Body-Focused Repetitive Behavior Disorder, According to the DSM-5

In a small, little-noticed subcategory of the Other Specified Obsessive-Compulsive and Related Disorder (DSM-5, 300.3; ICD-10, F42) diagnosis in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5), lies body-focused repetitive behavior disorder.

Although they are not each specifically indexed in the DSM-5, these oft-overlooked behavioral difficulties can cause a great deal of distress and functional impairment in the lives of those who struggle with them.

Body-focused repetitive behaviors (BFRBs) include any repetitive self-grooming behavior that involves biting, pulling, picking, or scraping one’s own hair, skin, lips, cheeks, or nails that results in damage to the body and have been met with multiple attempts to stop or decrease the behavior.

Like their more formally recognized relatives trichotillomania and excoriation disorder, BFRBs which rise to clinical significance must cause notable distress or impairment in the individual’s daily functioning and cannot be better accounted for by a stereotypic movement disorder or non-suicidal self-injurious behavior.

Types of Body-Focused Repetitive Behavior Disorder

 BFRBs include, but are not limited to:

• Trichotillomania: Recurrent hair-pulling, resulting in hair loss. Data suggest that trichotillomania occurs in approximately 1% - 3% of the population.
• Excoriation Disorder: recurrent skin picking, resulting in skin lesions. Studies suggest that pathological skin picking affects 1.4% - 5.4% of the U.S. adult population, 75% of whom are female.
• Onychophagia: Destruction of fingernails or toenails by means of habitual biting. Estimated to occur in approximately 28% - 45% of the population, this behavior may lead to complications such as visible damage to the skin and nails, skin infections, and dental problems including periodontal disease, malocclusion, crowding or rotation and attrition of the incisors.
• Onychotillomania: Destruction of the fingernails or toenails by means of chronic picking, pulling, and manicuring. Although little empirical data is available on this problem, a number of case reports have been published in both the psychological and dermatological literature. Complications of this disorder are similar to onychophagia. 
• Lip Biting (Lip Bite Keratosis): The repetitive biting of the skin of one’s own lips.
• Cheek Biting (Cheek Keratosis): The recurrent destruction of one’s oral mucosa by means of biting with one’s own teeth, typically involving the area of the middle, inner cheek. Estimated to occur in approximately 3% of U.S. adults, complications of lip biting and cheek biting behavior include ulcerations, sores, and infections of the oral tissue as well as the development of keratosis – a callous-like formation.
• Tongue Chewing: Chronic chewing on the tongue, most frequently the sides of the tongue, is a common oral problem. Complications of the behavior include soreness and keratinization, pigmentation, and hyperkeratosis. Although there has been little study of this problem, it has been noted in the dental literature.

Misunderstandings

One of the greatest misunderstandings regarding BFRBs is the underlying psychopathology. Contrary to early literature on these behaviors suggesting that they are self-mutilative, recent research suggests they are not related to intentional self-injury.

Most individuals who engage in these behaviors are responding to a physically felt urge (comparable to a premonitory urge to tic) which is relieved by the behavior, or, they are attempting to correct, fix, or otherwise improve some self-perceived aspect of the target area (e.g., the appearance, tactile sensation, etc. For example, to pick a scab with the intent of promoting smoother appearance and faster healing). 

Individuals usually do not intend to inflict pain or cause bodily harm. In fact, they are upset by the resulting damage to the skin, hair, or nails, and make repeated efforts to decrease or stop the behavior. 

Treatment of Body-Focused Repetitive Behavior Disorder

Evidence-based treatment for BFRBs such as trichotillomania and excoriation disorder includes a specific cognitive-behavioral therapy (CBT), habit reversal training (HRT).

HRT includes awareness training (i.e., self-monitoring), the identification of behavior triggers, stimulus control (modifying the environment to decrease the likelihood of picking behavior), and competing response training (identifying a substitution behavior that is incompatible with skin picking).

Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) skills training have also been shown to be effective as adjunctive strategies to HRT.