Body Focused Repetitive Behaviors
Driving alone to do errands, my friend realizes she’s picking at an old mosquito bite. The scab has remained on her leg all summer because she can’t keep her hands off of it. She is dismayed that it shows when she wears a dress or shorts, but at least she can hide the scab on her ear with her hair. There have always been scabs on her body ever since she was a child, some visible and some concealed.
Why doesn’t my friend just stop picking? No matter how often she puts “Let scabs heal” on her to-do list, she’s pulled off at least one by bedtime. The next day, the process starts all over again.
My friend suffers from a problem called Body-Focused Repetitive Behavior (BFRB). The category includes behaviors such as skin picking, nail biting, hair pulling, lip chewing, and even nose picking, which can develop as a means of self-soothing, a result of serotonin insufficiencies, or due to genetic factors. Selective Serotonin Reuptake Inhibitors (SSRI) can be helpful to dull some of the urges to engage in these actions, but without behavioral modification, BFRB’s won’t likely diminish.
Sure, everyone plucks out a grey hair or even pulls off a scab once in a while, but with BFRBs, the behavior is repetitive and impulsive. These “irresistible” and excessive grooming behaviors are not without consequence, as they can cause balding, injury, infection, scarring, pain, and discomfort. Additionally, shame, isolation, and functional impairment are all possible, as most of these behaviors often take place in secret and can be time-consuming. Furthermore, these behaviors can be socially undesirable and lead to ostracization.
What can be done about BFRB’s?
The Comprehensive Behavioral (ComB) Model developed by Dr. Charles Mansueto is a habit reversal training that has proven to treat BFRBs effectively.
Assessment and Self-Monitoring
A functional analysis of the particular BFRB should reveal what antecedents or “triggers” are present to prime these actions. Triggers could include internal sensations or thoughts, sensory information (see, touch, taste, hear, and smell), emotional states, motor habits (such as how the hands or feet are placed), environment, or time of day and/or place.
It is also necessary to discover the “payoff” for the behavior. Is it a dulling of a skin sensation, such as tickling or itching? Perhaps it is a desire to experience a feeling of completeness, accomplishment, or pleasure. It could also be a desire for uniformity in the skin.
Careful monitoring and charting of these behaviors, triggers, and payoffs takes place between therapy sessions, and a chart is used to build a strategy to target the behaviors.
Interventions
The next step would be to look for alternatives to performing the BFRB. For instance, if the client is looking for a sensation of smoothness, they could carry a smooth rock with them and rub it to feel the sensation.
If scratching the arm leads to skin picking, then they can scratch the itch using a fine-tooth comb. If the compulsion is picking or biting at the cuticles, daily appropriate nail manicuring will take place to remove anything that could be picked at or bitten off.
As with any compulsive behavior, resisting the urge to compulse will eventually lead to its extinction. To accomplish this, a therapist works with a client to implement a schedule for timed resistance.
For instance, they might decide that for the first few days, when the client feels the need to pull their hair, they will resist the behavior for 5 minutes, next, increase the time to 10 minutes, then 15 minutes, and so on. During this time, the client can use distractive techniques such as playing a video game or doing the dishes to keep their hands busy. Additionally, barriers such as gloves, a hat, or something else might be used to interfere with the undesired behavior.
Exploring faulty cognitions is also essential. Statements such as “I can’t resist doing this,” “All fuzzy hairs must be plucked,” or “I can’t help myself,” need to be challenged and replaced with grounding statements. Examples of grounding statements include “I can do anything for 5 minutes,” or “If I wait this out, my uncomfortable feeling will fade.”
Mindfulness and Motivation
Motivation for change is essential. Exploring why the behavior is undesirable and how it is detrimental to a client’s well-being is helpful.
Employing mindfulness is necessary to increase awareness of sensations and emotional cues, as many of these behavioral habits are unconscious. Charting is essential. Identifying times, body sensations, emotions, and places can remind a client of the danger of participating in BFRB. Then barrier/alternative behaviors can be implemented.
BFRB’s are not innocuous and are worth taking the time to extinguish. The neurological, social, and emotional toll that they can take is not to be underestimated. Using the ComB method, these habits can be extinguished, and healthy functioning can be restored.
