What is Body-Focused Repetitive Behavior Disorder?
Body-focused repetitive behaviors (BFRBs) are brain-related conditions in which a person compulsively engages in activities centered on their body. The impulses are recurrent and span a long period of time. A person with BFRB may want to stop the hair-pulling behaviors, but they cannot resist. When the behaviors and their consequences cause significant distress, impair the person’s ability to function socially, or cause physical harm, they may be diagnosed as body-focused repetitive behavior disorder.
Symptoms of BFRB Disorder
BFRBs rise to the level of a diagnosable disorder when they interfere with a person’s ability to function socially or emotionally. In some cases, the behaviors may cause physical harm over the long term.
Symptoms of the disorder can include:
- Repeated nail biting, lip biting, cheek chewing, knuckle cracking, teeth grinding, or other behaviors that involve tugging, pulling, picking, or biting at parts of the body
- Feeling of tension in anticipation of the behavior (or when trying to resist)
- Feeling of relief or pleasure after the behavior
- Unsuccessfully trying to stop the behaviors
- Distress at school, work, or home associated with the behaviors
Variation of BFRB Symptoms
The severity of BFRB symptoms varies widely from case to case. Some people experience only mild symptoms, but others are significantly impaired by their behaviors. Some recognize that the behaviors are problematic, while others deny the existence of a problem.
BFRBs also vary in terms of the person’s awareness of their behaviors. For example, some people engage in the behavior without realizing that they’re doing it (automatic behavior). Others engage intentionally to relieve stress (focused behavior).
What Causes Body-Focused Repetitive Behavior Disorder?
Doctors and researchers have not yet determined precisely what causes BFRB disorder, but they have identified several risk factors that increase an individual’s likelihood of developing the disorder.
- Genetic Predisposition. Having a parent, sibling, or child diagnosed with BFRBs may increase the chance that an individual will also be diagnosed with the disorder. Researchers have made some progress in identifying the genes that may play a role in developing OCD-related disorders, but more research is necessary to determine the precise genetic connections.
- Environmental Factors. BFRBs often seem to be triggered by stress. Childhood traumas may also be a risk factor for the development of the disorder.
- Age. BFRB disorder usually develops in late childhood or early adolescence.
Women are more likely than men to seek treatment for BFRBs, but studies suggest the disorder is equally prevalent in boys and girls.
Is Body-Focused Repetitive Behavior Disorder Hereditary?
Researchers have long suspected that biological factors rather than environmental factors primarily cause OCD, and some scientists believe that BFRBs are related to OCD. Studies of families where OCD occurs strongly suggest that a genetic component may be responsible.
Studies of people with BFRB disorder suggest that those with a close relative who also has the disorder are at increased risk. However, most people with a family history of BFRB disorder do not develop the disorder.
How Is Body-Focused Repetitive Behavior Disorder Detected?
Because the onset of BFRB disorder often occurs in childhood or adolescence, detecting the early signs of the disorder often falls on parents. In most cases, BFRBs are not serious enough to cause significant problems. However, in some cases, the behaviors can reach a point where they interfere with a child’s functioning. The symptoms may be subtle at first.
Potential warning signs of BFRB disorder include:
- Avoidance of social situations
- Wearing clothing that covers areas of the body damaged by the behavior
- Avoidance of close relationships
- Poor performance at school
- Use of alcohol or drugs
How Is Body-Focused Repetitive Behavior Disorder Diagnosed?
To diagnose BFRB disorder, a doctor will first rule out other potential medical causes of the symptoms. If the symptoms seem to meet the diagnostic criteria for the disorder, the patient will likely be referred to a mental health professional for further assessment.
Diagnostic steps may include:
- A physical exam. This exam aims to rule out physical conditions that could be causing the symptoms.
- Blood tests. These tests will look at the patient’s blood chemistry for issues such as thyroid function. Screenings for drugs and alcohol may also be conducted to rule out symptoms that may be caused by substance abuse.
- Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.
The results of the psychological assessments will be compared to the diagnostic criteria for BFRB disorder in the Diagnostic and Statistical Manual of Mental Disorders. Comparing these criteria will help a mental health professional decide whether the symptoms indicate BFRB disorder or another psychiatric problem (such as obsessive-compulsive personality disorder, anxiety disorders, or depression).
The diagnostic criteria for BFRB disorder include:
- Chronic behavior involving picking at or manipulating a body part that causes physical damage
- Unsuccessful attempts to stop the behavior
- Another mental or medical disorder doesn’t better explain the behavior
- The behavior causes significant distress or impairment in social, occupational, or other daily functioning
How Is Body-Focused Repetitive Behavior Disorder Treated?
BFRB behavior currently has no cure, but a combination of medications and psychotherapy may effectively reduce the severity of symptoms in many patients.
Several different medications may be used to treat and manage BFRBs, and individual medication plans depend on the patient’s age, the patient’s responsiveness to treatments, and the severity of their symptoms.
- Antidepressants. Selective serotonin reuptake inhibitors (SSRIs) may be prescribed to treat BFRB symptoms. Clomipramine, naltrexone, and olanzapine are also sometimes used.
- Other Medications. The amino acid N-acetylcysteine may have some benefit for people with BFRB disorder.
The most commonly used therapeutic approach is cognitive behavioral therapy (CBT). This process focuses on helping the patient identify a pattern of harmful thoughts and construct strategies and solutions for dealing with them that don’t interfere with functionality.
Other types of therapy sometimes used to treat BFRB disorder include habit reversal training and acceptance and commitment therapy.
How Does Body-Focused Repetitive Behavior Disorder Progress?
