What are Body-Focused Repetitive Behaviors (BFRBs) & are they a form of stimming
Disclaimers: We want to affirm our commitment to neurodiversity and inclusive language practices. We utilize identity-first language, acknowledging the preferences of the community we serve. Therefore, you may notice us referring to individuals as "autistic people" rather than "people with autism." This choice reflects our dedication to respecting the autonomy and identity of each individual. Studies have indicated that many within the autistic community prefer the term "autistic person," emphasizing the importance of recognizing and honoring diverse perspectives. Thank you for joining us on this journey of understanding and acceptance.
Language: There is a sordid history of the DSM. I may use direct language from the DSM, this is for educational purposes. The language in the DSM, including the use of the word disorder (D in acronym) is harmful. When this language is used, it is either because I am quoting the DSM, or because there is unfortunately a lack of different terminology out there (i.e. leaving the “d” in OCD or the “D” in ADHD). Because I leave this, does not mean that I agree with the wording.
Educational Purposes: The information presented here is for educational purposes, and not meant to diagnose, treat or cure medical conditions or challenges, including neurodivergence (including mental health challenges), or physical health.
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What are Body-Focused Repetitive Behaviors (BFRBs) & are they a form of stimming
First, let’s start with some definitions about BFRBs!
The TLC foundation (2024) defines a Body-focused repetitive behavior (BFRB) as: “any repetitive self-grooming behavior that involves biting, pulling, picking, or scraping one’s own hair, skin, lips, cheeks, or nails that can lead to physical damage to the body and have been met with multiple attempts to stop or decrease the behavior.”
So what are some common BFRBs?
Hair Pulling Disorder (Trichotillomania)
Skin Picking Disorder (Excoriation)
Nail Biting Disorder (Onychophagia)
Cheek biting / “cheek chewing”
Other BFRBs:
Frequently include lip biting, nail picking, scab eating, and other self-grooming-related behaviors
As you can see BFRBs describe the overarching category of these experiences, as well, there is a diagnosis in the DSM-5-TR that is called “Other Specified Obsessive-Compulsive and Related Disorder,” one example of this presentation is called Body-focused repetitive behavior disorder which the DSM-5-TR defines as:
“recurrent body-focused repetitive behaviors (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning and are not better explained by trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, stereotypic movement disorder, or nonsuicidal self-injury” (American Psychiatric Association, 2022).
As you may have noticed… Hair Pulling Disorder (Trichotillomania), and Skin Picking Disorder (Excoriation) have their own diagnosis under the diagnostic category of “Obsessive-compulsive and related disorders.”
Now let’s look at the diagnostic criteria for Trichotillomania & Excoriation.
Trichotillomania (hair pulling):
Recurrent pulling out of one’s hair, resulting in hair loss.
Repeated attempts to decrease or stop hair pulling.
The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).
Excoriation (skin-picking)
Recurrent skin picking resulting in skin lesions.
Repeated attempts to decrease or stop skin picking.
The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The skin picking is not attributable to the physiological effects of a substance (e.e., cocaine) or another medical condition (e.g., scabies).
The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypical movement disorder, or intention to harm oneself in nonsuicidal self-injury).
It’s important to note that typically people with BFRBs do not intend to cause harm to themselves. It can feel incredibly compulsive, and be challenging to stop. It’s often something that a person feels ashamed about, and they may make efforts to hide their BFRBs from others. Some folks with BFRBs may examine, play with, mouth or swallow the skin or hair. Some folks with trichotillomania may get satisfaction from pulling hair from the root.
People with BFRBs may spend significant amounts of time engaging in their BFRB, sometimes spending several hours per day.
You might be wondering, do kids, teens and adults have BFRBs, and the answer is yes! BFRBs are seen across the lifespan! According to the TLC foundation (2024): “body-focused repetitive behaviors (BFRBs) are common among children due to a combination of developmental, psychological, and environmental factors. Some of the common causes for adoption of BFRBs in children include sensory exploration, habit formation, and environmental stressors. That's why it's crucial to prioritize emotional development support for children. If you’re wondering if your child has a BFRB, as your child psychologist, pediatrician, or another provider in their life!
So now that you understand a bit more about what BFRBs are, let’s now chat about how BFRBs may differ from, or be similar to stims. If you’d like more background information on Autism, head here or here. If you’d like more background information on ADHD, head here or here.
How does the DSM compare & contrast BFRBs with stimming?
Before we dive in, let’s start with a definition!
Stimming, short for, “self-stimulatory behavior,” that the National Autistic Society (2024) defines stimming as: “arm or hand-flapping, finger-flicking, rocking, jumping, spinning or twirling, head-banging and complex body movements.” Though stimming is not limited to these things, stimming may also include vocal, auditory (listening to the same song on repeat), use of objects, etc.
Stimming is done for a variety of purposes:
Joy or pleasure
For sensory input (i.e. rocking can stimulate the balance [vestibular] system).
