'Bad Habits’ or Body-Focused Repetitive Behaviors?

by Natalie Brei, PhD, LP

There are many places where mental health and medical conditions intersect. Some of these we call “habit or impulse disorders” or, more specifically, “body-focused repetitive behavior disorders.” These can present in many different ways, but I would like to focus on a few that you might have noticed in yourself or those around you and dismissed as a “bad habit”: hair pulling (trichotillomania), skin picking, and nail biting. If they interfere with well-being to a significant degree and the person has tried to stop, then these are something different than bad habits: they are true clinical disorders, which are difficult to change with ‘will power.’ In fact, there are entire treatments designed to support people who engage in these behaviors, because sometimes they occur to the degree that they cause physical distortion or significant mental distress. Let’s look at these one by one, with the caution that we will be getting nitty-gritty with details that, sometimes, we just don’t want to talk about (even though it is helpful):

Hair pulling: Hair is everywhere; therefore, people can pull hair repetitively from anywhere on their bodies. Common pulling sites are from the scalp, eyebrows, and eyelashes. This does not include regular pulling for cosmetic reasons, like plucking eyebrows. Trichotillomania involves repetitive pulling or breaking off of hair to the point that it may even be noticeable to others. The person may create a bald spot, extra-wide part, or be missing some or all of his/her eyebrows or eyelashes. Individuals are often quite good at styling hair in a way to make it less noticeable, but the behavior is still causing harm. Sometimes an individual will repetitively pull another person’s hair or a pet’s hair without intending harm. Note that if the hair is being ingested, which sometimes happens, the person should immediately be seen by a doctor.

Skin picking: Skin is also everywhere, so a scratch, wound, or dry skin can be picked at from anywhere on the body. However, common problem locations are the lips (think how hard chapped lips are to resist in winter), scalp, around the nails, and scabs. Picking to the point of damage or bleeding, over and over, puts the skin picking in that ‘clinically significant’ category that makes it different from the occasional damage caused by a less severe habit.

Nail (or lip, or cheek) biting: Biting can also occur anywhere, but these three are common sites. This can obviously create very painful effects. Again, someone may bite at his or her nails before a big event like a test or presentation without it being a disorder. However, once the behavior itself starts causing significant damage or distress (think: “I want to stop, but I can’t! I’ve tried! And it keeps getting worse!), it may necessitate outside help.

Most people are ashamed and embarrassed about their habit disorder. Many report that it seems difficult or impossible to stop, even when the behavior is purposeful rather than automatic/mindless. The other thing that creates a sense of shame is that many people report a sense of satisfaction or relief from engaging in the behavior, similar to scratching an itch. It can be helpful to know that these repetitive behavior disorders are fairly common over the course of one’s life and that many people report similar thoughts and feelings (such as that sense of urge and relief) as others who have the same problem. These behaviors may be driven by anxiety, hence the label ‘nervous habit’ that many people use. They may also be driven by boredom or, simply, by habit – the fact that a behavior was done in the past makes it more of a go-to in certain situations. It becomes automatic in the sense that the person is often not even aware of performing the behavior, which can make it difficult to prevent. Some say it feels like OCD, but these conditions are something separate from OCD that warrant a different type of treatment.

Often, family members may not know that the behavior is a problem, or they notice a “bad habit” and begin a cycle of nagging at the person to stop, which does not help the situation. Again, keep in mind that many people bite their nails or pick at skin without meeting criteria for the disorder we are discussing here, so do not despair if you have been the ‘nagger.’ Some tips for actually helping the person to stop, no matter how severe the behavior, are included further below.

There is help! Behavioral treatment consists of a few steps that can drastically improve the condition across the course of a few months with a trained provider:

1. Increasing awareness of the behavior through a “functional behavior assessment” (which investigates when, where, and why the behavior is more likely to occur) and careful monitoring and tracking of the behavior.

2. Learning to notice – but not respond to – the “urge” to engage in the behavior, instead helping the mind accept that the urge is there but that it DOES eventually go away. This involves practice and learning some tools for how to handle very strong urges!

3. Learning environmental control strategies to help make the behavior less likely to happen. For example, some people who pull their hair mainly while watching TV can wear thin mittens each time they watch TV, which makes it very difficult to pull out hair.

4. Learning an alternative, competing response to the behavior can also be helpful. In the case of nail picking, a person might be instructed to sit on his or her hands for one minute when the urge to pick comes along. Over time, the feeling of needing to pick becomes weaker and weaker. In addition, if this is done with commitment, people often see their skin start to look healthy again or watch their hair grow back, which helps with motivation to keep up the good work.

5. Social support is a critical step. In addition to praise and encouragement from a therapist, the person with the habit disorder benefits from having at least one support person who knows about the situation and the techniques that work for healing. This person offers encouragement, shares in success, and responds to slip-ups appropriately. Some tips for support people might be:

a. Refrain from telling the person to stop the behavior. Most importantly, do not shame the person.

b. Instead, gently point out the behavior and offer alternative behaviors. Ask how to do this in a way that does not annoy the person. For example, a parent might see a child picking at her lips at the table and remind her to keep a utensil in both hands. A spouse who notices hair-pulling could say, “I see you’re pulling; let me grab your hat” (to block the pulling) or “I’ll go get your fuzzy blanket” (helps give the fingers something to do). Some people will prefer a more secretive code word or signal.

c. Think of rewarding activities for milestones reached. If hair is growing back visibly, this might be cause for a celebration night. If nails are looking good again, a manicure could be very satisfying.

d. Always be encouraging. Remember that the brain and body get very stuck in their ways, and change takes time. There will be setbacks. Remind the person of his or her goals and of any progress that has been made. Keep a bright outlook.

People who have a body-focused repetitive behavior disorder sometimes, but do not always, have another condition, such as depression, anxiety, or OCD. These conditions might spring from the repetitive behavior disorder or could be underlying conditions that contribute to it. At times, medication side effects can even contribute to these habit disorders. It is always important to look at the whole picture and the whole person, which is why visiting with a doctor or psychologist can be helpful. When we remove the stigma that something is mentally wrong with us if we have a ‘mental health disorder’ and realize how closely physical and mental health are connected, we start to seek and find the help we actually need. In this way, Jesus helps us to submit our crosses to him rather than keeping them all to ourselves, allowing us to lead less burdened, more purposeful lives.