Body-focused repetitive behaviours are more than just bad habits

Often dismissed as bad habits, BFRBs can range from incessant hair-pulling and nail-biting to even plucking eyelids. Can they be understood in isolation or is there a deeper context that we often miss?

For as long as she can remember, Akanksha Chauhan, a 30-year-old marketing manager based in Mumbai, has always plucked her eyelids. The reasons? Initially, she didn’t quite know. Almost involuntarily, her fingers would reach her eyelids and the plucking would begin: one, two, three strands of hair disappearing from her eyelids.

“This started from school,” she recounts. “And my parents dismissed it as a bad habit. However, things came to a head when the eyelid hair-plucking became so intense that there were almost gaps in my eyelids.”

Chauhan later realised that this particular form of body-focused repetitive behaviour (BFRB) involving hair pulling– specifically trichotillomania–was her response to any kind of stress. The hair pulling later graduated to the scalp when some personal issues in her family stressed her out even more.

BFRB is an umbrella term that refers to a range of body-focused behaviours that may or may not cause more serious damage to one’s body, depending on the degree of the underlying issue. Dr Syeda Ruksheda, a psychotherapist and psychiatrist with over 20 years of experience, says that the scale of the intensity of different behaviours under BFRBs can be classified into three categories.

“The technical term for self-harm is Non-Suicidal Self-Injury (NSSI) which is different from BFRBs, both in nature and pathology,” Ruksheda explains. “They are more common than one would realise and they occur across a spectrum. The lowest is classified as a ‘habit,’ then comes ‘subclinical BFRB’ and the most extreme case is ‘pathological BFRB’ when it becomes excessively difficult to give up.”

Family triggers?

According to a review of various studies published by the University of Chicago, understanding a BFRB patient’s unique biochemistry and neurobiology can tell us a lot about the why of certain behaviours. Chauhan faced trichotillomania for years, only regulating it a year ago after opting for therapy and a focused understanding of her stress points. Although there was no history of such behaviour in her family, the UC review points out that patients with alcoholism in their family responded less efficiently to medication–hinting that genetics is an important factor in the same.

For Shreya Chaudhury, a 23-year-old who works in the hospitality sector, her skin-pulling BFRB was always dismissed as a bad habit by her parents, thus leaving it untreated for a long time. “For years, all it was to me was a bad habit that I had no control over and it increased during times of change or excess stress,” she tells The Established. “I was in and out of therapy but nothing they said or asked me to do (like wearing gloves or picking something else up immediately when I had the urge to pick my skin) really worked.”

However, Chaudhury admits that she didn’t take those suggestions seriously because, in a twisted way, she “enjoyed the satisfaction” of pulling her skin. “These were never long-term solutions; I mean, gloves come off at some point and I am bound to do it [pull my skin] then,” she says. “I have come to be more aware in recent years and understood that I actually, sometimes, liked doing it. There was some sort of need for perfection that came out in the way of picking my skin until it was smooth and trust me, it was never smooth because I kept picking it and now it is an endless cycle.”

Treating BFRBs

Dr Ruksheda says that all the therapies to treat different kinds of BFRBs mostly focus on containing “emotional dysregulation,” such as habit reversal therapy which involves awareness training, competing response practice, habit control motivation and generalisation training.

“You might want to take a professional opinion before misdiagnosing it,” she clarifies. “If you are distressed, or anxious, different parts of your brain trigger different physical responses. Exfoliation of adult acne is also common. What starts as a survival instinct becomes pathological. It requires to be regulated and sometimes it doesn’t. The only thing the person genuinely has control over is their body.”

If you have a partner grappling with a certain kind of BFRB, you become a support system and must understand their behaviour as opposed to being dismissive about it. “Any kind of shame, sarcasm or anger will not resolve anything as you will end up creating more resentment in the relationship,” says relationship counsellor, Ruchi Ruuh. “If you can't support them, leave them alone and don't blame them. Especially the parents; it's not the child's fault if they have a disorder. It's not a weakness or lack of willpower, they don't have any control over it.”

More importantly, Ruuh says, the idea is to stop body-shaming anyone with BFRBs, regardless of the scale of it. “If you see a patch of missing hair or bruised skin, ignore it. They already know what they have done. Pointing a finger towards it won’t solve the issue. You are not their therapist, motivational coach or guru. Stop sharing nuggets of wisdom. There is a reason why therapists exist. Just be kind and caring, and let them feel normal for a change.”

Even Chaudhury says her skin-pulling BFRB will only be regulated when she tackles the underlying anxiety. “I need to find better outlets for those issues–probably healthier ones,” she shares. “Since I started medication, I have been doing much better. My brain feels empty from the previous extremely anxious and panic-inducing thoughts.”

Chaudhury now reads, jogs and finds solace in productive and healthy habits from a different life when things were not so bad. “I am in the process of getting better and finding better outlets but well, I picked my skin during the course of this interview, so we are not quite there yet but I am hoping we will be.”

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