Body-focused repetitive behavior

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Body-focused repetitive behavior
Other names: Body-focused repetitive behavior disorder (BFRBD)
Knuckle biting resulting in disfiguration of the skin over the joints of the middle and little fingers
SymptomsNail biting, lip biting, cheek chewing[1]
Differential diagnosisHair pulling disorder, skin picking disorder, stereotypic movement disorder, self-harm, normal habits[1][2]
TreatmentCounselling, medications[3]
MedicationSSRIs, N-acetylcysteine[3]

Body-focused repetitive behavior (BFRB) is a group of psychiatric disorders were people repeatedly harm part of their body by either pulling or picking at it.[4] Specific behaviors may include nail biting, lip biting, or cheek chewing.[1] People are unable to stop these behaviors despite trying to do so.[3] Complications may include nail damage.[3]

It is within the category of obsessive-compulsive and related disorders.[1] In the DSM-5, body-focused repetitive behavior disorder (BFRBD) is only diagnosed if the symptoms are not better explained by hair pulling disorder or skin picking disorder.[1] Other sources; however, include those two disorders as types of BFRBD.[4] Diagnosis requires the behavior to occur to such a degree that functioning is impaired or distress occurs.[3][2] Additionally the behavior must be unrelated to efforts to change ones appearance.[3]

Treatment may include counselling, such as cognitive behavioral therapy, and medications, such as SSRIs or N-acetylcysteine.[3] Cognitive behavioral therapy may involve increasing awareness around when the behavior occurs, efforts to avoid triggers, and attempts to replace the specific behavior with something else like knitting.[3] While these behaviors have been described throughout history, it was in the late 1800s that they were named as health problem.[5] Hair pulling disorder was first included in the DSM in 1987 while skin picking disorder was officially included in 2013.[5]


The cause of BFRBs is unknown.

Emotional variables may have a differential impact on the expression of BFRBs.[6]

Research has suggested that the urge to repetitive self-injury is similar to a body-focused repetitive behavior but others have argued that for some the condition is more akin to a substance abuse disorder.

Researchers are investigating a possible genetic component.[7][8]


BFRBs most often begin in late childhood or in the early teens.[9]


Body-focused repetitive behavior disorders (BFRBDs) in ICD-11 is in development.[10]


The main BFRB disorders are:[11]



Treatment can include behavior modification therapy, medication, and family therapy.[7][9] The evidence base criteria for BFRBs is strict and methodical.[12] Individual behavioral therapy has been shown as a "probably effective" evidence-based therapy to help with thumb sucking, and possibly nail biting.[12] Cognitive behavioral therapy was cited as experimental evidence based therapy to treat trichotillomania and nail biting.[12] Another form of treatment that focuses on mindfulness, stimuli and rewards has proven effective in some people. However, no treatment was deemed well-established to treat any form of BFRBs.[12]


Excoriation disorder, and trichotillomania have been treated with inositol and N-acetylcysteine.[13]


BFRBs are among the most poorly understood, misdiagnosed, and undertreated groups of disorders.[14] BFRBs may affect at least 1 out of 20 people.[9] These collections of symptoms have been known for a number of years, but only recently have appeared in widespread medical literature. Trichotillomania alone is believed to affect 10 million people in the United States.[15]

See also


  1. 1.0 1.1 1.2 1.3 1.4 Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). American Psychiatric Association. 2013. pp. 263-264. doi:10.1176/appi.books.9780890425596.156852. ISBN 978-0-89042-555-8. {{cite book}}: Cite has empty unknown parameter: |1= (help)
  2. 2.0 2.1 Geddes, John R.; Andreasen, Nancy C. (2020). New Oxford Textbook of Psychiatry. Oxford University Press. p. 988. ISBN 978-0-19-871300-5. Archived from the original on 2021-08-28. Retrieved 2021-02-18.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 "Body-Focused Repetitive Behavior Disorder - Psychiatric Disorders". Merck Manuals Professional Edition. Archived from the original on 9 January 2021. Retrieved 18 February 2021.
  4. 4.0 4.1 Sampaio, DG; Grant, JE (2018). "Body-focused repetitive behaviors and the dermatology patient". Clinics in dermatology. 36 (6): 723–727. doi:10.1016/j.clindermatol.2018.08.004. PMID 30446195.
  5. 5.0 5.1 Fontenelle, Leonardo F.; Yücel, Murat. A Transdiagnostic Approach to Obsessions, Compulsions and Related Phenomena. Cambridge University Press. p. 367. ISBN 978-1-107-19577-6. Archived from the original on 2021-08-28. Retrieved 2021-02-18.
  6. Teng; et al. (2004), "Body-Focused Repetitive Behaviors: The Proximal and Distal Effects of Affective Variables on Behavioral Expression", Journal of Psychopathology and Behavioral Assessment, 26: 55–64, doi:10.1023/B:JOBA.0000007456.24198.e4
  7. 7.0 7.1 Scientific Advances in Trichotillomania and Related Body-Focused Repetitive Behaviors Archived July 21, 2011, at the Wayback Machine, November 4, 2004, National Institute of Mental Health
  8. ABC News 20/20 Hair Pulling, 2006
  9. 9.0 9.1 9.2 9.3 AAMFT Consumer Update - Hair Pulling, Skin Picking and Biting: Body-Focused Repetitive Disorders Archived 2009-04-25 at the Wayback Machine, American Association for Marriage and Family Therapy
  10. "Archive copy". Archived from the original on 2018-02-17. Retrieved 2017-05-06.{{cite web}}: CS1 maint: archived copy as title (link)
  11. Trichotillomania (TTM) & Related Body-Focused Repetitive Behaviors (BFRBs) Archived 2011-12-29 at the Wayback Machine, The Center for Emotional Health of Greater Philadelphia
  12. 12.0 12.1 12.2 12.3 Woods, Douglas W.; Houghton, David C. (13 July 2015). "Evidence-Based Psychosocial Treatments for Pediatric Body-Focused Repetitive Behavior Disorders". Journal of Clinical Child & Adolescent Psychology. 45 (3): 227–240. doi:10.1080/15374416.2015.1055860. PMID 26167847.
  13. Torales J, Barrios I, Villalba J (2017). "Alternative Therapies for Excoriation (Skin Picking) Disorder: A Brief Update". Adv Mind Body Med. 31 (1): 10–13. PMID 28183072.
  14. Families & Health Archived March 28, 2009, at the Wayback Machine, American Association for Marriage and Family Therapy
  15. Diefenbach GJ, Reitman D, Williamson DA (2000). "Trichotillomania: A challenge to research and practice". Clinical Psychology Review. 20 (3): 289–309. doi:10.1016/S0272-7358(98)00083-X. PMID 10779896.

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