Body-Focused Repetitive Behaviors

The short version: BFRBs like skin-picking and hair-pulling are probably distantly related to obsessive-compulsive disorder. There are no silver bullet treatments, but it can be helpful to treat associated anxiety or to restrict practical access to the relevant body part (either through clever hacks or various high-tech products). Any anxiety or OCD medication can be mildly effective against BFRBs, and the supplement n-acetylcysteine (start with 500 mg twice a day, titrate up after one month) seems especially promising.

The long version:

1. What are body-focused repetitive behaviors?

Body-focused repetitive behaviors include compulsive hair-pulling, skin-picking, and nail-biting. Some people include compulsive lip-biting, cheek-biting, and joint-cracking. These come from the same place as the universal urge to pick at a scar, but for some people they can be constant, overwhelming, and disabling.

We don’t know exactly what’s going on here. We know the condition is partly genetic, because relatives of patients have 5-10x elevated risk of being patients themselves. We know that the condition is deeply rooted in primitive brain areas, because many different kinds of animals have BFRBs – monkeys pull their hair, birds pull their feathers, dogs compulsively lick their paws to the point of damaging them. And we know that anxiety is by far the most important risk factor; most people’s urges to pick or pull wax or wane with their anxiety levels.

The psychiatric establishment classifies BFRBs as an obessive-compulsive-spectrum disorder, along with OCD and hoarding, based on all of these tending to co-occur in the same people and families. But other researchers think they’re more closely related to “stereotypies” like when autistic people bang their heads or rock back and forth. And they may even have some relationship to the strange motor behaviors seen in people who overuse dopaminergic medications – for example, after abusing methamphetamine, some people will compulsively brush their hair, lick their nails, etc. At this point the whole condition is still kind of a mystery, even moreso than usual in psychiatry.

2. How can you treat BFRBs?

There are at least four treatment options for BFRBs, all of which can be pursued in parallel. First, treating the underlying anxiety. Second, taking pragmatic measures to prevent the behavior. Third, psychotherapy. Fourth, medication. Moving through them in order:

First, you can treat anxiety.

Almost all BFRBs get worse with underlying anxiety, and get better when the patient feels like their life is calm and stress-free. Often they get so much better that no other treatment is needed. We know much more about treating anxiety than we do about treating BFRBs, and it’s usually safer and has fewer side effects, so anything you can do to decrease anxiety is a first-line treatment here. Quitting your stressful job or breaking up with your abusive partner will be much better for you in the long run, in terms of BFRBs and everything else, then taking some exciting high-tech medication.

Second, you can take direct steps to prevent yourself from engaging in the behavior.

This gets complicated, because BFRB patients have very different experiences of how voluntary their behaviors are. Some people feel like they do their behaviors completely automatically, without thinking about it, and as soon as they notice the behavior they’re able to stop. Other people do it almost like an addiction, where they know what they’re doing but can’t stop.

If you’re more of the first type – you just don’t notice when you’re doing it – take steps to notice. My favorite such step is the HabitAware bracelet ($149). You put it on your dominant hand, and when your hand gets too close to the part of your body you’ve programmed in – eg your hair or your face – the bracelet vibrates and then you realize what you’re doing.

A few of my patients have gotten good results with fake nails – the same kind people use for fashion. These make it really hard to bite your nails or effectively pick at your skin; certainly it makes trying to do these things more noticeable. I’ve never used these and honestly I have no idea how they would interact with hair-pulling. You can also just get really bad-tasting nail polish.

If you have problems with lip, tongue, or cheek biting, you can buy mouth guards. Something like this one should be fine. Here’s a paper talking more about how to make this solution work.

Finally, eliminating the thing you want to pick at may be easier than stopping yourself from picking. If you pick at your nails because they have snags or hangnails, you can use moisturizing cream to have fewer of those. The most common way to get a complete cure for acne-related skin-picking is to cure the acne; I realize this is easier said than done, but there are many more good acne medications than there are good BFRB medication. And if you’re really the sort of person who likes cutting Gordian knots, the most radical solution for trichotillomania is to either cut your hair so short that you can’t pull it effectively, or shave your hair entirely and buy a wig. This obviously isn’t the right solution for everyone, but the people who really need it really need it.

If you can’t eliminate the target body features, and seeing them is a trigger for you, you can also consider just getting rid of mirrors.

Third, you can get psychotherapy.

The most commonly recommended therapy for BFRB is habit reversal training (abbreviated HRT, but be very careful using the abbreviation since it can also stand for the hormone replacement therapy used in gender change; people who just ask their doctor for “HRT” may end up getting more than they bargained for!). HRT focuses on raising awareness of the behavior, coming up with a competing response (eg when you get the urge to bite your nails, you clasp your hands together in a prayer-like position in front of you instead), and getting social support for these things. It works about as well as anything does for this condition, ie not great.

Fourth, you can use medication.

I recommend this as a last-line option, because medication doesn’t work great for these kinds of conditions. Still, there are some possibilities.

Studies disagree over whether SSRI antidepressants work for BFRBs. I assume they work a little, because they work a little for anxiety, and anything that decreases anxiety will also decrease BFRBs.

Some studies suggest that clomipramine, an older antidepressant, works best of all. This is very plausible, because it increases serotonin levels more than SSRIs, and probably works better than SSRIs for anxiety – and, again, anything that decreases anxiety will also decrease BFRBs.

Some studies show that antipsychotics help with BFRBs. This is also very plausible, because antipsychotics are sedative, are anxiolytic, and generally decrease all behaviors. I’m agnostic as to whether they have any special anti-BFRB potency beyond this. It’s not completely implausible that they do – remember that methamphetamine abuse can cause BFRB-like behaviors, methamphetamine increases dopamine – and antipsychotics block dopamine – so they might at least be targeting the right system. Still, as usual antipsychotics should be your last-line treatment only for when you are very desperate.

Naltrexone is an opioid antagonist that seems to help with many addictive and compulsive behaviors. Some people speculate that it might help with BFRBs because BFRBs involve opiates in some way – maybe pulling your hair or picking your skin causes pain which releases endorphins which make it addicting. I find this theory a little implausible, but some small studies have given it a little support, especially in people who have a personal or family history of opioid or other addiction. If that’s you, maybe this is worth a try.

Anecdotally, many people have stories of totally random drugs being magic bullets that completely stop their BFRBs. I’ve seen people who swear by bupropion or valproate – neither of which has any business being on a list like this – and say nothing else has worked for them. I think this is probably related to anxiety. Any medication that you need will make your life better and make you less anxious, and being less anxious will help BFRBs.

N-acetylcysteine is an over-the-counter supplement you can buy at Whole Foods or online (eg here). This is the only substance I can recommend for BFRBs without at least a little bit of embarrassment. It works in studies, has few side effects, and seems to be genuinely addressing the root problem instead of decreasing anxiety or behaviors in general or something like that. See eg this article. If you want to use the same dosing protocol as in the most successful studies, take 500 mg twice a day (total 1000 mg/day) for a month, then 1000 mg twice a day (total 2000 mg) for another month, then go up to 1500 mg twice a day (3000 mg a day) after that. This will be much more than whatever vitamin company sold you the NAC recommends, and might involve taking six large pills a day, but that’s the right way to take it according to the studies. If you don’t feel any better after three months, give up and try something else. Ask your doctor before starting NAC, especially if you take anything else or have any co-occuring health problems. You may want to avoid drinking large amounts of alcohol when on NAC.

3. Where can I learn more about BFRBs?

Try the TLC Foundation For Body-Focused Repetitive Behaviors website.