Hair Pulling! Skin Picking! Nail Biting! Oh, My!
Body-focused repetitive behaviors upset and mystify many of us. Here, learn about its causes, its link to ADHD, and its treatment options.
Most of us know that mood disorders, anxiety, and oppositional defiant disorder frequently come along with a diagnosis of ADHD. Not many realize that something called body-focused repetitive behaviors (BFRBs) do as well. Jane is concerned about her son Kevin, who pulls his hair while watching television and plucks out his eyelashes in the bathroom. Serena, a 40-year-old mother with ADHD, has a secret. She picks at her skin nightly, often to the point of bleeding. When Matthew has trouble focusing, he bites his nails and chews on them.
BFRBs are related to self-grooming, anxiety management, or sensory stimulation. The most common BFRBs are trichotillomania (hair pulling), dermatillomania (skin picking), onychophagia (nail biting), dermatophagia (skin biting), rhinotillexomania (nose picking), as well as cheek biting and joint cracking. These behaviors tend to be chronic, and those who have them report feeling pleasure and/or pain from these habits. Although many people with BFRBs want to stop these behaviors, they are compelled to perform the behavior. Many sufferers are not aware of them.
Causes of BFRBs
These repetitive behaviors often begin with a desire to remove an unwanted stimulus. After checking himself in the mirror, Franco wants to rid himself of the blackheads on his face. Juliet is bothered by the asymmetry in her fingernails, while 10-year-old Alan cannot leave the scab on his knee alone. Clients report stroking their hair before pulling it, or feeling the contours of a pimple before squeezing it. Marci pulls at the hair on a certain spot on her head, and then rolls it between her thumb and index finger. Ricky likes to chew the nail he has just bitten off.
People with BFRBs spend minutes or hours doing these behaviors. Sufferers often do physical damage to their body – leading to bald spots, skin scarring, blood loss, acne, damaged nails, and cuts in the mouth (from chewing on nails or cheek chewing). Gastrointestinal problems develop in hair pullers or nail biters who eat the hair or nails. These physical consequences bring more self-disgust and frustration, which leads to social isolation. One patient reported, “I feel like a freak. I feel alone, as if I have a dirty little secret.”
BFRBs aren’t uncommon. Trichotillomania and dermatillomania have been widely studied, and experts say that approximately three million people are affected by each of these disorders.
BFRBs have been long thought of as part of the obsessive-compulsive disorder (OCD) family. Currently only a few studies are looking at BFRBs in people with ADHD. Based on my experience, many patients with BFRBs do not have OCD, but ADHD. Anecdotal evidence suggests that attention deficit predisposes them to developing these problems.
Individuals with ADHD have poor impulse control, which is a major feature of BFRBs. Lots of people want to squeeze an unsightly blackhead, but they don’t because they have “stop” mechanisms. Having ADHD makes urges harder to control. Marisol, a college student with ADHD, says, “I know I am damaging my skin, but I just cannot stop. When I see the damage that I’ve caused, I feel even worse.”
People with BFRBs are stimulated by the behaviors. “The intense feeling I get when I am picking is like nothing else,” says Ben. “It is painful, but a good pain, like getting a tattoo. I am laser-focused when I am picking.” Arousal, even that which is neither safe nor healthy, stimulates the ADHD brain. ADHDers say that their BFRBs are an escape from the chaos in their lives. Kate, 40, says, “When I pull [my hair], I am drowning out all the things on my agenda. Pulling has a beginning and an end. I get my reward quickly and easily.”
BFRBs elevate dopamine levels in the brain, and the ADHD brain needs more stimulus to feel rewarded than non-ADHD brains. Some patients say that BFRBs are a form of fidgeting. One patient says that she focuses better in class when she chews the inside of her cheek.
Donna didn’t have a problem with BFRBs until she began using stimulant medication. Just as ADHD stimulants may lead to tics in vulnerable individuals, so might the medications lead to BFRBs. The roles played by stimulants (and at what dosages) and the presence of other conditions are still subjects for study.
Behavior therapy is a good first-line strategy for managing BFRBs. Habit reversal training (HRT) brings the best results. The goal of this therapy is to replace the BFRB with another action when the urge strikes. HRT a) charts the history of the BFRB; b) identifies its triggers, situational and emotional; c) determines the frequency of the behavior; and d) comes up with a competing response. Mindful awareness alone may reduce the frequency and/or intensity of the BFRB. Kevin has developed several strategies to substitute for his hair pulling. When he has the urge to pull, he clenches his fists, puts on gloves, rubs Vaseline on his hands, uses a fidget toy, or folds his hands. In addition to HRT, relaxation training is helpful. It reduces stress and impulsive behavior, and promotes mindfulness.
Medications complement behavior therapies. Selective serotonin reuptake inhibitors (SSRIs) are antidepressant medications that also reduce anxiety. Fluoxetine (Prozac) has been shown to help with skin picking, but is not as effective in reducing hair pulling. Fluoxetine increases serotonin levels in the brain, lowering impulsivity and obsessive-compulsive thinking while improving mood.
Clomipramine (Anafranil), a tricyclic antidepressant that may reduce obsessional thinking, is beneficial in reducing hair pulling. Researchers are studying opioid antagonists, such as naltrexone (Revia), in treating BFRB. The drug targets dopamine pathways that may be involved in dependent behaviors, resulting in a reduced urge to engage in BFRBs, as well as decreased pleasure from doing so.
Empirical studies have found that N-acetylcysteine (NAC) does a good job of treating skin picking, hair pulling, and nail biting. It is an amino acid supplement that affects glutamate neurotransmitter levels in the brain. Abnormally high levels of glutamate have been implicated in OCD and related behaviors, such as BFRBs. None of these medications is without side effects, so it is important that they be prescribed only by a skilled psychopharmacologist who has experience working with BFRBs.
Don’t leave support groups out of the treatment equation. Sufferers are usually ashamed of their behaviors, so they lose motivation to seek treatment. A support group can help them get treatment and stay on track with it. Support and resources for BFRBs can be found at the Trichotillomania Learning Center (TLC) (trich.org) and the International Obsessive-Compulsive Disorder Foundation (IOCDF) (iocdf.org).
All of these strategies help reduce BFRBs in children and adults with ADHD. So don’t fret. There is hope, and recovery is possible.
All names in this article have been changed.
Roberto Olivardia, Ph.D., is a member of ADDitude’s ADHD Medical Review Panel.
Updated on December 28, 2020