Everyone occasionally scratches their face or touches their hair. Still, for people with body-focused repetitive behaviors (BFRBs), these impulses feel impossible to ignore and can cause physical damage. Body-focused repetitive behaviors affect many people, particularly ADHDers.

Let’s dive into the complex subject of BFRBs, how they relate to ADHD, and the steps for relief and treatment.

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• Body-focused repetitive behaviors take different forms and affect people differently.
• ADHD risk factors, such as dopamine deficiency and impulse control issues, can make BFRBs more challenging.
• BFRBs are not beyond treatment, and different types of therapy and medication can help.

What are body-focused repetitive behaviors?

BFRBs involve extreme self-grooming behaviors that can cause physical bodily injuries, such as on the skin, hair, and eyes. BFRBs include many behaviors like excessive skin picking, hair pulling, and nail biting.

Common BFRBs

• Skin picking (Excoriation disorder or skin picking disorder)
• Hair pulling (Trichotillomania)
• Nail biting (Onychophagia)

Lesser known BFRBs

• Compulsive joint cracking¹
• Lip and cheek biting²
• Dermatophagia, or compulsive skin biting
• Bruxism, or teeth grinding and jaw clenching

Body-focused repetitive behaviors and ADHD

The links between ADHD and BFRBs are still being studied. However, ADHDers possess some risk factors which may worsen the effects of BFRBs.

Dopamine deficiency

ADHDers suffer from dopamine deficiency. Dopamine is a neurotransmitter produced in the midbrain and is responsible for feelings of reward and pleasure.

Lack of dopamine means that ADHDers often use dopamine-seeking behaviors when they feel particularly understimulated. These include BFRBs, as they can increase dopamine levels.

Insufficient impulse control

ADHDers often suffer from impulsivity or a lack of impulse control. Impulsive actions commonly associated with ADHD in adults include impulsive buying, impatience, and quick relationship decisions with little regard for consequences.³

The impact of BFRBs

• Embarrassment—People who struggle with BFRBs can feel social embarrassment and shame from doing things others may consider strange. This can lead to social isolation and emotional distress, and even cause mood or anxiety disorders.
• Medical complications—Due to constant bodily damage, BFRBs can cause infection, tissue damage, and muscle or joint injuries. Further complications include viral or bacterial infections, dental problems, or potential disfigurement.

Treatments and interventions

Habit reversal training and therapy

Different forms of therapy have been proven to help people move away from BFRBs, including cognitive behavioral therapy and habit reversal training (HRT). HRT focuses on creating awareness of the BFRB and developing a competing response to replace the BFRB with an opposite action. Awareness training includes learning about situations and avoiding triggers.

HRT can be combined with other forms of behavioral therapy, like dialectical behavior therapy (DBT), to make the treatment more effective.⁴

Aside from behavioral therapy, other types of talk therapy can help people with BFRBs overcome feelings of embarrassment and help deal with anxiety and depression underlying the destructive behavior.

Medication

In combination with HRT and therapy or alone, medication has been used to deal with BFRBs.

• N-Acetyclysteine (NAC) medication interacts with glutamates, which nerve cells use to transmit signals, and has been proven effective in treating BFRBs like excoriation disorder.⁵
• Selective serotonin reuptake inhibitors (SSRIs) and other antidepressant medications have been used to treat BFRBs like trichotillomania by raising serotonin levels and helping with anxiety and depression issues often underlying and accompanying BFRBs.⁶

Substituting the behavior

Aside from treatment, fidgeting with small toys or objects can be a useful measure to reduce repetitive movement. For example, fidget toys can be substitutes for picking at your skin or pulling your hair. Look to household items, such as brushes, scrubbers, or bubble wrap, or natural objects like branches or pinecones for free alternatives to provide sensory stimulation instead of BFRBs.

Sources:

¹ Guilford Press Periodicals | Adaptation of movement decoupling for compulsive joint cracking: A case report
² Journal of Obsessive-Compulsive and Related Disorders | Escaping the mouth-trap: Recovery from long-term pathological lip/cheek biting (morsicatio buccarum, cavitadaxia) using decoupling
³ Frontiers in Human Neuroscience | Frontal Dysfunctions of Impulse Control – A Systematic Review in Borderline Personality Disorder and Attention-Deficit/Hyperactivity Disorder
⁴ Cognitive Therapy and Research | Habit Reversal Training and Variants of Decoupling for Use in Body-Focused Repetitive Behaviors. A Randomized Controlled Trial
⁵ JAMA Psychiatry | N-Acetylcysteine in the Treatment of Excoriation Disorder: A Randomized Clinical Trial
⁶ Cochrane Database of Systematic Reviews | Pharmacotherapy for trichotillomania