To reduce the impact of sensory input
To self-regulate / deal with and manage emotions that may cause distress (i.e. anxiety, stress)
In terms of the DSM and diagnostic criteria for Autism, stimming is used synonymously with “stereotyped or repetitive motor movements, use of objects or speech.”
As you may have noticed, there is no diagnostic criteria for ADHD related to stimming or “stereotyped or repetitive motor movements, use of objects or speech.” We’ll explore that a bit later on, but first, let’s dive into the DSM a bit more.
The DSM goes into more detail for each of the criteria for trichotillomania and excoriation, as well, with any diagnosis, there follows a category called, “differential diagnosis” which is basically a list of other diagnoses which may have similar presentation and, as the term suggests, it differentiates between these diagnoses.
One of those differentials for trichotillomania to note are what the DSM calls, “normative hair removal/ manipulation:” removing hair for cosmetic reasons, or twisting/ playing with hair.
Interestingly, there is a differential for “Neurodevelopmental disorders:” and the DSM lists “stereotypic movement disorder,” but not Autism or ADHD.
One of the differentials for Autism is “Stereotypic movement disorder,” and the American Psychological Association (2022) has this to say about it: “motor stereotypies are among the diagnostic characteristics of Autism Spectrum disorder, so an additional diagnosis of stereotypic movement disorder is not given when such repetitive behaviors are better explained by the presence of Autism… when stereotypies cause self-injury and become a focus of treatment, both diagnoses may be appropriate.”
There is no differential for ADHD and any BFRBs, nor for stereotypic movement disorder, even though we know that ADHDers stim too (well all people stim, actually).
What does the research say?
One study found elevated rates of probable Autism (based on a self-report screening tool) among those with trichotillomania (Grant, & Chamberlain, 2022).
People with BFRBs report more frequent and intense experiences with filtering out irrelevant or redundant sensory input, as compared to neurotypical adults, and showed more sensitivity to tactile stimuli, and also differences in feed-forward inhibition (which my brain is having a hard time understanding and translating) (Houghton, Tommerdahl & Woods, 2019). Some of this is sounding familiar to Autism and ADHD brains…..
Another study found that adults with clinical BFRBs reported increased sensory sensitivity as compared to persons with subclinical BFRBs (people with none or some BFRBs that do not meet clinical cutoff), and elevations in sensation avoidance (Houghton, Alexander, Bauer, & Woods, 2018).
Serotonin and dopamine dysfunctions are a possible reason for trichotillomania (Golubchik, Sever, Weizman, & Zalsman, 2011).
“Research has given preliminary insights to the neuroanatomical underpinnings of TTM. Such structures include the basal ganglia, prefrontal cortex, and midbrain” (Woods, & Houghton, 2014).
It’s been reported that there is an increased prevalence of ADHD with those that experience trichotillomania (Golubchik, Sever, Weizman, & Zalsman, 2011).
Unfortunately, I could not find much research on the co-occurrence rates of BFRBs with Autism and/or ADHD. More research on BFRBs and the co-occurrences are needed, most definitely!
So what does all of this mean?
In conclusion
An Autistic person’s stim may be a BFRB. In fact, I, myself, did, and currently do, a lot of check chewing, lip biting, etc., it was a way for me to stim mostly unnoticed. Before my Autism diagnosis, I had learned of the term BFRB, and felt so seen! I did not feel seen, however, when my dentist scolded me for chewing on my cheeks, noting tissue damage, and warned that continuing to do so could lead to mouth cancer (thanks, that’s exactly what my OCD needs to hear).
For me, clinically, if a therapy participant walked in and said, hey, I’m Autistic, and/or an ADHDer, and I do these stims, and proceeded to list BFRBs as some of their stims. If they are not bothered by them, they do not wish to stop, there is no damage, nor has a medical provider expressed concern, then, why stop them?
Now if someone is bothered (distressed) by these stims, they get in the way of you living your life, cause damage, and/or you wish to stop, that’s another story!
If you have a BFRB (with or without, Autism and/or ADHD, then check out the next section below!
So what can be done about BFRBs?
First of all, if you have a BFRB, you. are. not. Alone!
Second, there are many options of things you can do, listed in no particular order:
Read the book Overcoming Body-Focused Repetitive Behaviors (Mansueto, Mansfield Vavrichek & Goldfinger Golomb, 2020). Side note: I read it and found it incredibly helpful, it does take consistent work and practice to break the habit. #notsponsored
The above book talks about finding replacement behaviors to provide the emotional regulation that your body is seeking! Some of these ideas are: having fidgets nearby, especially in places when you are prone to engage in BFRBs.
For those with oral sensory needs (I.e. cheek chewers, lip biters, tongue biters) there is jewelry you can get that you can chew on. It’s fun name is Chewelry. Find some here : https://www.arktherapeutic.com/chewelry/ (i personally love my chewlinder from them) #notsponsored
There is a form of therapy called “habit-reversal training” which the Cleveland Clinic (2024) defines as: “Habit reversal training (HRT) is a behavioral therapy that helps you eliminate unwanted behaviors (habits) by replacing them with other actions. Habits are repetitive behaviors that are often automatically reinforced and happen without you realizing it.”
