Overcoming Body-Focused Repetitive Behaviors

1. Understand the nature of Body-Focused Repetitive Behaviors (BFRBs)

BFRBs are not just simple problems or "bad habits" that are easily overcome.

Neurobehavioral disorders. BFRBs, such as hair pulling (trichotillomania) and skin picking (excoriation disorder), are complex neurobehavioral conditions affecting millions worldwide. These behaviors often begin as seemingly harmless grooming activities but can escalate into compulsive patterns that cause significant distress and physical damage.

Prevalence and impact. Studies suggest that 3% to 6% of the general population experiences BFRBs, with women outnumbering men by about nine to one. The personal toll can range from mild to severe, often resulting in:

• Shame and embarrassment
• Low self-esteem and anxiety
• Social isolation
• Avoidance of everyday activities
• Interference with work or school performance

2. Recognize the multifaceted triggers of BFRBs

Coming to terms about the reality of your attempts to improve your appearance will at least begin to chip away at your unhelpful beliefs.

SCAMP model. The Comprehensive Behavioral (ComB) approach uses the SCAMP model to identify and address the various domains that contribute to BFRBs:

• Sensory: Physical sensations that trigger or maintain the behavior
• Cognitive: Thoughts and beliefs that encourage picking or pulling
• Affective: Emotional states that drive the behavior
• Motor: Physical movements and habits involved in the BFRB
• Place: Environmental factors that set the stage for episodes

Interplay of triggers. BFRBs often involve a complex interplay of these domains. For example, a person might experience an itchy sensation (sensory), believe they need to remove an "imperfect" hair (cognitive), feel stressed (affective), habitually touch their scalp (motor), and find themselves alone in front of a mirror (place) – all contributing to a pulling episode.

3. Build awareness through self-monitoring

If knowledge is power, learning as much as you can about your BFRB will maximize your chances of success.

Self-Monitoring Forms. The first crucial step in the ComB program is to increase awareness of your BFRB patterns. Use Self-Monitoring Forms to document:

• Where and when episodes occur
• Triggers from each SCAMP domain
• Level of awareness when the urge or behavior begins
• Amount of picking or pulling during the episode

Importance of documentation. Consistently recording these details helps you:

• Identify patterns you may not have noticed before
• Understand the specific triggers and maintaining factors of your BFRB
• Gather essential information for developing an effective treatment plan

4. Develop a personalized action plan using the SCAMP model

The ComB model will be your essential guide as you move through the process of recovery, and SCAMP will help you organize your plan.

Three-stage process:

1. Building Awareness: Use Self-Monitoring Forms to identify triggers and consequences
2. Planning and Preparation: Select interventions from the Master List of Interventions
3. Putting Your Plan into Action: Implement interventions and track progress using Action Plan forms

Tailored interventions. Choose interventions that address your unique BFRB profile across all relevant SCAMP domains. Aim for the "3x3 approach":

• Use at least three interventions
• From three different domains
• In each problematic setting

5. Implement sensory interventions to manage urges

Engaging in a variety of health-promoting activities will help you feel better physically, mentally, and emotionally, and will improve your ability to manage things.

Sensory substitutes. Address the sensory needs that your BFRB fulfills with healthier alternatives:

• Tactile stimulation: Fidget toys, stress balls, textured objects
• Visual input: Engaging artwork, nature scenes, calming imagery
• Oral stimulation: Gum, hard candies, crunchy snacks
• Auditory input: Soothing music, nature sounds, white noise

Reduce sensory triggers. Minimize cues that can lead to picking or pulling:

• Dim lighting in trigger areas
• Cover or remove unnecessary mirrors
• Wear gloves or fingertip bandages to reduce tactile sensations
• Use gentle hair and skin care products to reduce irritation

6. Challenge and replace unhelpful thoughts

Cognitive interventions will give you healthy and realistic rebuttals that you can think about, write down, and practice saying or reading.

Common cognitive distortions:

• Perfectionism about appearance
• Beliefs about needing to "fix" minor imperfections
• All-or-nothing thinking about recovery
• Negative self-talk and shame

Cognitive restructuring techniques:

• Identify unhelpful thoughts and beliefs
• Challenge these thoughts with evidence and logic
• Develop more realistic and supportive self-talk
• Create and practice using "coping statements" or mantras

Example coping statement: "I can learn to live with imperfect skin. Picking makes my skin less smooth and less healthy."

7. Address emotional triggers with healthy coping strategies

Even without that problem, there will of course be challenges to face—life can be very difficult, even for people who seem to have many obvious advantages.

Common emotional triggers:

• Anxiety and stress
• Boredom and restlessness
• Sadness and depression
• Anger and frustration

Healthy coping strategies:

• Practice relaxation techniques: Deep breathing, progressive muscle relaxation, meditation
• Engage in physical exercise: Walking, yoga, dancing
• Pursue enjoyable activities and hobbies
• Connect with supportive friends and family
• Consider professional help for underlying mental health concerns

8. Modify your environment to reduce BFRB opportunities

Even small physical changes can have a big impact for many people.

Environmental modifications:

• Reduce privacy: Leave doors ajar, study in public spaces
• Limit time in high-risk areas: Set timers for bathroom activities
• Remove or secure triggering implements: Store tweezers, scissors, or magnifying mirrors out of sight
• Create reminders: Place sticky notes with encouraging messages in trigger areas
• Keep hands busy: Have fidget toys or other activities readily available in problem locations

Develop new routines. Alter your daily habits to minimize opportunities for BFRBs:

• Change the order of your grooming routine
• Sit in a different spot while watching TV
• Use a timer to limit time spent in front of mirrors

9. Cultivate patience and persistence in your recovery journey

Think of this process as one of exploration and experimentation, so try to be patient, persistent, and honest with yourself as you move forward.

Realistic expectations. Understand that recovery from BFRBs is often a gradual process:

• Progress may be nonlinear, with ups and downs
• Small improvements are worth celebrating
• Setbacks are opportunities for learning and refining your plan

Ongoing refinement. Continuously evaluate and adjust your action plan:

• Regularly review your Self-Monitoring Forms and Action Plans
• Be willing to try new interventions if current ones aren't effective
• Seek support from loved ones or BFRB support groups when needed

10. Maintain progress and troubleshoot setbacks

We tell people that they are never back to square one once they have worked with the ComB program.

Gradual phase-back. When you've achieved consistent success:

• Slowly reduce reliance on interventions in controlled settings
• Keep supplies on hand for unexpected urges
• Replace temporary interventions with long-term healthy habits

Managing setbacks:

• Recognize common triggers: Life transitions, stress, complacency
• Act quickly to prevent slips from becoming full relapses
• View setbacks as learning opportunities to strengthen your plan
• Return to self-monitoring and increase use of interventions as needed

11. Prioritize overall skin and hair health

Even many people who have picked or pulled for long periods of time have found that, when they learned techniques to help them resist engaging in excessive grooming and begin to support the natural healing process through healthy grooming, their skin and hair responded better than they could have imagined.

Understanding skin and hair anatomy. Recognize the complex structure and functions of your skin and hair:

• Skin layers: Epidermis, dermis, hypodermis
• Hair growth cycle: Anagen, catagen, telogen phases
• Healing processes and timeframes

Healthy grooming practices:

• Use gentle, non-irritating skin and hair care products
• Moisturize regularly to maintain skin and hair health
• Protect your skin from sun damage
• Allow time for natural healing processes
• Consult with dermatologists or other professionals for persistent issues

By focusing on overall skin and hair health, you support your body's natural healing processes and reduce triggers for BFRBs.

Last updated: January 23, 2025