Experts say three specific body-focused repetitive behaviors (BFRBs) can be more common in teens, especially now. Fortunately, there are ways to spot and manage them.

By Nicole Clancy
November 13, 2020
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For all of us, stressful feelings come and go. For teens? Ups and downs are often more pronounced as both a surge in hormones and the growing pains of becoming an adult contribute to mood swings.

And sometimes, a less-than-ideal reaction to stress is to be expected.

But with increased social isolation and sedentary schedules, many mental health issues are on the rise. And given that teens don't often have the awareness and coping skills to identify how they're feeling, experts say that stress can also manifest in new physical behaviors or habits called body-focused repetitive behavior (BFRB). Essentially, BFRB is a general term for a group of related disorders including hair pulling, skin picking, and nail biting—all of which can unintentionally damage the body, explains Nicole St. Jean, Psy.D., a licensed clinical psychologist and director of the Kovler Center Child Trauma Program in Chicago.

If left unattended, they can lead to long-term health consequences. But what exactly is BFRB, and how should you approach your teen if you notice signs? Here, experts explain.

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What Is BFRB?

Technically speaking, BFRBs are classified under obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the standard classification for mental health disorders.

They include trichotillomania (hair pulling), excoriation disorder (skin picking), and other body-focused repetitive behaviors such as biting nails or chewing your cheeks. If your teen has a BFRB, they might, for example, pick their skin repeatedly while doing schoolwork.

And while BFRBs can affect people of all ages, teens might be at an increased risk as they're still learning how to handle their emotions and stress, experts say.

Some BFRBs are more common than others. For example, trichotillomania affects 1 to 2 percent of the population (with the average peak age of onset between 12 and 13), and nail biting affects 20 to 30 percent of the population.

As for why your teen might be turning to one of these actions to cope? Sensory needs—needing to be stimulated orally, tactilely, or visually—or emotional needs—relief from boredom or self-soothing from stress—could drive the actions, says Ruth Goldfinger Golomb, LCPC, a senior clinician at the Behavior Therapy Center of Greater Washington. In a way, it's like your body is reverting back to a primal state, similar to the way babies suck their thumbs to calm themselves down.

There could also an obsessive-compulsive component, Golomb adds. Certain thoughts—these hairs have to be removed or my skin must be completely smooth, for example—can contribute to the behavior. And sometimes physical patterns provide distraction and physical release of feel-good hormones.

It's also important to note that BFRB behaviors are considered different from self-harm behaviors such as cutting, explains Dr. St. Jean. "People who engage in BFRB behaviors more typically are seeking stress relief or gratification." This is often different than the punishment or distraction from overwhelming emotions that often drives self-harm behavior.

Everything from a genetic predisposition, environmental factors (stress), as well as buffers such as positive social support, family support, or religion can influence how symptoms manifest, says Dr. St. Jean. And experts still aren't completely sure why some teens adopt BFRBs when stressed and others don't.

The good news? These behaviors are manageable. And they're worth managing: While they're not usually life-threatening, the actions do have roots in stress and anxiety—and thus can contribute to depression and low self-esteem over time. There are also physical consequences from BFRBs such as permanent skin damage, scars, and thinning or brittle hair.

How to Effectively Address BFRBs With Your Teen

If you've noticed signs or symptoms of a BFRB, it can be difficult to know the best way to approach your teen—and gauge how severe symptoms might be. Here are a few places to start.

Keep an eye on your teen's appearance

Golomb notes that observing BFRBs is the most important first step in getting your teen the help they need. If you notice frequent new, unexplained scabs on your teen's face, hands, and arms, hair missing from your teen's eyebrows or eyelashes, or bald patches on his or her scalp, give your pediatrician a call. These are signs that your teen is picking or pulling.

Have a conversation with your teen

Remember, these actions are changeable—so bringing them to your teen's attention is important. Just keep in mind: "It's extremely important to make sure that the child does not feel shame for engaging in this behavior," says Golomb. "They are not doing this on purpose and are often confused themselves as to why they are engaging in this perplexing behavior."

One way to start a conversation? Ask your teen to rate their stress levels on a scale of 1 to 10. "If a teen is stressed at a level 7 more than half the time, we would want to assess whether a course of treatment would be useful," says Rachel H. Jacobs, Ph.D., an adjunct assistant professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine.

If they're not exactly open to conversation but can't get out of bed regularly, have seemed to have lost interest in their friends, or aren't able to focus due to anxiety? It's time to check in with your pediatrician or another doctor, says Golomb, as these behaviors can signal a more serious mental health issue such as depression.

Seek out a trained professional

Since all family dynamics differ, you can seek out advice from your pediatrician or therapist if you're uncomfortable about how to approach a conversation with your teen. Your medical care team can help you format a conversation and talk about how to present ideas, such as utilizing hats, long sleeves, bandaids, or other physical cover-ups to help your teen avoid the behaviors.

The gold standard form of therapy for BFRBs is called habit reversal training, which helps people tackle unwanted repetitive behaviors. It can be highly effective in helping teens become aware of their habits and practice alternative, healthier behaviors and coping strategies in moments of stress, says Dr. St. Jean. The TLC Foundation for Body-Focused Repetitive Behaviors maintains a directory of trained therapists.

Help your teen make a self-care plan

Fidget toys, brushing or petting a dog or cat, playing with textured materials (feathers, quilted cloth, lotions, bubble wrap), chewing gum, or even journaling can all provide the sensory stimulation your teenager might be craving in a healthier way, says Dr. St. Jean. Exercise (a proven stress-reliever) and healthy social activities, such as cooking as a family, can also be helpful lifestyle changes that can help your teen adopt new stress-coping strategies and even work to buffer stress, she adds.

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