People with BFRB disorder often feel shame and embarrassment due to their compulsions, and their self-esteem generally suffers. Attempts to avoid embarrassing or humiliating situations can lead to social isolation, which may feed feelings of depression or anxiety. These negative feelings, in turn, may make BFRBs.
Left untreated, BFRB disorder may eventually lead to long-term mental and physical complications, including:
- Lack of close relationships
- Emotional distress
- School or work problems
- Damage to hair or skin
- Substance abuse
How Is Body-Focused Repetitive Behavior Disorder Prevented?
BFRB disorder cannot be prevented, but early diagnosis and a consistent treatment plan can help manage symptoms and prevent them from becoming disruptive if left untreated. Most people with BFRB disorder need to manage the disorder throughout their lifetime. Faithful adherence to a treatment plan, especially if it’s working well, can help prevent severe symptoms from occurring. Therefore, it’s essential for those diagnosed with BFRB disorder to seek regular evaluation from their mental health providers and stick to any prescribed medication plan.
Body-Focused Repetitive Behavior Disorder Caregiver Tips
Caregivers for someone with BFRB disorder should consider these tips to help the sufferer and themselves cope with the disorder:
- Learn as much as possible about the disorder.
- Seek appropriate professional treatment for the sufferer.
- Do everything possible to support the sufferer in the pursuit of treatment.
- Find ways to have positive experiences with the sufferer that don’t focus on the disorder.
- Find a support group for caregivers.
Many people with BFRB disorder also suffer from other brain and mental health-related issues, a situation called co-morbidity. Here are a few of the disorders commonly associated with BFRB disorder:
Body-Focused Repetitive Behavior Disorder Brain Science
Researchers are currently working on studies to find the source of BFRBs. Some studies have found differences in the brains of people with BFRBs compared to healthy brains. These differences include structural changes in the putamen, cerebellum, anterior cingulate cortex, and right inferior frontal gyri.
These diverse parts of the brain are responsible for varied functions, but a common thread among them is the control of movement. Some researchers believe that interaction between these brain areas regulates how susceptible we are to developing habitual behaviors and how good we are at suppressing habits when they’re inappropriate.
Some scientists also believe increased connectivity between the orbitofrontal cortex and the basal ganglia in people with BFRBs may play a role. They theorize that this hyperconnectivity may interfere with the brain’s reward-and-motivation system, which may explain why people with BFRBs feel satisfaction and relief when they engage in the behaviors.
Body-Focused Repetitive Behavior Disorder Research
Title: Task Control Circuit Targets for Obsessive Compulsive Behaviors in Children
Principal investigator: Rachel Marsh, PhD
New York State Psychiatric Institute
New York, NY
This study will use magnetic resonance imaging (MRI) to assess the function and structure of overlapping task control circuits in children with a range of Obsessive-Compulsive symptoms (OCS). The functioning of task control circuits will be assessed using the well-validated Multisource interference task (MSIT). This study will also evaluate functional and anatomical connectivity within task control circuits in the same children and determine whether disturbances in these overlapping circuits are associated with Obsessive-Compulsive Disorder (OCD) symptom severity. Behavioral measures will be administered to further assess regulatory, learning, and memory functions. Children with OCD will then be offered a standard course of up to 12 cognitive behavioral therapy (CBT), either via remote video conference sessions or in-person visits when clinically indicated, before scanning (along with age-and gender-matched control participants) to assess how these circuits may change with treatment. Children with subclinical OC symptoms will be offered a referral for treatment on an as-needed basis. In addition, de-identified data may be used in the future to conduct secondary data analyses. As more about OC symptoms and neurobiological mechanisms of interest in the current study are understood, data may be used to answer questions beyond those described in this protocol. All study procedures will be conducted on-site at Columbia University/the New York State Psychiatric Institute (New York, NY) and the University of Michigan’s outpatient Child and Adolescent Psychiatry (Ann Arbor, Michigan).
Title: Memantine in Body-Focused Repetitive Behaviors
Principal investigator: Jon E. Grant, MD, JD, MPH
University of Chicago
This study is eight weeks long and involves subjects taking memantine or a placebo. If they are randomly assigned to the memantine arm and are eligible to participate in the study, they will begin by taking 10mg once daily of memantine for two weeks, then 20mg for the remaining six weeks. Efficacy and safety measures will be performed at each visit. Participants will be randomized to receive either memantine or a placebo on a 1:1 basis. This blinding will be maintained by the IDS pharmacy at the University of Chicago.
The proposed study aims to evaluate the efficacy and safety of memantine in 80 subjects with DSM-5 trichotillomania (TTM) or skin picking disorder (SPD).
The hypothesis to be tested is that memantine will be more effective and well-tolerated in adults with trichotillomania or skin picking disorder compared to placebo. The proposed study will provide needed data on treating a disabling disorder where there are no current treatment options.
This will be one of the few studies assessing the use of pharmacotherapy to treat TTM and SPD in adults. Assessing the efficacy and safety of memantine will help inform clinicians about additional treatment options for adults suffering from this disorder.
Title: Theta Burst Stimulation Plus Habit Override Training for Compulsive Behaviors
Principal Investigator: Rebecca B Price, PhD
University of Pittsburgh
This project seeks to identify causal neural mechanisms underlying unwanted, repetitive behaviors (compulsions). Using non-invasive brain stimulation coupled with practice in a computer task, we will modulate activity in a target brain region and measure effects on compulsive behaviors and related measures. This work could ultimately lead to the ability to treat compulsions more effectively by targeting the regions of the brain that can help or hinder attempts to overcome compulsions.