Effective Treatments for Body-Focused Repetitive Behaviors Like Dermatillomania & Trichotillomania

Understanding Body-Focused Repetitive Behaviors (BFRBs)

You might find yourself repeatedly pulling your hair or picking your skin. Does this mean that you are experiencing what is referred to as dermatillomania or trichotillomania? You might notice this happens during times of stress, anxiety or boredom. Should you be seeking treatment for dermatillomania? 

Read on to learn more!

Body-focused repetitive behaviours (BFRBs), such as skin picking (excoriation disorder/dermatillomania) and hair pulling (trichotillomania) have been categorized as OCD related disorders within the DSM-5 TR Diagnostic Manual. They are distinct from OCD and, therefore, require different treatment approaches. It is important to find a dermatillomania therapist who is aware of how to assess and provide proper treatment. 

When individuals are engaging in body-focused repetitive behaviours (BFRBs), individuals will use their own fingers or other ways to engage in repetitive body-focused behaviours. This could instruments, like tweezers, to engage in BFRBs. When referring to BFRBs, we often think about hair pulling and skin picking disorders. There are also lesser known BFRBs, such as lip and cheek biting, nose picking, nail-biting and hair cutting. In this blog we will be referring most often to dermatillomania (skin picking) and trichotillomania (hair pulling).

Differences and Similarities Between BFRBs and OCD

Individuals with BFRBs share similarities and differences compared to individuals who experience symptoms of OCD. When meeting with a therapist who provides treatment for dermatillomania, you might have questions about your symptoms and want to better understand why you experience them. It is essential to work with someone who can help you to better understand yourself provide the appropriate treatment interventions as well. 

You might notice some similarities if you are an individual who experiences both BFRBs and OCD.  For example, both behaviours can include some repetitive behaviours and they can both feel compulsive in nature. 

Let’s review these similarities in detail:

1. Behaviour Repetition – individuals with both BFRBs and OCD will often experience repetitive behaviours. For an individual with BFRBs this might involve repetitive lip biting, hair pulling or skin picking. For individuals with OCD, they may describe repetitive behaviours, or, rituals that occur in response to specific obsessional concerns or intrusive thoughts. Therefore, individuals might experience increased repetitive behaviours during times of increased anxiety and stress in both of these disorders. It is also known that these behaviours can serve as coping strategies at times.
   
2. Difficulty Refraining from Urges – individuals with BFRBs and OCD may indicate that they find it hard to resist these urges to engage in repetitive behaviours. There is often a very strong desire to engage in BFRBs as it can sometimes relieve stress, anxiety or boredom. It can also be self-soothing. Therefore, the urge to refrain is difficult to push away at times. OCD behaviours might also be very hard to resist as there are often belief systems around what might happen should an individual not perform their compulsion. 

It is also important to note that there are also differences between OCD and OCD related behaviours, such as BFRBs. We will explore a few of these below:

1. Presentation of Behaviours – these presentations generally look different from a behavioural perspective. For an individual with BFRB, we will often see body-focused repetitive behaviours that cover a wide repertoire of behaviours. But they are all focused on bodily actions. These include trichotillomania (hair-pulling), dermatillomania (skin-picking) as well as some lesser known BFRB presentations, such as cheek biting and nail pulling. An individual with OCD may engage in some behaviours that involve their body but there is generally a very wide variety of obsessions and compulsions that are reported. These include obsessional concerns related to contamination, perfectionism, harm, just rightness and more. The compulsions that occur, in response to these obsessions, may include washing, checking, organizing, figuring it out and more.
   
2. Underlying Thought Processes – individuals with OCD are far more likely to report that they are experiencing obsessional concerns as compared to individuals with BFRBs. An individual with BFRB is often more likely to speak about the physical behaviour and there might be thoughts and feelings related to those behaviours as well. The obsessional concerns and intrusive thoughts that an individual with OCD experience is often not shared by individuals with BFRBs.

Dermatillomania (Skin Picking Disorder) and other BFRBs: Why Do They Happen? 

Many people who engage in BFRBs might wonder: why is this happening and why is this so difficult to stop? As with many disorders, there are a variety of factors that might lead to someone engaging in these behaviours.

Genetics is one factor that has been suggested to play a role. For example, it has been found that there is a higher number of individuals with BFRBs than would be found in the general population. Although genetics might play a role, we also often see genetic factors and other stressors interacting, which may allow for the emergence of that disorder. 

