Background

A set of mental health disorders known as body-focused repetitive behavior disorder (BFRB) are defined by self-grooming habits that are repeated and cause physical harm to the body. These often-rash behaviors can serve as a coping method for tension, worry, or other emotional states. 

The excessive desire to pull out one’s hair in trichotillomania results in noticeable hair loss. Stress, worry, or a need to release tension may be the driving forces behind this behavior. This is repeatedly picking at own skin which can cause tissue damage. 

Epidemiology

BFRBs are relatively common, with estimated prevalence rates varying across different studies. Trichotillomania and excoriation (skin-picking) disorder are among the most researched BFRBs. 

BFRBs tend to occur more frequently in females than males, though there is variability. 

Skin-picking disorder is relatively common with prevalence rates estimated to be around 1.4% to 5.4% in the general population. 

Anatomy

Pathophysiology

Neuroimaging studies have suggested differences in brain structure and function in individuals with BFRBs.  

BFRBs often serve to cope with stress, anxiety, or negative emotions. These habits can become maladaptive coping mechanisms that people resort to find relief or a sense of control. 

BFRBs are considered repetitive, habitual behaviors that are reinforced by the relief they provide. The neurotransmitters may contribute to difficulties in emotional regulation and impulse control. 

Etiology

BFRBs often serve to cope with stress, anxiety, boredom, or negative emotions. Individuals may behave differently in order to reduce their emotional suffering or to feel more in charge of their lives.  

Adverse childhood events or traumatic experiences may contribute to the development of BFRBs in some individuals. Stressful life events can act as triggers or exacerbate these behaviors. 

Genetics

Prognostic Factors

Individuals with long-standing and severe BFRBs may find it more challenging to achieve significant improvement. Early intervention and treatment may contribute to better outcomes. 

Addressing comorbidities through comprehensive treatment approaches is important for overall recovery.  

Early-onset BFRBs, starting in childhood or adolescence, may be associated with a more chronic course. People who do well on evidence-based treatments, might be in better health.  

Clinical History

Age Group:  

BFRBs like trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder often emerge during childhood or adolescence. 

Hair-pulling and skin-picking behaviours may begin as early as preschool or elementary school age, but they can also start in adolescence. 

Nail-biting is another common BFRB that may start in childhood but can persist into adulthood. 

Physical Examination

• Observation of Behaviors: The clinician may observe and discuss the specific BFRBs reported by the individual, such as hair-pulling, skin-picking, or nail-biting. 
• Assessment of Functional Impairment: Evaluating the impact of BFRBs on the individual’s daily functioning, relationships, and overall quality of life is a crucial aspect of the assessment. 
• Screening for Comorbidities: Screening for comorbid mental health conditions, such as anxiety disorders, depression, or obsessive-compulsive disorder (OCD), is essential for comprehensive care. 

Age group

Associated comorbidity

BFRBs are frequently linked with various anxiety disorders, such as generalized anxiety disorder (GAD), social anxiety disorder, or panic disorder. 

Individuals with BFRBs may experience depressive symptoms or major depressive disorder. The impact of BFRBs on self-esteem, body image, and daily functioning can contribute to depressive symptoms. 

Impulsivity and difficulty with attention regulation may contribute to the development or maintenance of BFRBs. BDD involves preoccupation with perceived flaws in appearance, and individuals with BFRBs may also experience symptoms of BDD. 

Associated activity

Acuity of presentation

Individuals with mild acuity may engage in BFRBs intermittently, and the behaviors may not significantly interfere with daily life. 

Moderate acuity involves more frequent or intense engagement in BFRBs, leading to noticeable effects on daily functioning. 

Severe acuity indicates a high frequency and intensity of BFRB engagement, significantly affecting various aspects of the individual’s life. 

