When Body Focused Repetitive Behaviors (BFRBs) Take Over

According to DSM 5, Body-Focused Repetitive Behaviors (BFRBs) are classified as Obsessive-Compulsive Related Disorders. These behaviors include hair pulling, skin picking, and nail biting (along with other repetitive behaviors). While these behaviors can often be common habits, they become pathological when performed frequently despite wanting to stop and a physical, distress, or functional impact (David et al. 2018).

The question remains: How do we treat BFRBs?

Psychotherapy is a great place to start. This should include a form of cognitive behavioral therapy. A good therapist will individualize this approach and match treatment to the individual’s specific symptoms. This may include habit reversal training, integrative behavior therapy, acceptance and commitment therapy, and/or dialectal behavior therapy.

What happens when psychotherapy is not enough?

Sometimes patients find it difficult to participate in therapy when the symptoms are too severe. Other times, patients participate in therapy but can’t seem to progress. These are times when medication should be considered.

What medication options are there?

Studies have done some support for the following drugs:

• SSRIs (first-line treatment): used first because of high OCD comorbidity, but efficacy is limited.
• clomipramine (first-line treatment): It has been shown to be useful in OCD, but not necessarily in BFRB.
• Lamotrigine: Thought to be useful due to its impulse control efficacy in working on glutamate; however, studies have not shown clinical significance.
• Olanzapine: Thought to be useful due to root causes that are similar to Tourette’s syndrome. Safety and efficacy have been demonstrated in small studies.
• N-acetylcysteine: This is a naturally occurring amino acid. Efficacy has shown promise, especially among those who pull out their hair.
• Inositol: Has been beneficial in other disorders such as OCD, binge eating, panic disorder, PTSD, and depression; however, few studies have been done on BFRBs and none have shown that they reduce symptoms.
• Naltrexone – Often used for cravings with alcohol use disorder. Due to the overlap of BFRBs who have difficulties with impulse control, this medication may be helpful; however, no studies have supported its use.

How do you choose the right medication to treat BFRBs?

1. Understand the patient’s symptoms and comorbid disorders.

• The use of a first-line treatment for other disorders may provide insight into the root cause.

2. Get a good family history.

• Most patients with BFRB have a family member with OCD spectrum disorder.
• Patients who have a family member with alcohol use disorder have found more significant benefit from using naltrexone to lower BFRBs.

3. Ask the patient about his treatment preference.

• Patients are more likely to continue treatment when they are inverted.
• Possible side effects can help choose the best treatment to start with.

4. Provide good expectations.

• What do the studies suggest? How is successful treatment? How much can medications help without therapy? Be open and honest about what you know.

5. Practice being patient.

• It may take some drug testing to find one that provides benefits.

6. Remember that medication is not always magic.

• Currently, drug treatments are evolving, and experts continue to struggle to find strong evidence to support that one drug is superior.

Sometimes in healthcare we want a one size fits all “go to treatment”. The BFRBs are another good example that we may never find that. Patients come to us when they need help. My goal is to offer support to patients and help them understand their body and mind. I want to empower them by giving them information and helping them navigate available treatments rather than telling them what to do. When we get stuck during a treatment plan, we can use platforms/groups/partnerships/organizations like ADAA to collaborate because one treatment is never one size fits all.

What to do when therapy and medications don’t work? What have you found to be the most successful treatment in your practice? Are there other key points to consider when choosing a treatment plan?

This publication is presented in collaboration with the ADAA’s OCD and Related Disorders SIG. Learn more about GIS.

References

Houghton, DC, Alexander, JR, Bauer, CC, & Woods, DW (2018). Body-Focused Repetitive Behaviors: More Common Than Thought? Psychiatry Research, 270, 389-393. https://doi.org/10.1016/j.psychres.2018.10.002.

Redden, SA, Leppink, EW, & Gran, JE (2016). Body-focused repetitive behavior disorders: Importance of family history. Integrative Psychiatry, 66, 187-192. https://doi.org/10.1016/j.comppsych.2016.02.003.

The TLC Basis for Body Centered Repetitive (nd) What is a bfrb? behaviorshttps://www.bfrb.org/your-journey/what-is-a-bfrb