Body-focused Repetitive Behavior Disorders Research Articles

Impact of alexithymia, attachment styles, and childhood traumas on the severity of body-focused repetitive behavior disorders

It is known that childhood traumas is associated with attachment problems, alexithymia and lead to some psychiatric disease. This study was investigated the relationship of body focused repetitive behavior disorders (BFRBDs) to childhood trauma, attachment styles, and alexithymia, and the impact of these factors on the severity of the disorder. 105 patients with BFRBDs and 90 healthy controls matched for age and sex were comprised in the study. Participants were administered sociodemographic data form, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Clinical Global Impression (CGI), Toronto Alexythimia Scale (TAS-20), Experiences in Close Relationships-II (ECR-II) and Childhood Traumatic Experiences Questionnairre (CTQ-28). Presence of childhood trauma, depression and anxious attachment score were found to be risk factors for the occurrence of BFRBDs. Physical neglect was found to have an indirect effect on the disease severity through the high score of externally-oriented thinking. Therefore, it should be kept in mind that patients who tend to present themselves as normal and do not express their problems/conflicts have a high severity of disease. In addition, it may be important to plan therapeutic interventions in patients according to their comorbidities such as alexithymia, attachment and childhood trauma.

Non-suicidal self-injury in trichotillomania and skin picking disorder.

Trichotillomania and skin picking disorder have been characterized as body-focused repetitive behavior (BFRB) disorders (i.e., repetitive self-grooming behaviors that involve biting, pulling, picking, or scraping one's own hair, skin, lips, cheeks, or nails). Trichotillomania and skin picking disorder have also historically been classified, by some, as types of compulsive self-injury as they involve repetitive hair pulling and skin picking, respectively. The question of the relationship of these disorders to more conventional forms of self-injury such as cutting or self-burning remains incompletely investigated. The objective of this study was to examine the relationship of these two disorders with non-suicidal self-injury (NSSI). Adults with trichotillomania (n=93) and skin picking (n=105) or both (n=82) were recruited from the general population using advertisements and online support groups and completed an online survey. Participants completed self-report instruments to characterize clinical profiles and associated characteristics. In addition, each participant completed a mental health history questionnaire. Of the 280 adults with BFRB disorders, 141 (50.1%) reported a history of self-injury independent of hair pulling and skin picking. Participants with a history of self-injury reported significantly worse pulling and picking symptoms (p<.001) and were significantly more likely to have co-occurring alcohol problems (p<.001), borderline personality disorder (p<.001), buying disorder (p<.001), gambling disorder (p<.001), compulsive sex behavior (p<001), and binge eating disorder (p=.041). NSSI appears common in trichotillomania and skin picking disorder and may be part of a larger constellation of behaviors associated with impulse control or reward-related dysfunction.

The Primary Psychiatric Conditions: Clinical Characteristics

Abstract Primary psychiatric conditions are those conditions, wherein the cutaneous manifestations are secondary to functional psychopathology in the brain. These comprise of psychiatric disorders with dermatologic manifestations and include conditions such as dermatitis artefacta, delusions of parasitosis, obsessive–compulsive disorders, body-focused repetitive behavior disorders, or somatoform disorders. Herein, we describe the clinical features and diagnostic methods of the individual primary psychiatric conditions, most of which have definitive diagnostic criteria in Diagnostic and Statistical Manual of Mental Disorders, and discuss the differential diagnoses encountered in clinical practice, in brief.

Body-Focused Repetitive Behavior Disorders in Children and Adolescents: Clinical Characteristics and Treatment Outcomes in a Naturalistic Setting

Body-focused repetitive behavior disorders, including trichotillomania (hair-pulling disorder) and excoriation (skin picking) disorder, typically emerge in early adolescence, but little is known about the clinical characteristics and treatment outcomes of these disorders in young people, particularly in real-world clinical settings. Participants were 63 children and adolescents (51 girls; age range 9–17) with a diagnosis of trichotillomania (n = 33) and/or skin-picking disorder (n = 33) attending a specialist outpatient clinic in Stockholm, Sweden. Demographic and clinical characteristics were gathered at the initial assessment. Of the 63 assessed youths, 56 received manual-based behavior therapy mainly focusing on habit reversal training, which was combined with medication when deemed appropriate. The mean clinician-reported trichotillomania and skin-picking disorder symptom severity at baseline (n = 63) was in the moderate range. We observed high rates of psychiatric comorbidity (63.5%) and use of psychiatric medication (54.8%). For the 56 individuals undertaking treatment at the clinic, mixed-effects regression models showed a significant decrease in symptom severity from baseline to posttreatment, with gains maintained up to the 12-month follow-up. Substantial and durable improvements were also seen on self-reported symptoms, self-reported depression, and global functioning. Specialist care should be made more widely available to improve the prognosis and quality of life of young people with trichotillomania and skin-picking disorder.

