What are body-focused repetitive behaviors and how are they treated?
4/26/2021 by Sydney Kelpin, Ph.D.; Olivia Bogucki, Ph.D.; Craig Sawchuk, Ph.D., L.P.
Picking at dry skin, biting a hangnail, twisting your hair — these are all common things people do when stressed or bored. They also can be nervous habits or ways to get rid of bodily imperfections.
Most of the time, these behaviors are infrequent, temporary and do not cause physical damage. However, for some people, skin picking, nail biting and hair pulling can become such a problem that they struggle to control these behaviors to the point where wounds do not heal, nails become ripped and bleed, and bald patches appear on the scalp.
What's in a name?
Body-focused repetitive behaviors involve any self-grooming behavior that damages the body. The most common body-focused repetitive behaviors are skin picking, nail biting and hair pulling. These behaviors also go by a variety of names —trichotillomania, dermatillomania, factitial dermatitis, excoriation disease, neurotic excoriation, onychophagia, habit control disorder, impulse control disorder and obsessive-compulsive spectrum disorders, just to name a few.
How common are these behaviors?
Up to 60% of the population may experience times in their life when they may get caught up in cycles of picking, biting and pulling behaviors. Approximately 1%-5% of people suffer with body-focused repetitive behaviors, which are recurring patterns of behavior that can be difficult to control. These behaviors often result in significant distress and may lead to serious health consequences.
Body-focused repetitive behaviors usually start in late childhood through the teenage years, and these behaviors can become a chronic, lifelong problem if left untreated. These behaviors are equally common among girls and boys in childhood, but they become much more frequent in females than males into adulthood. Body-focused repetitive behaviors also can occur, along with anxiety and mood disorders.
Types of body-focused repetitive behaviors
Body-focused repetitive behaviors generally fall into one of two categories:
The impulsive type tends to be automatic, with picking, biting or pulling often happening outside of one's awareness. It happens in a wide variety of situations, tends to be frequent and brief, and often comes out during times of boredom and stress, such as while watching TV, driving or working on the computer.
The compulsive type tends to be deliberate and purposeful, such as getting in front of a mirror and looking for wiry hairs that need to be plucked out. These episodes also tend to happen in private settings, such as the bathroom or bedroom, and often occur during times of high stress. While compulsive behaviors happen less frequently, when they happen, they can last for much longer periods of time, increasing the likelihood of causing serious damage to skin, nails and hair. People who engage in compulsive repetitive behaviors also may use instruments, such as tweezers, clippers, pins and needles. Many people can have impulsive and compulsive features of their body-focused repetitive behaviors.
Treating body-focused repetitive behaviors with habit control therapy
Body-focused repetitive behaviors are treatable conditions, but they take work. The most-effective behavioral intervention is called habit reversal therapy, which essentially involves trying to learn and strengthen new habits to reduce and offset the body-focused repetitive behaviors.
Habit reversal therapy generally involves four steps:
1. Awareness training
During this phase, people monitor where, when, how often and how long they engage in body-focused repetitive behaviors. They also may rate their emotions and physical sensations before, during and after these episodes. Then they start to learn to pay attention to how their hands move when engaging in these behaviors to serve as an "early warning detection system." They also may place external reminders in high-risk environments, such as brightly-colored stickers on a computer monitor, to remind them to be more aware of their hands and the risk for engaging in body-focused repetitive behaviors.
2. Competing response training
During this stage, people learn and practice alternate behaviors that interfere with or disrupt the body-focused repetitive behavior. They may practice tensing and releasing muscles in their hands and fists, or fanning out their hands and fingers as a means of reducing tension. Some of the most-helpful competing responses involve fiddling with objects that have a unique texture, such as a nail file, pen or ridges on a coin. It is important to test out a variety of objects to find one that best holds their attention. The goal is to practice these competing habits several times per day in a wide variety of environments.
3. Increasing habit strength
During this phase, people deliberately go into the high-risk body-focused repetitive behavior environments and routinely practice their competing responses. Engaging in their competing responses several times per day for several minutes each time will help increase the strength of these alternate habits while weakening the body-focused repetitive behavior habit.
During this stage, people continue to work on increasing the strength of their competing responses. Any time they notice engaging in a body-focused repetitive behavior, they try to stop as best they can, estimate how long they were engaging in the behavior, and then immediately start practicing their competing responses for twice as long. For example, if a person was picking at the skin for about three minutes, then that person would practice their competing responses for six minutes. Doing so increases the likelihood that the competing responses now become the new, dominant habit as they start to become associated with these high-risk body-focused repetitive behavior environments.
Body-focused repetitive behaviors can be difficult to treat, and these behaviors are often frustrating and embarrassing for the people who struggle with them.
Additional ideas to help manage body-focused repetitive behaviors include:
- Increase social support.
It is good to have support from family members who notice the body-focused repetitive behaviors. Rather than criticizing or routinely telling people to stop, it is useful to work out a game plan where family members can help people be more aware of their hands, such as "Notice your hands," and encourage them to practice their competing responses. The compulsive type of body-focused repetitive behaviors can be private, so it can be helpful to ask a family member to check on people if they have been in their bathroom or bedroom for too long.
- Try blocking behaviors.
Sometimes it can be helpful to wear gloves, Band-Aids or hats to offset the likelihood of further damaging the body. However, these blocking behaviors tend to help only temporarily while working to increase the habit strength of their competing responses.
- Treat anxiety and depression.
Treating an underlying or co-occurring mental health condition also can reduce problems and impairments associated with body-focused repetitive behaviors. Working with a therapist to learn cognitive behavioral therapy, or meeting with a primary care provider or psychiatrist for medication management can improve one's mood and overall functioning. In some cases, effectively treating an anxiety or mood disorder can result in "self-correcting" the body-focused repetitive behavior.
- Work with a healthcare specialist.
Impulsive and compulsive body-focused repetitive behaviors place people at risk for chronic infections and further bodily damage. A referral to a healthcare specialist, such as a dermatologist, can help treat body-focused repetitive behaviors. Sometimes, underlying medical conditions that cause skin, nail and hair problems can be properly addressed, thereby reducing certain triggers for these behaviors.
Body-focused repetitive behaviors are treatable conditions. Talk with your primary care team about available treatment options. Gaining education on the nature and effective management of hair pulling, nail biting and skin picking is an important first step. The TLC Foundation for Body-Focused Repetitive Behaviors is an excellent source that provides information, support and resources for these behaviors, including a locator to identify therapists who are trained in evidence-based, habit reversal therapy.
Additional self-help options include:
- "Overcoming Body-Focused Repetitive Behaviors" (Mansueto, 2020)
- "Trichotillomania: An ACT Enhanced Behavior Therapy Workbook Approach" (Woods and Twohig, 2008)
Sydney Kelpin, Ph.D., and Olivia Bogucki, Ph.D., are clinical health psychology fellows in Primary Care in Rochester and Kasson.
Craig Sawchuk, Ph.D., is a clinical psychologist in Primary Care in Rochester and Kasson and co-chairs the Division of Integrated Behavioral Health.