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Skin-picking and hair-pulling: managing body-focused repetitive behaviours

Body-focused repetitive behaviours (BFRBs), such as pulling your hair out or picking your skin, are often dismissed as bad habits. However, for some people these are complex disorders requiring treatment.

If you've ever bitten your nails, squeezed a spot or tweezed out a rogue chin hair, you probably didn't think too much of it. We all have habits, and avoiding these behaviours altogether would make you the exception and not the rule.

However, for some people these behaviours are more than just a habit or tic. Around one in 20 people are thought to suffer with a 'body-focused repetitive behaviour' (BFRB). These can include, for example, trichotillomania (pulling your hair out) or dermatillomania (compulsive skin-picking).

In these cases, the behaviour is repeated and hard to stop. It can cause damage to the body - sometimes serious - along with emotional distress.

"These are 'disorders' rather than just habits that everyone experiences, so they have a large impact on people's lives," says a spokesperson for the charity OCD Action

Similarities to OCD

While BFRBs are not quite the same as obsessive compulsive disorder (OCD), they do have some things in common. OCD is characterised by compulsions, like washing your hands or turning the lights on and off. These are repetitive and ritualistic, and provide a momentary reprieve from distress.

Something similar could be said for BFRBs. Pulling out your hair, picking your skin or chewing your cuticles are certainly types of compulsion, and they do provide sufferers with a temporary sense of relief. However, there are important differences too.

"Compulsive behaviours in OCD are driven by anxiety, which stems from distressing intrusive thoughts, images, urges or feelings," says the OCD Action spokesperson. "With BFRBs it's usually to relieve stress or tension or because of guilt. Healthcare professionals sometimes use the term 'OCD spectrum disorders' to refer to conditions that are similar to OCD, in that the people who experience them have a compulsion to act in a certain way."

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What causes BFRBs?

In some cases, BFRBs and OCD can occur together. And while BFRBs don't always point to a deeper issue, people with these compulsions do have higher levels of depression, anxiety and other psychiatric conditions.

What's more, if you have one BFRB you're more likely to engage in other pulling or picking behaviours. Some researchers think this may point to a single underlying cause.

According to one model, introduced in the early 2000s, BFRBs occur in response to over- or under-stimulation. You might pick your skin when you're stressed and anxious, or conversely when you're sedentary and bored.

While this area of research is only just beginning, one 2018 study suggests people with BFRBs may have abnormalities in the way they process sensations. This means the behaviours might be a way to correct a sensory imbalance.

"As with OCD, the causes are relatively unclear," says the OCD Action spokesperson. "Trichotillomania usually begins in childhood or adolescence and evidence suggests that several biological factors (eg brain structure, viral infection) may be responsible for its onset. Environmental factors can contribute too. Dermatillomania most commonly begins in the early teens though it can start at a much younger or older age. It may well have an underlying genetic cause."

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Seeking help

Many people with BFRBs report that the behaviours feel pleasant in the short term, transporting them into a calm, even trance-like state. However, the after effects can be distressing. People affected by these disorders often feel depressed and ashamed, which might cause them to hide away from social situations, school and work.

If you pull your hair out, for example, you might worry about people noticing bald patches, and if you pick your skin you might worry about scars. You might also feel ashamed about the amount of time you spend on the behaviour, or struggle with a lack of understanding from others.

The physical effects can be damaging too. According to the TLC Foundation for Body Focused Repetitive Behaviors, a US organisation that helps sufferers, 5-20% of trichotillomania sufferers also swallow the hair, which can occasionally lead to an intestinal blockage. Those who pick their skin may cause soreness, bleeding, tissue damage and infection.

This means, if you're dealing with any of these issues, it's important to seek help. BFRBs are treatable and can be controlled.

"If someone is worried they may be affected by a BFRB, they should contact their GP or a mental health professional who can either assess them or refer them on to an assessment," says the OCD Action spokesperson. "The treatments are similar to those for OCD. Cognitive behavioural therapy (CBT) may be offered, using an added technique called 'habit reversal'. Medication may also be offered (SSRIs)."

OCD Action also has support forums, including a Skype/phone support group for people with dermatillomania and trichotillomania. These disorders are more common than most people realise, and if you don't have one yourself, chances are you know someone else who does.

As the OCD Action spokesperson explains: "Everyone has habits, but when it is starting to have an impact on your life and causing you distress, that's when we'd encourage you to seek help."

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