Habit-reversal training: a psychotherapeutic approach in treating body-focused repetitive behaviour disorders.

Body-focused repetitive behaviours (BFRBs) are recurrent, compulsive, destructive behaviours directed towards the body. Although studies have demonstrated a 12-14% prevalence rate, researchers found that dermatologists and psychiatrists show a lack of knowledge regarding psychodermatology resources and information about BFRB disorders (BFRBDs) such as trichotillomania (TTM). There is limited research about treatments including ones investigating the clinical applications of various self-help training such as decoupling (DC) and DC in sensu (DC-is) as well as about habit-reversal training (HRT). HRT is a five-component behavioural intervention that aims to develop a competing response to a specific unwanted behaviour. Studies have found substantial support for HRT's efficacy in treating a variety of maladaptive repetitive behaviours including onychotillomania, TTM, skin-picking disorder and chronic cheek biting. Additionally, many psychotherapies can augmented HRT. Psychotherapies include acceptance and commitment therapy, dialectical behaviour therapy, psychodynamic psychotherapy, mindfulness mediation and the cognitive psychophysiological model. A recently investigated variant of HRT, DC-is, resulted in consistently satisfactory objective and subjective improvement for treating BFRBDs, and HRT showed good subjective but poor objective improvement compared with standard DC. HRT and HRT variants are effective therapeutic treatments for BFRBDs; however, further randomized double-blinded and placebo-controlled trials are required to examine HRT's therapeutic profile.

The Role of Age and Gender in Developing Body-Focused Repetitive Behavior Disorders among Adolescents

This study sought to examine the role of age and gender in developing Body-Focused Repetitive Behavior Disorders (excoriation, trichotillomania, and nail-biting) among adolescents. The sample(n=130) of this study was comprised of adolescents, including both educated males and females. The scales that were used in the current study are; The Trichotillomania Scale for Children/adolescents (Tolin et al., 2008), skin picking scale (Snorrosam et al., 2012), and Nail-Biting Scale (Claes &amp; Vandereycken, 2007). There was no significant difference found between age and gender with respect to BFRBD. The findings of the study will increase the understanding of the knowledge of critical age period of adolescence with respect to Body focused repetitive disorders. The findings of this study will help psychologists, counselors, psychiatrists, and therapists to design and plan therapeutic interventions for BFRBD.

N-acetylcysteine (NAC) and in psychodermatological conditions. Is it useful?

IntroductionPathologic grooming disorders can lead to clinically significant distress and functional impairment. Various psychopharmacological and nonpharmacological treatments have been used to ameliorate the symptoms of these disorders. N-Acetylcysteine (NAC) is a newer modality in the treatment of these disorders and has shown promise in treatment of obsessive-compulsive and related disorders.ObjectivesTo determine whether NAC is useful in the treatment of body-focused repetitive behavior disorders.MethodsA literature review was carried out in PubMed using the descriptors: “body-focused repetitive behaviour disorders” “grooming disorders” AND “N-Acetylcysteine”.Six results were obtained when using the time limit of 5 years. We selected two of them for their relevance to the PICO question. Subsequently, the search was repeated using the same descriptors and the time limit in the Cochrane Library, Epistemokinos and Tripdatabase, in which no additional results were found.ResultsOverall, thirty-three articles were included in these systematic reviews that we studied, which consisted of 23 case reports, one case series, and seven randomized controlled trials. Dosing of oral NAC ranged from 450 to 3,000 mg per day, and treatment periods lasted from 1 to 8 months. Side effects were uncommon, mild, and usually gastrointestinal in nature, with severe aggression reported in one child. Two randomized controlled trials showed a significant improvement in trichotillomania and excoriation disorder in adults. The other two were performed in pediatric population, showing no statistical difference. Two randomized controlled trials and six case reports studying the effects of NAC in patients suffering from trichotillomania (one performed in adults and the other one in infants) were included. Only the one performed in adults showed improvement when adding NAC to the treatment using the Massachusetts General Hospital, Hairpulling Scale (MGH-HPS). Four case reports and two randomized controlled trials included patients with excoriation disorder showed statistical differences in all of them. Three case reports and one randomized controlled trial in patients with onicotylomania showed a difference that wasn’t consistent after two months of treatment.ConclusionsThere are multiple case reports an several clinical trials supporting both the safety and efficacy of NAC in the treatment of body-focused repetitive behavior disorders. Based on these positive preliminary results and the absence of serious adverse effects, carrying out a therapeutical trial with NAC is a plausible option in the management of this pathology, especially in those in which other therapeutic options have not been effective. Further studies are needed to develop a treatment algorithm and elucidate the difference in the efficacy of NAC between children and adults with this disorder.Disclosure of InterestNone Declared

