In moments of stress, anxiety, or even sheer boredom, many of us may find ourselves picking at a hangnail or twirling our hair. But when does simple fidgeting become something more concerning, like body-focused repetitive behavior (BFRB)?
People with body-focused repetitive behaviors may bite their nails, pick at their skin, pull their hair, or bite their lips, cheeks, or tongue. BFRBs can lead to scarring, infection, or other complications, leaving the person feeling ashamed of the repetitive behavior that can present like an obsessive behavior. While body-focused repetitive behaviors can feel like “bad habits” the reality is more complex.
What is Body-Focused Repetitive Behavior or BFRB?
Body-focused repetitive behaviors are intense self-grooming urges that result in unintentional physical damage. Common repetitive behavior examples include nail biting, hair pulling, skin picking, nose-picking, pimple-popping, and biting the lips, cheeks, or tongue. Although these behaviors can injure the body, BFRB is not self-injury or self-harm.. The repetitive actions provide sensory input to the brain, bringing a higher level of awareness to the involved body part. This increased awareness can feel self-soothing or self-regulating, can help to distract or re-direct thoughts, and can even trigger a release of dopamine – a hormone in the body that provides a burst of positive energy and can provide a release of tension. Despite having negative consequences for these body-focused repetitive behaviors, these “rewards” make overcoming BFRBs more challenging than simply breaking a habit.
In addition to the self-soothing nature of body-focused repetitive behaviors, most people with BFRBs experience intense shame over the behaviors. They understand that action and outcome are undesirable, yet they still struggle to control the behavior, resulting in feelings of failure and shame. Neuroimaging studies have found that those with BFRB disorder also have distinct differences in patterns of brain connectivity in certain brain regions, making them more sensitive to stimuli and creating differences in their “dopamine reward system.”
The Signs and Symptoms of BFRB
While most people have bitten a nail or picked at a scab, body-focused repetitive behavior symptoms are characterized by the intensity and frequency of these actions. The most obvious sign of BFRB is the physical damage done. Skin-picking (Excoriation), nail biting (Onychophagia), and hair-pulling (Trichotillomania) all cause damage and can risk infections, scarring, and hair loss.
Repetitive body-focused behaviors intensify during moments of boredom or relaxation and may escalate during times of stress. People with BFRB often experience a mounting tension that is released by engaging in the behavior. Following the release of tension comes a wave of shame or embarrassment, which may paradoxically lead to a build-up of tension that again triggers the damaging behavior. Many try to quit their BFRDs but struggle to do so. Some try to hide the physical damage and may become socially reclusive to do so.
While body-focused repetitive behaviors share some of the same symptoms as obsessive-compulsive disorder (OCD), it is classified as a subset of OCD, and often the disorders are distinct and are treated differently. BFRDs do not always respond well to the medications used to treat OCD. Instead, approaches that acknowledge the brain’s role in this condition has been found to be more effective. Cognitive behavioral therapy is one example that works to increase awareness of triggers, feelings, and actions. The Brain Balance program is another example of a program that identifies areas of immaturity in the brain and then works to exercise and improve brain functions including sensory processing and inhibitory control.
For BFRB the primary focus is often on the physical actions and consequences, such as skin irritation or hair pulling, yet it is important to understand the overlap in other underlying mechanisms. People with BFRB also often experience differences in sensory processing, inhibitory control, and attention.
The Science Behind BFRB: More Than a “Bad Habit”
The brain is a complex organ, and its intricate pathways and chemical reactions play a significant role in BFRBs. What may appear to be simple “bad habits” are rooted in neurological differences. Neuroimaging studies indicate that those with body-focused repetitive behaviors have greater connectivity between the orbitofrontal cortex and the basal ganglia of their brains. That is, they experience hyperconnectivity between their decision-making centers and motor-control functioning, where habits are formed. This means a simple action can more easily turn into a repetitive habit. A habit is an action that is performed without thought or awareness, rather than a conscious decision. This combination of increased connectivity, combined with differences in the “dopamine reward system,” makes overcoming BFRDs especially challenging.
Dopamine is a neurotransmitter, often called the “feel good” hormone. The brain seeks out dopamine release despite the damage BFRBs cause. The momentary pleasure of dopamine is often followed by feelings of shame or embarrassment. These negative feelings can increase the pressure for the brain to seek out the dopamine release, continuing the cycle.
BFRB often Presents with Other Conditions
Body-focused repetitive behaviors typically emerge in early adolescence but can be seen at earlier ages. It is also important to note the high prevalence of BFRB presenting with other conditions, most commonly anxiety, mood disorders, and ADHD. The high rate of co-occurrence may be due to the overlap in differences in the brain pathways involved in inhibitory control that are present in ADHD, anxiety, and mood disorders.
Physical repetitive behaviors such as hair pulling and nail-picking can be easier for a parent to observe than repetitive thoughts that are consistent with anxiety yet can provide insights into a reduced level of control” shares a Brain Balance executive.
Understanding that BFRB rarely presents alone and can be an outward sign of increased challenges with sensory processing, attention, and inhibitory control is critical to supporting an individual with BFRB holistically, rather than just focusing on the main disruptive symptom.
How BFRB Affects Learning and Development
Not only do body-focused repetitive behaviors negatively impact one’s physical health, but they can also be disruptive to education and a child’s classroom experience. Trying to overcome the repetitive action takes conscious thought and inhibitory control, which can pull attention away from external stimuli in the classroom, to internal thoughts and feelings. This distraction of trying to control actions, then paired with feelings of failure and shame when the action is repeated amplifies the internal focus. Kids with BFRBs may be deeply embarrassed by their actions and the resulting consequences which can include open sores or bald patches. The physical damage from these behaviors can also lead to bullying and social challenges. This emotional toll can make children more anxious and lack confidence, which can start the whole cycle again.
Even when we do start down the rabbit hole of research we often receive mixed messages about what ADHD is, what causes it, and how to best support our child. This confusion can leave all of us feeling frustrated and unsure of where to turn. And there is certainly no shortage of opinion, judgment, and stigma that comes along with it.
Help and Support for BFRB
There are several strategies for people with body-focused repetitive behaviors to get help. The first step is recognizing that this is not a choice or a behavior, but an action that happens as a result of a reduced level of inhibitory control. For many, there are also differences in sensory processing, which may contribute to the individual’s need to seek increased sensory input from the action. Multi-modal programs designed to improve multi-sensory processing and integration and strengthen inhibitory control, such as Brain Balance, is an approach to address the challenge at its core, rather than masking symptoms.
Another important step in supporting someone struggling with BFRB is recognizing what triggers the BFRBs. Two people who exhibit the same behavior may be responding to different triggers. Common triggers for BFRBs include:
- Fatigue
- Stress
- Boredom
- Skin blemishes
- Ingrown hairs
- Hormonal changes
- Negative emotions
Recognizing their triggers lets someone with body-focused repetitive behaviors attempt to avoid the triggers, distract from them, or substitute another response, like playing with a fidget toy.
Consider joining a BFRB support group to learn successful distraction strategies and find acceptance. Many groups are available, with some meeting online or in person. Cognitive behavioral therapy can also be effective in helping people with BFRB. Some find relief with medication or nutritional supplements.
To learn more about how Brain Balance could potentially help, contact us at Brain Balance of Allen & Dallas, or contact us for information about how we can help you with BFRB.
