BFRBs and ‘Bad Habits’
Author: Anna Kiesewetter(Issaquah High School)
Part of a Collaboration with The Helyx Initiative
Oftentimes, we hear our mothers nag at us about our ‘bad habits.’ The second that our cuticles approach the vicinity of our mouths, we can expect a resounding “don’t bite your nails!” Other times even we are the naggers, vexedly reminding our toddler siblings to please stop picking their noses. However, there’s actually a fine line where these ‘bad habits’ can become compulsive disorders—and it’s time for this difference to be recognized as such.
Body-Focused Repetitive Behaviors, or BFRBs, are an emerging concept in the study of mental health. Currently categorized as “obsessive- compulsive and related disorders,” all BFRBs involve common self-care routines or absentminded stress-relief tactics which turn into compulsive, or uncontrollable, conditions . For example, nail biting is often known as a ‘bad habit,’ done during times of duress or to remove a hangnail. But for a small portion of the population, it can turn into onychophagia, a compulsive disorder of excessive urges to bite one’s nails. BFRBs like onychophagia cause the patient significant stress and interfere with normal functioning despite repeated attempts to stop. For many, anxiety is the trigger for this action. The nail biting then creates some feelings of pleasure or satisfaction, and often results in feelings of shame and guilt afterwards .
Generally, BFRBs tend to show up during the late childhood and teenage years, and decrease in prevalence with age. These disorders are present in at least 3% of the population, though this number may be larger due to stigmas around mental health discussion preventing many from reporting their condition and seeking help [1, 2]. BFRBs disproportionately affect women, with 90% of adults who seek help being female, though again, this number may be skewed because of an even greater stigma around mental health among men [1, 3].
Let’s get into the details of a few of these conditions. Onychophagia is the term for compulsive nail biting, with the Greek root onych meaning “nail” and phago meaning “eating.” Usually, this applies to the fingernails. Onychophagia is often triggered by stress, tension, hunger, loneliness, or boredom, and leaves the nail beds raw and prone to infection or irritation. It can also introduce harmful bacteria into the mouth. Researchers have found this BFRB to be more common in those with attention deficit hyperactivity disorder, or ADHD, as well as oppositional defiant disorder and separation anxiety .
Dermatillomania is the term for compulsive skin picking, while dermatophagia denotes compulsive skin biting. The root derm, naturally, means “skin,” while till means “pull” and mania means “hyperactivity.” Similar to onychophagia, phag in dermatophagia also means “eating.” Dermatillomania is most commonly associated with obsessive-compulsive disorder, in that it is ongoing and uncontrollable. Dermatillomania and dermatophagia most commonly occur around the cuticles and fingers, though they may also occur elsewhere. Oftentimes, this can leave the skin raw or bleeding, increasing the likelihood of skin infection. Biting and eating the skin can also introduce harmful pathogens into the body .
Trichotillomania involves irresistible urges to pull out the hair from one’s scalp, eyebrows, or other areas despite efforts to stop. As you can probably guess, the word roots follow those of dermatillomania, the only difference being that tricho means “hair.” Trichotillomania is most often triggered by anxiety and stress, such as during exams or internal struggles. It can also create a vicious cycle of anxiety. People pull their hair out when they are anxious, and then end up becoming even more anxious because they cannot stop pulling their hair. This can result in widespread balding and uneven hair, which damage is sometimes permanent. The damage caused by trichotillomania can exacerbate social anxiety and issues with self-esteem, prompting some patients to invest in expensive wigs or other hair solutions in order to hide their condition .
Perhaps the least-understood BFRB, rhinotillexomania involves compulsive nose picking. For most children, teens, and even adults, nose picking is simply a time-to-time method to clear out the nasal passageway when it feels overly dry or moist [6, 7]. However, for some individuals, it is continually triggered by stress, anxiety, and other BFRBs, bringing with it feelings of shame. In a study of 254 Wisconsin adults, it was found that rhinotillexomania is commonly coupled with other BFRBs; many who picked their nose also picked their cuticles, bit their fingernails, and/or pulled out their hair . Rhinotillexomania can cause increased risk of infection or illness as well as nosebleeds. In extreme cases, it can also cause damage to the nasal cavity and septum. The overwhelming effect reported by those with the condition, however, is feelings of embarrassment and indignity, as seems to be the case with all BFRBs .