Pain perception and physiological correlates in body-focused repetitive behavior disorders.

Behaviors typical of body-focused repetitive behavior disorders such as trichotillomania (TTM) and skin-picking disorder (SPD) are often associated with pleasure or relief, and with little or no physical pain, suggesting aberrant pain perception. Conclusive evidence about pain perception and correlates in these conditions is, however, lacking. A multisite international study examined pain perception and its physiological correlates in adults with TTM (n=31), SPD (n=24), and healthy controls (HCs; n=26). The cold pressor test was administered, and measurements of pain perception and cardiovascular parameters were taken every 15seconds. Pain perception, latency to pain tolerance, cardiovascular parameters and associations with illness severity, and comorbid depression, as well as interaction effects (group×time interval), were investigated across groups. There were no group differences in pain ratings over time (P=.8) or latency to pain tolerance (P=.8). Illness severity was not associated with pain ratings (all P>.05). In terms of diastolic blood pressure (DBP), the main effect of group was statistically significant (P=.01), with post hoc analyses indicating higher mean DBP in TTM (95% confidence intervals [CI], 84.0-93.5) compared to SPD (95% CI, 73.5-84.2; P=.01), and HCs (95% CI, 75.6-86.0; P=.03). Pain perception did not differ between those with and those without depression (TTM: P=.2, SPD: P=.4). The study findings were mostly negative suggesting that general pain perception aberration is not involved in TTM and SPD. Other underlying drivers of hair-pulling and skin-picking behavior (eg, abnormal reward processing) should be investigated.

Update on Diagnosis and Management of Onychophagia and Onychotillomania.

Onychophagia (nail biting) and onychotillomania (nail picking) are chronic nail conditions categorized as body-focused repetitive behavior (BFRB) disorders. Due to a limited awareness of their clinical presentations, embarrassment on the part of patients, and/or comorbid psychiatric conditions, these conditions are frequently underrecognized and misdiagnosed. This article reviews the prevalence, etiology, diagnostic criteria, historical and physical exam findings, and treatment options for these conditions. The PubMed/MEDLINE database was searched for relevant articles. Onychophagia and onychotillomania are complex disorders necessitating a detailed patient history and physical examination and a multidisciplinary treatment approach for successful diagnosis and management. Due to the dearth of clinical trials for treatment of nail biting and nail picking, large clinical trials are necessary to establish standardized therapies.

Response Inhibition as a Latent Phenotype: Impairment in Body-Focused Repetitive Behavior Disorders, and its Neurochemical Modulation

The symptoms of body-focused repetitive behavior (BFRB) disorders may reflect, in part, loss of top-down executive control mechanisms that would ordinarily regulate habits. Initial case-control studies have reported impairments on tasks of top-down inhibitory control in patients with body-focused repetitive behaviors (BFRBs), but findings in the literature are inconsistent.

Identifying Subtypes of Trichotillomania (Hair Pulling Disorder) and Excoriation (Skin Picking) Disorder Using Mixture Modeling in a Multicenter Sample

Body-focused repetitive behavior disorders (BFRBs) include Trichotillomania (TTM; Hair pulling disorder) and Excoriation (Skin Picking) Disorder (SPD). These conditions are prevalent, highly heterogeneous, under-researched, and under-treated. In order for progress to be made in optimally classifying and treating these conditions, it is necessary to identify meaningful subtypes.

