Body- Focused Repetitive Behaviours (BFRB’s) is an umbrella term for any chronic behavior that causes a person to consistently cause physical damage to oneself unintentionally through a compulsive. The key difference between BFRB and other compulsive behaviours that cause harm to the body is that BFRBs are characterised by direct body-to-body contact. BFRBs such as dermatillomania (skin-picking) and trichotillomania (hair-pulling) are common disorders, but are largely undiagnosed. As a result, people who have these conditions suffer alone, ashamed, and in silence. The greatest travesty of this is that the loneliness and isolation can be prevented if there was greater awareness and acceptance of these disorders.
What are the various BFRBs?
While compulsive hair pulling and skin picking are the more well-known BFRBs, there are a number of others that can be equally distressing to an individual who suffers from the disorder. BFRBs are collectively grouped among Obsessive Compulsive and Related Disorders in the Diagnostic and Statistical Manual 5 (DSM5). These behaviours can manifest in a variety of ways, with the overarching similarity between the different disorders being the regulatory effect experienced by the person engaging in this behaviour, on overwhelming emotions or cognitive thought patterns such as intense anxiety.
Trichotillomania (compulsive hair pulling)
Trichotillomania is one of the main BFRBs and the criteria for diagnosis are as follows:
- Recurrent pulling out of one’s hair, resulting in hair loss
- Repeated attempts to decrease or stop the hair-pulling behaviour
- The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The hair pulling or hair loss cannot be attributed to another medical condition (eg, a dermatologic condition)
- The hair pulling cannot be better explained by the symptoms of another mental disorder (eg, attempts to improve a perceived defect or flaw in appearance, such as may be observed in body dysmorphic disorder)
Excoriation disorder (compulsive skin picking)
Also known as dermatillomania, this disorder is characterized by the obsessive or compulsive picking of the skin. People with excoriation disorder exhibit the uncontrollable urge to pick, squeeze, or scratch, rub, or dig into their skin during periods of tension, anxiety, or stress. The most commonly targeted area is the face, however any area of the body may be affected and there each individual’s picking patterns is unique. The consequences of the behaviour are damage to the site of picking, and complications such as infection, permanent scarring and physical disfigurement also commonly occur.
Onychophagia (compulsive nail biting)
Of the BFRBs, compulsive nail biting is the most “socially accepted” habits, viewed as simply a ‘nervous habit’. It is also commonly occurring in childhood with frequency tending to decrease by adulthood. However, the behaviour is known to intensify or persist through adulthood, and the severity of onychophagia can range from a very mild presentation to behaviours that are so severe that physiological complications occur, such as infection, pain in the fingers and bleeding skin around nails.
Trichotemnomania (compulsive hair cutting)
Although very similar to trichotillomania, the key difference is that the compulsion is characterised by the use of scissors or razor to cut the hair as opposed to pulling the hair strands from the surface of the scalp or skin. This results in the shortening of the hair without damage to the follicles beneath the surface of the skin.
Dermatophagia (compulsive skin biting)
People suffering from dermatophagia are sometimes called “wolf biters” because they bite off chunks of flesh. Unlike wolves, they bite off their own skin causing bleeding, unsightly scars, and skin discoloration. When stress and anxiety pile up, they find it impossible to resist biting.
Rhinotillexomania (compulsive nose picking)
Compulsive nose picking, not to be confused with people picking their nose from time to time for strictly hygienic purposes. Compulsive nose picking causes a greater risk of infection/damage to the lining of the nose. Because the nose and nasal passages are situated very close to the brain, they share the same blood supply, so getting an infection anywhere in the area known as the “danger triangle” presents a good cause for alarm. Any time infection in this area occurs, there is the very rare but very real risk that the infection can spread to the brain.
This is described as the compulsive urge to eat or ingest hair and is closely associated with trichotillomania. Trichophagia is not when an individual is mindlessly chewing on the ends of their hair, but rather when hair is chewed and then swallowed. The hair will eventually collect in a sufferer’s stomach and will cause stomach problems such as indigestion and pain. If severe enough, a person can be given medication to induce vomiting or undergo surgery to remove the massive amounts of accumulated hair.
Scab Eating Disorder
Strictly speaking, scab eating disorder is a form of excoriation disorder in that the person compulsively picks at the scabs, but this is then followed up by eating them, much the same way that trichophagia is commonly associated with trichotillomania.
Onychotillomania is the compulsive need to pick at or tear off one’s nails, named by Polish dermatologist Jan Alkiewicz. Although similar, it should not be confused with onychophagia, where the nails are bitten or chewed. The constant destruction of the nail bed can lead to onychodystrophy (malformation of the nails), paronychia (Inflammation of the tissue surrounding a nail), and darkening or discolouration of the nail.