skin-picking and hair-pulling, but that doesn’t mean that you are the only person who is struggling with them. And regardless of which subtype of BFRB you are dealing with, the process for dealing with and improving your symptoms and behaviors is the same. When a mental health struggle is rare, what is important is that you find a way to feel understood and that you are not isolated in your efforts. I see people take on all types of body-focused repetitive behaviors as a Woodland Hills therapist, and even though each individual is unique, the methods of therapy are the same. No matter how long you’ve been struggling, there is always a way forward. Maybe you’ve never shared with anyone before, or maybe you’ve been met with a lack of empathy. What matters is that you know there is a way to improve your life by tackling these behaviors and making consistent progress in replacing them with more positive action.
BFRB Treatment in Woodland Hills
Bodily Focused Repetitive behaviors, a mental health issue under Obsessive Compulsive Disorders, often feel like the most poorly understood and often most judged. When we live in a world that shows tons of empathy when people struggle with physical health issues like cancer or a broken arm, we wonder why there is not much empathy for mental health issues like Nail-biting, hair-pulling, or skin-picking.
Here at Embracing You Therapy, it is our mission to change this for all who suffer from BFRBs. Our therapist, who specializes in treating BFRBs and OCD-related disorders, understands the unique research and treatment available to give you your life and confidence back. You deserve to live out your dreams and not have the BFRB get in your way.
Contact us today for your complimentary 20-minute phone consultation with our Client Care Coordinator.