Identifying subtypes of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder using mixture modeling in a multicenter sample

Body-focused repetitive behavior disorders (BFRBs) include Trichotillomania (TTM; Hair pulling disorder) and Excoriation (Skin Picking) Disorder (SPD). These conditions are prevalent, highly heterogeneous, under-researched, and under-treated. In order for progress to be made in optimally classifying and treating these conditions, it is necessary to identify meaningful subtypes. 279 adults (100 with TTM, 81 with SPD, 40 with both TTM and SPD, and 58 controls) were recruited for an international, multi-center between-group comparison using mixture modeling, with stringent correction for multiple comparisons. The main outcome measure was to examine distinct subtypes (aka latent classes) across all study participants using item-level data from gold-standard instruments assessing detailed clinical measures. Mixture models identified 3 subtypes of TTM (entropy 0.98) and 2 subtypes of SPD (entropy 0.99) independent of the control group. Significant differences between these classes were identified on measures of disability, automatic and focused symptoms, perfectionism, trait impulsiveness, and inattention and hyperactivity. These data indicate the existence of three separate subtypes of TTM, and two separate subtypes of SPD, which are distinct from controls. The identified clinical differences between these latent classes may be useful to tailor future treatments by focusing on particular traits. Future work should examine whether these latent subtypes relate to treatment outcomes, or particular psychobiological findings using neuroimaging techniques.

40.2 ANIMAL MODELS OF TRICHOTILLOMANIA AND COMPULSIVE SKIN PICKING: A FOCUS ON THERIOEPISTEMOLOGY

Trichotillomania is the archetype for a group of closely related disorders, including compulsive skin picking, compulsive nail biting, and compulsive lip and cheek chewing, which together are referred to as body-focused repetitive behavior disorders. Trichotillomania has a relatively unique epidemiological profile—the vast majority of sufferers are female, its peak age of onset is tightly associated with pubarche, and it is secondarily associated with reproductive events such as the menstrual cycle, pregnancy, and menopause. Hair- and feather-pulling behaviors are widespread abnormal behaviors in animals, and where data exist, they follow the same pattern of risk factors.

Habit reversal therapy in the management of body focused repetitive behavior disorders.

Body-focused repetitive behavior disorders are a group of disorders characterized by repetitive actions that include skin picking, hair pulling, nail biting, and other compulsions. These disorders can range from a common habit to a pathological disorder, that negatively impacts the psychiatric health and social well-being of an individual. Diagnosis can be made clinically, and monitored using different scales and assessments. Various treatments have been tried with differing successes. There are currently no first line curative medications for these disorders, but cognitive behavioral therapy has seen the most success in treatment. Specifically habit reversal therapy has shown the most promise in reducing the repetitive behaviors and symptoms seen in these disorders. Habit reversal therapy has also seen success through augmentation with additional therapies such as mindfulness, or treatment with a selective serotonin reuptake inhibitor in a patient with comorbid obsessive compulsive disorder. This paper aims to explore the efficacy of different treatment modalities specifically the effectiveness and approach of habit reversal therapy.

N-Acetylcysteine in psychodermatological disorders.

Treatment of psychodermatological conditions, particularly body-focused repetitive behavior disorders, is often unsatisfactory. Various psychopharmacological and non-pharmacological treatments have been used to ameliorate the symptoms of these disorders. N-Acetylcysteine (NAC) is a newer modality in the treatment of these disorders. This short review focuses on pharmacology, mode of action, and use of NAC in common body-focused repetitive disorders such as trichotillomania, skin-picking disorders, and onychotillomania (nail biting). Current research and literature review have been evaluated and will be discussed.

Skin-Picking Disorder: A Guide to Diagnosis and Management.

Skin-picking disorder, also known as excoriation disorder or psychogenic skin excoriations, is an obsessive-compulsive and related disorder that is classified with other body-focused repetitive-behavior disorders in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Skin-picking disorder is associated with significant comorbidity and psychosocial dysfunction. The disorder has a female predominance across studies, and the average age of onset is variable but commonly in adolescence and adulthood. A full clinical and dermatologic examination and multidisciplinary approach is important in the diagnosis of this condition. There is no specific or recommended treatment option, but cognitive-behavioral therapy, particularly habit-reversal therapy and acceptance and commitment therapy have shown promise. Various pharmacological interventions have also been described to treat this condition in case reports and open and controlled trials. Specific classes of agents implemented include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, antipsychotics, and glutaminergic-modulating agents. SSRIs and N-acetylcysteine have been shown to be the most effective of the pharmacological interventions.