Differential Diagnoses

• Obsessive-Compulsive Disorder (OCD): OCD involves the presence of obsessions and compulsions includes repetitive behaviors or mental acts performed to reduce anxiety. 
• Autism Spectrum Disorder (ASD): Repetitive behaviors are a common feature of ASD, and in some cases, individuals with ASD may engage in behaviors that overlap with BFRBs. 
• Tics and Tourette’s Syndrome: Motor or vocal tics, common in Tourette’s syndrome, involve sudden, rapid, and repetitive movements or sounds. 
• Prurigo Nodularis: Prurigo nodularis is a skin condition characterized by intensely itchy nodules that may lead to repetitive scratching. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

• Cognitive-Behavioral Therapy (CBT): CBT is a widely used therapeutic approach for BFRB. It focuses on identifying and challenging distorted thoughts and beliefs associated with the behaviors. 
• Psychoeducation: Providing individuals with information about BFRB, its potential causes, and the impact on mental health is an essential first step. 
• Habit Reversal Training (HRT): HRT is a specific behavioral therapy designed for BFRBs. It involves identifying the triggers for the behaviors, learning alternative responses, and implementing competing responses to replace the repetitive behaviors. 
• Exposure and Response Prevention (ERP): ERP, commonly used in the treatment of obsessive-compulsive disorder (OCD), involves gradual exposure to triggers for repetitive behaviors without engaging in the behaviors. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-non-pharmacological-approach-for-body-focused-repetitive-behavior-disorder

• Identify Triggers: Work with the individual to identify specific triggers that contribute to the onset of BFRBs. Triggers can be emotional, situational, or environmental factors. 
• Create a Calming Environment: Design a living or working environment that promotes relaxation and reduces stress. Consider elements such as lighting, colors, and decorations that contribute to a calming atmosphere. 
• Remove Triggers from the Environment: Identify and eliminate or minimize triggers for BFRBs in the environment.  

Use of Selective Serotonin Reuptake Inhibitors (SSRIs)

• Serotonin: It is a neurotransmitter that plays a role in mood regulation, and SSRIs are believed to alleviate symptoms by enhancing serotonin activity. Sertraline and other SSRIs are indicated for various mental health conditions due to their ability to increase serotonin levels in the brain.  

Role of N-acetylcysteine (NAC)

N-acetylcysteine: It is an over-the-counter supplement that has shown promise in some studies for reducing symptoms of trichotillomania and other repetitive behaviours. 

use-of-intervention-with-a-procedure-in-treating-body-focused-repetitive-behavior-disorder

• Cognitive-Behavioural Therapy (CBT): CBT is one of the most researched and effective therapeutic approaches for BFRB. It involves identifying and challenging distorted thoughts and beliefs related to the behaviours. 
• Habit Reversal Training (HRT): HRT is a specific behavioral intervention designed for BFRBs. It involves awareness training, where individuals learn to identify triggers and situations that lead to the behaviors. 
• Dialectical Behaviour Therapy (DBT): DBT incorporates elements of CBT with mindfulness techniques. It focuses on developing skills in emotional regulation, distress tolerance, and interpersonal effectiveness. 

use-of-phases-in-managing-body-focused-repetitive-behavior-disorder

• Assessment Phase: The assessment phase begins with the identification of BFRB symptoms and a comprehensive evaluation by a mental health professional.  
• Intervention Phase: Providing individuals with information about BFRBs, their triggers, and the potential impact on mental health fosters understanding and empowerment. 
• Behavioral Interventions: Techniques like Habit Reversal Training (HRT) focus on increasing awareness of the behaviors, identifying triggers, and implementing alternative responses to interrupt the habit loop. 
• Maintenance Phase: The maintenance phase involves strategies to prevent relapse and maintain progress. This may include ongoing psychotherapy sessions, continued use of coping strategies, and monitoring for signs of relapse. 
• Regular Follow-Up: Regular follow-up appointments with mental health professionals help monitor progress, adjust treatment plans if necessary, and address any emerging challenges. 

Medication

Future Trends

Media Gallary

References

Body-Focused Repetitive Behavior | BFRB | BFRB Awareness 

Body-Focused Repetitive Behaviors (BFRBs) | Anxiety and Depression Association of America, ADAA