6 Myths — and Truths — About Body-Focused Repetitive Behaviors

Body-focused repetitive behaviors (BFRBs) — hair pulling, skin picking, and the like — officially affect 2.5% to 5% of people.¹ But the true prevalence rates are likely much higher, as BFRBs are understudied, misunderstood, and underreported.² It’s not easy trying to understand a group of people who are in hiding and silent about their struggles due to stigma. The result, unfortunately, is that BFRB myths and misconceptions continue to flourish. Here, we dispel common myths and misunderstandings about this very treatable condition that is more common than most people think.

Many people assume a person endured something terrible and seriously traumatic that caused them to engage in skin picking, hair pulling, and/or other BFRBs. This is simply not the case. That said, many individuals with BFRBs say they experienced a stressful event — from changing schools to going through a divorce — around the time that the BFRB started. While it’s entirely possible that an individual with BFRB could have a history of trauma, trauma is not the reason for their behaviors. BFRBs are driven by a complex set of internal and external factors. Over time, these behaviors become so ingrained in a person’s life that they feel automatic and uncontrollable. BFRBs also tend to run in families, suggesting a strong genetic component. ^{3 4}

BFRBs are absolutely not a form of self-harm or self-mutilation, the latter of which are associated with different psychopathology than BFRBs. The truth is that BFRBs are self-soothing, self-regulating behaviors.

[Take This BFRB Self-Test: Skin-Picking Disorder (Dermatillomania) Symptoms in Adults]

BFRBs do not stem from self-loathing or one’s desire to be unattractive. Most people with a BFRB can’t stand the outcomes of the BFRB, but they really do like engaging in the behavior, or they feel the need to engage in it. (This goes back to BFRBs being self-soothing behaviors.) Unfortunately, years of frustration and lack of access to good information about the condition can cause individuals with BFRBs to develop low self-esteem. How parents respond to the BFRB can have a huge impact on the self-esteem of a child for years to come.

BFRBs and OCD are not the same thing. They both appear in the DSM-5 under “Obsessive-compulsive and related disorders,” which is where the confusion might stem from. BFRBs and OCD have repetitive, unwanted behaviors in common, but that’s about where the similarities end. BFRBs and OCD have very different phenomenology, processes, and treatments.

Parents often ask me if BFRBs will cause their child to develop other conditions — anything ranging from an eating disorder to bipolar disorder. The truth is that we can’t predict any specific outcome from a child’s BFRB diagnosis. We do see higher rates of depression and generalized anxiety disorder in individuals with BFRBs⁵ , but the why is unclear. Perhaps all these conditions are somehow related neurologically, or perhaps a lifetime of struggling with BFRBs may lead individuals to feel more depressed and anxious.

We do know that BFRBs like hair pulling and skin picking co-occur with attention deficit hyperactivity disorder (ADHD). In one study of individuals with trichotillomania, about 30% had co-occurring ADHD.⁶ Sensory dysregulation is also associated with BFRBs.^{7 8 9}

If this were the case, an entire field dedicated to understanding and treating patients with BFRBs wouldn’t exist. These behaviors are not easy to stop, and they’re not necessarily within an individual’s direct control. Think about any behaviors that you’ve tried to start or stop in your life, be it changing your diet or breaking a bad habit. Not so easy, right? Behaviors are entrenched in our daily lives, and making changes takes lots of time and effort.

Ultimately, BFRBs are treatable and should not define an individual or become the center of the family structure. BFRBs are only one small part of a person — not an aspect that defines them on any level.

Body-Focused Repetitive Behaviors: Next Steps

• Read: Raising a Child with BFRBs — A Guide for Parents
• BFRB Self-Test: Trichotillomania (Hair-Pulling Disorder) in Children
• Watch: Nail Biting! Skin Picking! Hair Pulling! Understanding Body-Focused Repetitive Behaviors with ADHD

The content for this article was derived  from the ADDitude ADHD Experts webinar titled, “BFRB + ADHD: Helping Your Child with Hair Pulling and Skin Picking” [Video Replay & Podcast #453] with Suzanne Mouton-Odum, Ph.D., which was broadcast on May 4, 2023.

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Sources

¹ Madan, S. K., Davidson, J., & Gong, H. (2023). Addressing body-focused repetitive behaviors in the dermatology practice. Clinics in dermatology, S0738-081X(23)00031-7. Advance online publication. https://doi.org/10.1016/j.clindermatol.2023.03.004

² Greenberg, E. L., & Geller, D. A. (2023). Cautious Optimism for a New Treatment Option for Body-Focused Repetitive Behavior Disorders. The American journal of psychiatry, 180(5), 325–327. https://doi.org/10.1176/appi.ajp.20230226

³ Zhang, J., & Grant, J. E. (2022). Significance of family history in understanding and subtyping trichotillomania. Comprehensive psychiatry, 119, 152349. https://doi.org/10.1016/j.comppsych.2022.152349

⁴ Monzani, B., Rijsdijk, F., Cherkas, L., Harris, J., Keuthen, N., & Mataix-Cols, D. (2012). Prevalence and heritability of skin picking in an adult community sample: a twin study. American journal of medical genetics. Part B, Neuropsychiatric genetics : the official publication of the International Society of Psychiatric Genetics, 159B(5), 605–610. https://doi.org/10.1002/ajmg.b.32067

⁵ Grant, J. E., & Chamberlain, S. R. (2022). Characteristics of 262 adults with skin picking disorder. Comprehensive psychiatry, 117, 152338. Advance online publication. https://doi.org/10.1016/j.comppsych.2022.152338

⁶ Grant, J. E., Dougherty, D. D., & Chamberlain, S. R. (2020). Prevalence, gender correlates, and co-morbidity of trichotillomania. Psychiatry research, 288, 112948. https://doi.org/10.1016/j.psychres.2020.112948

⁷ Houghton, D. C., Tommerdahl, M., & Woods, D. W. (2019). Increased tactile sensitivity and deficient feed-forward inhibition in pathological hair pulling and skin picking. Behaviour research and therapy, 120, 103433. https://doi.org/10.1016/j.brat.2019.103433

⁸ Falkenstein, M. J., Conelea, C. A., Garner, L. E., & Haaga, D. A. F. (2018). Sensory over-responsivity in trichotillomania (hair-pulling disorder). Psychiatry research, 260, 207–218. https://doi.org/10.1016/j.psychres.2017.11.034

⁹ Houghton, D. C., Alexander, J. R., Bauer, C. C., & Woods, D. W. (2018). Abnormal perceptual sensitivity in body-focused repetitive behaviors. Comprehensive psychiatry, 82, 45–52. https://doi.org/10.1016/j.comppsych.2017.12.005