Common Myths of BFRB’s

Article by Max Maisel, PhD

Clinical Psychologist Practicing in Redondo Beach and Los Angeles, California

There's so much misinformation out there about body-focused repetitive behaviors, or BFRBs for short. Throughout this article, we're going to dispel some of the most frequent and harmful myths about this complex and nuanced disorder. 

Myth 1: Body-focused repetitive behaviors (BFRB) and trichotillomania (hair pulling disorder) are the same thing.

It is true that Trichotillomania is one of the most widely known types of BFRB. This manifestation of BFRB’s includes compulsive hair pulling from different parts of the body. This may include from the scalp, eye-brows, eye lashes, armpits, groin, or any other body part that grows hair. However, there's many other forms and types of BFRBs as well. For example, there's skin picking (also called “excoriation disorder), cheek biting, knuckle cracking, nose picking, nail biting, tongue-chewing, nail biting, and much more.

A body-focused repetitive behavior technically includes any sort of obsessional, compulsive, out-of-control grooming behavior that causes some sort of physical damage and/or discomfort to the sufferer. A person diagnosed with a BFRB like trichotillomania or excoriation disorder  has typically made many unsuccessful efforts to stop their pulling/picking. It’s also common that the nature of one’s BFRB will likely change over time. For example, a child may struggle with nail biting, which transforms to hair-pulling as a teen, and then skin picking as an adult. Further, individuals may engage in more than one BFRB at the same time (e.g. picking at skin and pulling the  hair).  Typically, BFRB’s are chronic conditions that ebb and flow over time. Fortunately, there are powerful, science-backed interventions and strategies which can help people get their BFRB to a much better managed place (read on for more info about the ComB approach).

Myth 2: people can “just stop” their BFRB

It's all too common for people with BFRBs to hear the same message over and over again from doctors, friends, family, and partners.

“Why can't you just stop?”

As if they haven’t not been trying. You have to understand that a BFRB is a neurobiological disorder. People with BFRBs feel that they have little to no control over the behavior, and suggesting they simply “stop” can cause much shame and anxiety. Paradoxically, the more shame and anxiety people feel about their BFRB, the more likely they are to engage in picking or pulling. “Just stopping” a BFRB would be akin to somebody “just stopping” blinking their eyes or swallowing saliva. It’s technically possible, but eventually the discomfort would be too much to sustain.

Now with proper treatment, people can learn tools and strategies to slowly but surely empower themselves to break out of the bonds of their BFRB, but that doesn't mean they can just stop. That’s like being thrown into the deep end of  a pool when you can’t swim. It’s absurd to tell the person “just swim to shore.” This person can, however, learn the specific skills and strategies to swim, thereby increasing the control they have while in the water the next time they find themselves in the deep end. When BFRB’s are treated properly using the gold-standard approach, individuals suffering from this disorder feel empowered to learn specific and targeted skills to overcome their disorder. It does take time, patience, and a devotion to the practice.

Myth 3: there is no treatment for BFRBs.

Very false. The gold standard approach for BFRBs is a very targeted behavioral intervention called ComB (pronounced like a hair “comb”) or comprehensive behavioral treatment for skin picking and hair pulling (e.g. trichotillomania or excoriation disorder). ComB treatment helps people identify all the psychological, emotional, and behavioral factors that are underlying their intense urges to engage in the BFRB and leading to the habitual nature of picking and pulling.  It’s called “comprehensive” because it takes into account the internal and external factors that contribute to the BFRB. Once these factors are identified, a therapist will a client with a BFRB build awareness of triggers, manage uncomfortable feelings associated with their BFRB, identify and challenge thinking patterns that lead to picking/pulling, make environmental changes, and intervene at every level that the BFEB effects.

Myth 4: BFRBs stem from unresolved trauma or stress.

Some people believe that a BFRB is due to some deep unresolved guilt or trauma that needs to be treated in order for the BFRB to get better. This is totally counter to the scientific data we have and the overall understanding of how human neurology works when it comes to BFRB’s. It is true that stress, anxiety, or trauma might tax one’s central nervous system, which could potentially amplify BFRB symptoms, but they are certainly not the root cause of BFRB’s and they don’t need to be solved” before the BFRB is treated.  

BFRB’s involve a  highly complex interaction of behaviors stemming from the dynamic interplay between thoughts, sensations, physical location, emotions, physiological needs, and urges. It's a disorder that is maintained by behaviors that are happening in the present moment, rather than the result of past, unresolved wounds. For example, somebody might feel an incredibly strong urge to pull their hair out of their eyebrows. This would likely lead them to pull, which would temporarily alleviate their uncomfortable urge. They might then engage in a ritual where they rub the hair across their forehead to soothe the stress they feel from pulling.

Both of these behaviors (the initial pulling and subsequent hair rubbing) likely provide temporary relief and comfort, but they're inadvertently reinforcing the strength of the BFRB in the long term. Their brains are learning “oh, pulling feels good. Let’s send some more urges to pull in order to get that same relief!”

Proper treatment helps people identify the present moment factors that are maintaining the symptoms they don't want and will help break those cycles in a strategic, stepwise manner.

Myth 5: BFRB’s are the same thing as OCD.

BFRB is clumped in the same category as OCD (obsessive-compulsive and related disorders) but it is not OCD. You can think about it as an extended family member of OCD, maybe a first or second cousin. There are some similarities in terms of people feeling strong urges to engage in repetitive, compulsive behavior that has drastic long-term consequences, yet they continue to perform the behavior despite these consequences.

However, the nature of OCD primarily involves people experiencing uncomfortable, scary, or horrific intrusive thoughts and needing to do things (e.g. compulsions) to cope with or prevent the scary thoughts. In a BFRB, an individual pulls or picks to sooth a physiological need and to alleviate uncomfortable stress or anxiety.  Another way to look at it is people do compulsions in OCD in order to prevent a catastrophe from happening or to cope with scary thoughts. People engage in BFRB behaviors in order to soothe their nervous system or reduce physical sense of anxiety or stress.

Learn more about Body Focused Repetitive Behaviors and how specialized treatment at Beachfront Anxiety Specialists and help you. You can also read more blogs with other helpful information Here.