Find a medical and therapeutic provider here! #notsponsored
There is a device called HabitAware, which they advertise as “Break the trance of hair pulling, skin picking & nail biting with HabitAware's Keen2 smartwatch and recovery Masterclasses.” #notsponsored
Check out the TLC foundation’s health education and community programs, such as support groups, their conference, and more! #notsponsored
Dialectical behavioral therapy (DBT) may be a helpful therapy, as it can support folks in managing their underlying emotion regulation needs, and increase folks’ tolerance to distress. They’re all about skills, and there are oodles of skills that could be applied in replacement to BFRBs. (head to the link and scroll down to “DBT” or simultaneously click Ctrl + F key, which will trigger a search bar to open, and you can type in “DBT.”)
If you are thinking about BFRBs with Autism and/or ADHD, reach out! We would love to chat with you about evaluations or neurodivergent affirming therapy options!
Do you live on Wahpekute land (colonized as MN), or Chumash land (colonized as Los Angeles, CA), and want an Autism assessment, an ADHD assessment, neurodiversity affirming individual therapy, neurodiversity affirming group therapy or neurodiversity friendly DBT individual therapy? We got you covered! Reach out to learn more, we offer free consultations for therapy and assessments!
We live and work on the unseated territories of the Wahpekute and Chumash land, we pay respects to their elders past and present. We encourage folks to explore the ancestral lands they live and work on, and to learn about the Native communities that live there, the treaties that have been broken. If folks feel called, we encourage them to consider taking actions to support Native communities, reparations, and land back movements (see other resources below).
References
American Psychiatric Association. (2022). Neurodevelopmental Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787.x01_Neurodevelopmental_Disorders
American Psychiatric Association. (2022). Obsessive Compulsive and Related Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787.x06_Obsessive_Compulsive_and_Related_Disorders
Cleveland Clinic. (2024). Habit Reversal Training. https://my.clevelandclinic.org/health/treatments/habit-reversal-training
Grant, J. E., & Chamberlain, S. R. (2022). Autistic traits in trichotillomania. Brain and Behavior, 12, e2663. https://doi.org/10.1002/brb3.2663
Golubchik, P., Sever, J., Weizman, A., & Zalsman, G. (2011). Methylphenidate treatment in pediatric patients with attention-deficit/hyperactivity disorder and comorbid trichotillomania: a preliminary report. Clinical neuropharmacology, 34(3), 108–110. https://doi.org/10.1097/WNF.0b013e31821f4da9
HabitAware. (2024). https://habitaware.com/?srsltid=AfmBOooeQ_oZwGPf9XyTYYdQyx6jlTxg-etmC4mzwO7FY3BlUlpcA4ML
Houghton, D. C., Alexander, J. R., Bauer, C. C., & Woods, D. W. (2018). Abnormal perceptual sensitivity in body-focused repetitive behaviors. Comprehensive Psychiatry, 28, 45-52. https://doi.org/10.1016/j.comppsych.2017.12.005
Houghton, D. C., Tommerdahl, M., & Woods, D. W. (2019). Increased tactile sensitivity and deficient feed-forward inhibition in pathological hair pulling and skin picking. Behaviour Research and Therapy, 120 (103433). https://doi.org/10.1016/j.brat.2019.103433
National Autistic Society. (2024). Stimming. https://www.autism.org.uk/advice-and-guidance/topics/behaviour/stimming/all-audience
The TLC Foundation for Body-Focused Repetitive Behaviors. (2024). What is a BFRB?. https://www.bfrb.org/your-journey/what-is-a-bfrb
The TLC Foundation for Body-Focused Repetitive Behaviors. (2024). BFRBs in Children: Recognizing Signs and Supporting Recovery. https://www.bfrb.org/articles/bfrbs-in-children-recognizing-signs-and-supporting-recovery#:~:text=Body%2Dfocused%20repetitive%20behaviors%20(BFRBs,habit%20formation%2C%20and%20environmental%20stressors.
Woods, D. W., & Houghton, D. C. (2014). Diagnosis, evaluation, and management of trichotillomania. The Psychiatric clinics of North America, 37(3), 301–317. https://doi.org/10.1016/j.psc.2014.05.005
Other Resources:
Support starts with educating yourself about history, and being willing to sit with uncomfortable truths. It can then include things like: learning about cultural appropriation, and commit to not engaging in and perpetuating cultural appropriation; committing to calling people in to conversations; educating others, honoring Native folks on holidays such as Indigenous People’s Day, considering the implications of celebrating holidays such as Thanksgiving, or the Fourth of July; making land acknowledgements, having conversations with people about what you learn; financial support; uplifting and amplifying Native voices and stories; understanding and supporting Land Back efforts; researching and supporting Native causes, including supporting and advocating Native-led for legislation changes. Some options for financial support of Native communities on Wahpekute land are here, here, here, here, here or here; Chumash land here; National.