What compounds the shame and guilt associated with these mental health disorders is that very little is known and understood about BFRBs. To the general public, nail biting, skin picking, hair pulling, and nose picking are simply seen as ‘bad habits’ that can be stopped with time and willpower. Parents’ nagging, as well as a lack of portrayal in the media, culminate in this common perception that BFRBs do not really exist and can simply be stopped on one’s own. Thus, many with these conditions do not even realize they have them. Others go to great lengths to hide the evidence of their disorders, with a widespread reluctance to seek help [1, 5].
However, treatment is available and often quite effective in combating BFRBs. The type of treatment is dependent on the patient and their specific triggers. Specific therapies have been found to effectively treat many of the different conditions. Cognitive behavioral therapy, or CBT, addresses behavioral responses to certain thoughts in order to adjust reactions to triggers. Habit reversal training, or HRT, involves awareness training, competing response training, and social support . Acceptance and commitment therapy, or ACT, involves embracing thoughts rather than feeling shame for them, helping people to come to terms with their BFRB .
Ultimately, it’s important that we recognize the difference between ‘bad habits’ and body-focused repetitive behaviors in order to break the stigma, spread awareness, and promote wellness. BFRBs are very real aspects of many people’s lives, and the more we learn and understand about these conditions, the more we can work to support these people.
 Body-Focused Repetitive Behaviors. Psychology Today. https://www.psychologytoday.com/us/basics/body-focused-repetitive-behaviors. Published 2020. Accessed July 8, 2020.
 Holland K. Nose Picking: Why We Do It, If It's Bad for Us, and How to Stop. Healthline. https://www.healthline.com/health/nose-picking. Published March 22, 2019. Accessed July 8, 2020.
 Onychophagia (Nail Biting). Psychology Today. https://www.psychologytoday.com/us/conditions/onychophagia-nail-biting. Published April 10, 2019. Accessed July 8, 2020.
 Dermatophagia: Symptoms, causes, and treatment. Medical News Today. https://www.medicalnewstoday.com/articles/325111. Published May 2019. Accessed July 8, 2020.
 Brown CL. More Than a Fidget: Living with a Hair-Pulling Disorder. Healthline. https://www.healthline.com/health/hair-pulling-more-than-a-fidget. Published July 23, 2065. Accessed July 8, 2020.
 It's OK for your child to pick his nose. Really. ChildrensMD. https://childrensmd.org/uncategorized/its-ok-for-your-child-to-pick-his-nose-really/. Published June 17, 2013. Accessed July 8, 2020.
 Villazon L. Why do young children pick their noses and eat it? BBC Science Focus Magazine. https://www.sciencefocus.com/the-human-body/why-do-young-children-pick-their-noses-and-eat-it/. Published 2020. Accessed July 8, 2020.
 Jefferson JW, Thompson TD. Rhinotillexomania: Psychiatric Disorder or Habit? The Journal of clinical psychiatry. https://pubmed.ncbi.nlm.nih.gov/7852253/. Published February 1995. Accessed July 8, 2020.
 Evans JR. Dermatophagia: Symptoms, Treatment, Risk Factors, and More. Healthline. https://www.healthline.com/health/dermatophagia. Published August 30, 1983. Accessed July 8, 2020.
Image 2: “Trichotillomania” by Vitalicecila, licensed under Creative Commons: https://creativecommons.org/licenses/by-sa/4.0/deed.en. No changes made.
What Did You Learn?
What are BFRBs? What are the common types?
BFRBs are Body-Focused Repetitive Behaviors, related to obsessive-compulsive disorders. With BFRBs, absentminded grooming behaviors such as biting nails become uncontrollable urges which significantly hamper a person’s normal functioning. The common types we’ve discussed include onychophagia, or nail biting; dermatophagia and dermatillomania, or skin biting and picking; trichotillomania, or hair pulling; and rhinotillexomania, or nose picking.
What is the difference between a ‘bad habit’ and a BFRB? Why is recognizing this important?
The main difference is that the actions in a BFRB produce significant stress and impede the daily functioning of the individual. ‘Bad habits’ occur less often and are manageable, though at times irritating; BFRBs, on the other hand, can feel debilitating and are much more severe. It’s important to recognize this difference in order to spread awareness of BFRBs. Right now, it’s commonly thought that people can simply correct their own ‘bad habits,’ but in the case of people with BFRBs, the acknowledgement of their condition is the first step to addressing and treating it. The stigma around mental health and around many ‘bad habits’ prevents many people from seeking help, so it’s important to normalize the discussion and teaching of BFRBs.