My definition of body-focused repetitive behaviors (BFRBs): Body-focused repetitive behaviors are repetitive over-grooming acts, on the self-harm continuum, that serve as coping mechanisms. They do damage to the dermis. They are very effective in the short term in regulating physiological and emotional states and connect to a wide array of co-morbid conditions. They include skin picking, hair pulling, and cuticle/nail/cheek biting.

One element of this definition, that BFRBs are on the self-harm continuum, has proven controversial, as many in the BFRB field separate BFRBs from other self-harm behaviors like cutting. In my view, cutting is at one end of the continuum, where pain is a more conscious element of the desired result, with perhaps an unconscious motivation to cry for help, to express inner pain in an outward manner, and the experience of relief and release are side benefits. BFRBs tend to be at the other end of the continuum, with a focus on soothing, release and relief, and with the unconscious motivation to let frustrated energy out bit by bit, and pain is usually less of the desired result and more of an unintended effect. I specifically place both disorders on the same continuum to reduce the stigma of both poles of coping strategies involving bodily harm.

In contrast, the Scientific Advisory Board of the TLC Foundation for BFRBs has put an opinion paper (notedly without any citations) on their Instagram site on the topic, separating BFRBs from other self-harm behaviors like cutting. They point out the differences between cutting and BFRBs, including that they focus more on self-soothing than pain, do not tend to be connected to borderline personality disorder, and often have no intention to harm themselves in the process of picking or pulling but rather are usually focused on self-soothing. From my perspective, this distinction focuses on the differences while ignoring the similarities between BFRBs and other versions of self-harm, in a way that stigmatizes self-harm while simplifying engagement in BFRBs.

The field of Psychodermatology, a growing field that combines psychiatry, psychology and dermatology, places hair-pulling and skin-picking on the self-harm continuum. In 2013, the European Society for Dermatology and Psychiatry added a category to their classification system called Self-Inflicted Skin Lesions (SISL). They defined SISL as, “non-suicidal, conscious and direct damage to the skin” on the self-harm continuum (Tomas-Aragones, 2017, p. 159). The self-harm element is particularly important in both understanding and treating the disorders, as it reflects the complexity of the emotional regulation capacity of BFRBs and informs the treatment process.

In my experience as a recovering skin-picker, the picking could at times be focused around correcting a perceived imperfection, releasing stress, or, at times, reflecting my inner pain outwardly, or as part of an emotional self-attack. That last element, turning anger inward, has been found to be common among pickers and pullers (Keuthen et al., 2016). Anger turned inward has to come out in some way, and attacks on the skin are one way of releasing this inner tension. If we deny the self-harming element of BFRBs, we may well miss the intensity of internalized anger fueling the behaviors. If, on the other hand, we allow for self-harm to be a possible component of the behaviors, we can address the psychosocial factors that make it hard to express anger in healthy ways.

References:

Curley, E., Tung, E. & Keuthen, N. (2016). Trait anger, anger expression, and anger control in trichotillomania: Evidence for the emotion regulation model. Journal of Obsessive-Compulsive and Related Disorders, 9, 77-81.

Tomas-Aragones, L., Consoli, SM., Console, SG., Poot, F., Taube, KM…& Geiler, U. (2017). Self-inflicted lesions in dermatology: A management and therapeutic approach – A position paper from the European Society for Dermatology and Psychiatry. Acta Dermato-Venereologica. doi: 10.2340/00015555-2522.