Symptom Spotlight: Body-Focused Repetitive Behaviours
This week's feature looks at body-focused repetitive behaviours, often abbreviated to BFRB. This term encompasses a number of different issues, all of which involve a compulsive need to engage in behaviours which are focused on one's own body and can be destructive when out of hand. This feature will explore some of the most common BFRBs, the impact they can have, and some tips and tricks for reducing them.
The first thing to note is that, whilst BFRBs are not exclusive to those with mental illness, they are almost universally exacerbated by stress and anxiety. They tend to be very compulsive behaviours, often partially or wholly subconscious, and so can be a very difficult behaviour to curb. In their most extreme form, they can be hugely damaging to a person's body and require specific psychiatric treatment. They are also significantly more common in people with anxiety disorders, personality disorders, and particularly with OCD. In their more severe forms, BFRBs may be classified as an 'impulse control disorder', if the person is unable to resist the urge to engage in the behaviour. They tend to be grouped in with obsessive-compulsive disorders, though there is some speculation on their links to addiction and self-harm.
To start, I want to look at a BFRB that will be familiar to many, to show how these are not unique to mental illness or to neurodivergence. This is perhaps the most common BFRB in day to day life, and many people might not even identify it as such. Have you guessed it yet?
That's right. This simple 'bad habit' - medically termed 'onychophagia' - is a classic example of body-focused repetitive behaviour, and is a common habit amongst people of all neurotypes and states of mental wellbeing. A significant number of people bite their nails as a child. Fewer continue into adulthood, but it's not unheard of. Nail-biting almost always focuses on the fingernails, and occasionally extends to the surrounding skin. Unchecked, this can lead to skin damage, consistent open wounds leaving the skin vulnerable to infection. In severe cases, it can also lead to scarring or even deformity of the fingertip due to damage to the nail bed.
Whilst most cases of nail-biting are considered simply bad habits, in some cases it is classified as an impulse control disorder and can warrant psychiatric treatment. This is usually a form of cognitive behavioural therapy (CBT) called habit reversal therapy, which seeks to curb the habit completely or replace it with a less harmful behaviour. This type of CBT is commonly used for body-focused repetitive behaviours and is the first line in psychiatric treatment for most cases, alongside antidepressant medication.
Dermatillomania is a compulsive urge to pick at one's own skin. This is usually healthy skin, but can also manifest as picking at scabs. Often, the urge to pick is so continuous that those experiencing dermatillomania cause visible open wounds to the skin. This carries a risk of scarring and infection, as well as being highly uncomfortable and even painful, but the sufferer is often unable to resist because the urge is so compelling.
Dermatillomania often focuses on the face and lips, but can involve skin anywhere on the body. The person may pick at a visible blemish, or something invisible to others. However, the picking can also be unfocused, resulting instead from stress, anxiety or other difficult emotions. Much like body dysmorphic disorder, it's closely related to obsessive-compulsive disorder, and the standard treatment approach - medication and talking therapy such as CBT - is much the same.
Many people are unaware that their compulsions are actually a sign of a disorder. If you experience:
Cuts, bleeding, bruising or scarring as a result of picking at your skin
An urge to 'smooth out' imperfections or blemishes, including freckles and spots
Pick at your skin without realising, or in your sleep, or when you're stressed
Cannot resist the urge once it starts
Have cuts which take more than a few days to heal due to picking
… you may be experiencing dermatillomania and should see your GP.
Trichotillomania (sometimes referred to as 'trich') is a BFRB which focuses on the hair. This can be the hair on your scalp, but can also be focused on eyebrows, eyelashes and other hair types. It can be a conscious, irresistible urge to pull the hair, or it can be done without thinking. Most people pull at their hair using their hands, but for some people with trich, they may also use tweezers or other implements.
Much like other BFRBs, the cause for trichotillomania is not well understood. It too is categorised alongside obsessive-compulsive disorder, but in the past, it has also been labelled as an impulse control disorder, and even a form of self-harm. It can cause noticeable bald spots which are often uneven across the scalp, due to repeated pulling in the same place. This can compound the issue by making the person self-conscious, which can prompt social withdrawal and a further decrease in mental health which may exacerbate the condition.
Teeth grinding - or bruxism, as it's medically known - is one of the more well-known BFRBs on this list, and much like nail-biting it's broadly more well-known and less stigmatised than conditions such as trich or dermatillomania. Most cases occur during sleep, but it is now well-acknowledged that some sufferers will also grind their teeth when awake, and particularly when concentrating under stress.
The effects can be quite severe. Those with chronic bruxism can cause permanent tooth damage; wearing down their teeth causing sensitivity, and even breaking teeth and requiring fillings. The constant movement can also cause 'frictional hyperkeratosis', where the skin inside the mouth becomes thickened and rough to protect from injury. However, the effects can me wider-reaching. Constant over-clenching of the teeth can cause headaches and earaches, as well as putting additional strain on the temporomandibular joint which can cause TMJ disorder. Aesthetically, it can also cause the masseter (chewing) muscles to overdevelop, changing the person's facial shape. In fact, a number of cases of chronic bruxism are diagnosed when people approach their medical practitioner for cosmetic surgery to correct an overly-squared jaw.
As bruxism is more well-known, more treatments have been developed. Whilst antidepressants and CBT may be useful in cases which are exacerbated by stress, the recommended treatment for bruxism is a mouth guard or splint, which can be purchased online relatively cheaply. This can make bruxism easier to manage at home and indicates a wider awareness of the condition more broadly.
The group of behaviours termed 'morsicatio' involve the urge to bite or nibble at the oral mucosa; more simply, the skin inside your mouth. This can focus on the inside of the cheek (morsicatio buccarum), the tongue (morsicatio linguarum), or the lips (morsicatio labiorum). These can occur independently, but are also often associated with the frictional hyperkeratosis observed as a result of bruxism, as well as with other oral conditions and with OCD.
As with most BFRBs, it's not uncommon for everyone to do this on occasion, but it becomes a mental health disorder when it is chronic and/or causes serious injury. In this more extreme form, the person repeatedly breaks the skin, causing deep wounds and even mouth ulcers. This, in turn, can create a further sense of 'jagged' edges in the mouth, which can make the compulsion worse and perpetuate the issue. In addition to these injuries, it can also cause additional wear to the teeth, pain and stiffness in the jaw due to excessive movement, and in some cases deep and longstanding trauma to the tissues has been cited as a potential cause of oral cancer.
As such, it is essential that those with morsicatio seek treatment to prevent damage and complications. This can include CBT and medication, much like other BFRBs, but can also involve the use of a bite guard, much like those used for bruxism.
BFRBs are much more common than many people realise, but there is still a stark difference between the levels of stigma associated with each, and the availability of good treatment. Sadly because we don't talk enough about these conditions, many people are suffering in silence, unaware that their difficulties are common experiences and can be treated. If you think you may be experiencing BFRB, it's important to visit your GP (or dentist, in the case of bruxism) to explore the options available to you and avoid any long-term damage to your body.
I hope that this week's feature has been informative, and manages to shed a little light on body-focused repetitive behaviours.
Until next time!