It is important to always consider the multifaceted nature of mental health disorders. BFRBs can also be reinforcing because they serve to relieve tension or stress, reduce feelings of boredom or provide emotion regulation strategies. Individuals may also cite how the sensory experiences associated with hair pulling or skiing picking can be very reinforcing.

Regardless of why they occur, it is important to learn to be self-compassionate when we are engaging in behaviours that we want to eliminate. We never want to be overly harsh with ourselves or blame ourselves. There are always reasons why these behaviours develop and being gentle with ourselves can aid in our recovery. 

It is important to understand that many factors may be involved and that these issues can be treated effectively with evidence-based intervention strategies. Read on to learn more about treatment for dermatillomania as well as other BFRBs.

Effective Treatments for Dermatillomania and Trichotillomania

You might decide that you want to see a dermatillomania therapist or treatment for dermatillomania or any BFRB if it is interfering with your daily functioning. BFRBs can also leave people with scars, changes in their physical appearance or infections. You might wonder if curing dermatillomania or trichotillomania is possible. It is often difficult to think in terms of “cure” for mental health disorders (as many do wax and wane over time) but we can think in terms of effective treatments that are evidence-based. With these treatments, relief from symptoms and long-term management strategies are often possible!

Read on to learn more about what these might be!

Cognitive Behavioral Therapy (CBT) Approaches For Treating Dermatillomania and Other BFRBs

CBT for BFRBS is one of the most effective psychological treatments for treating dermatillomania as well as other BFRBs. Within CBT for BFRBs, specific techniques have been developed to target these behaviors. We will review some of the earlier models and more recent ones below:

• Habit Reversal Training (HRT): Within this early treatment approach for BFRBs, individuals would develop an increased awareness of their triggers and are able to develop competing responses to the repetitive behaviours. In doing so, they hopefully are able to decrease repetitive behaviours over time. For example, an individual might put glue on their skin and pick that off instead of engaging in skin-picking behaviours of their actual skin. This approach was developed in the 1970s by researchers Nathan Azrin and Gregory Nunn.
  
• The Comprehensive Behaviour (ComB) Model: This model of treatment was developed by Dr. Charles Manseuto and his colleagues in 2019. This approach allows therapists and clients to work together to identify the sensory, cognitive, affective, and motor and place/location (SCAMP) that contribute to BFRBs. Individualized strategies are also developed in order to address each. This helps people to understand the “why, where and how” aspects of their particular BFRB. 
  
• Acceptance and Commitment Therapy (ACT): ACT is a transdiagnostic approach developed by Dr. Steven Hayes that helps individuals to learn: emotion regulation strategies, present moment awareness, recognize and accept difficult thoughts, feelings and urges and develop self-compassion rather than push away or try to eliminate behaviours. This approach can enhance the strategies within HRT and ComB-based intervention models.
  
• Dialectical Behaviour Therapy-Informed Skills (DBT): DBT-informed therapy involves clinicians drawing on the main tenants of the DBT model to augment other skills that are being delivered in treatment. In order to do so, clinicians will draw from four skills-based modules that are at the core of DBT. These include mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. These skills can be used, as needed, to enhance or address other potential areas of difficulty for individuals with BFRBs.

How Do I Find a Dermatillomania Therapist?

You might wonder whether there is a dermatillomania therapist near you. And how do you find the best dermatillomania therapist? There are a few things you want to consider. You do want to ensure that they are well-trained within the area of assessment and treatment for OCD and OCD-related disorders. You can ask them about their experiences working with the different BFRBs.

You will always want to ensure that they are using evidence-based treatment for dermatillomania and other BFRBs, as described above. You might also be interested in having your loved one learn some of your strategies and approaches so they can support the work you do outside of your sessions. This could involve parent coaching if you are a teen seeking treatment or couples support for individuals in relationships. This can be a very helpful part of therapy and is definitely something your dermatillomania therapist should be able to discuss with you. It is important that therapy is individualized for you and meets your needs and presenting issues. 

If you find that you often engage in any of these body-focused repetitive behaviours and want to learn more then reach out to Forward Thinking Psychological Services®; our team offers treatment for dermatillomania, trichotillomania as well as treatment for other BFRBs. We offer assessment and therapy services for teens, adults and couples. We also offer services across Canada in  Ontario, Nova Scotia, British Columbia and New Brunswick. Contact us to learn more!

References

BFRBs vs. OCD: Similarities and Differences

What Causes BFRBs?

https://www.bfrb.org/articles/treatment-for-bfrbs

https://www.bfrb.org/faqs/diagnosis-treatment-what-treatments-are-available-for-bfrbs

http://American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787