Assessment and treatment of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder

Recommendations are provided for the assessment and treatment of trichotillomania (hair pulling disorder, or HPD) and excoriation disorder (skin picking disorder, or SPD), two body-focused repetitive behavior (BFRB) disorders, based on their severity, comorbidities, and behavioral style. Habit reversal training (HRT) and stimulus control are first-line behavioral treatments that can be used in cases of all severity levels and may be particularly helpful when pulling or picking is performed with lowered awareness/intention. Acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT) are behavioral treatments that can be employed to augment HRT/stimulus control, especially when negative emotions trigger the pulling or picking. There are currently no FDA-approved pharmacologic treatments for HPD or SPD, though certain medications/supplements have shown varying degrees of efficacy in trials. N-acetylcysteine (NAC) should be considered for all severity levels and styles given its moderate gain/low side effect profile. Other pharmacologic interventions, including selective serotonin reuptake inhibitors (SSRIs), should be considered in cases with significant comorbidities or previous behavioral/NAC treatment failure.

Emotion regulation deficits in persons with body-focused repetitive behavior disorders

BackgroundConceptualizations of emotion dysregulation (ED) and body-focused repetitive behavior disorders (BFRBDs) imply that ED may be a central component of BFRBDs as well as a factor that distinguishes BFRBDs from non-impairing, subclinical body-focused repetitive behaviors (BFRBs). The current study empirically tested these observations. MethodsOne hundred thirty-eight undergraduates (of 1900 who completed a screening survey) completed self-report measures assessing four emotion regulation (ER) deficits hypothesized to underlie ED (alexithymia, maladaptive emotional reactivity, experiential avoidance, and response inhibition when distressed); 34 of these participants had BFRBDs, 64 had subclinical BFRBs, and 42 were unaffected by BFRBs. ResultsResults indicated that participants with BFRBDs reported higher levels of maladaptive emotional reactivity, experiential avoidance, and response inhibition when distressed than participants with subclinical BFRBs and participants unaffected by BFRBs. These results held even when controlling for comorbidity and total number of reported BFRBs. Participants did not differ on alexithymia. LimitationsLimitations of the current study include the BFRB groups’ different distributions of BFRB types (e.g., hair pulling versus skin picking), the sample's demographic uniformity, and the fact that negative affectivity was not controlled when exploring BFRB group differences on ER deficits. Future research should improve on these limitations. ConclusionsThe current results suggest that ED is a factor that differentiates BFRBDs from subclinical BFRBs. Such results may be useful for generating hypotheses regarding mechanisms responsible for BFRBs’ development into BFRBDs. Furthermore, these results may provide insight into factors that explain the efficacy of more contemporary behavioral treatments for BFRBDs.

Relationship of Body-Focused Repetitive Behavior Disorders to OCD

Obsessive-compulsive disorder (OCD) and body-focused repetitive behaviors (BFRBs) have demonstrated considerable presence and impact among clinical populations. As consistent with any treatment approach, necessary intervention among these disorders begins with a comprehensive evaluation of client’s symptoms, with particular attention placed on potential comorbidities. Common practice among clinicians identifies exposure and response prevention (ERP) as a first line treatment of OCD. However, among client’s demonstrating BFRBs, habit reversal therapy (HRT) or novel emotion-based treatments (e.g., acceptance-enhanced behavior therapy [AEBT], dialectical behavioral therapy [DBT]) are used. Such therapies have demonstrated significant efficacy among their respective disorders. Notably, depending upon disorder severity, medications may also be suggested. Given frequent comorbidity between OCD and BFRBs, it is recommended that clinicians adequately modify interventions when presented with clients demonstrating such comorbid behaviors, perhaps combining effective facets of multiple approaches (see discussion below). From a pharmacological perspective, burgeoning research identifies two potential interventions applicable to both OCD and BFRBs (e.g., silymarin and n-acetyl-cysteine); however, given the novelty of this research, we recommend caution with use of such therapies. While current studies suggest potential efficacy, further research examining such pharmacological interventions is necessary.

Does comorbidity matter in body-focused repetitive behavior disorders?

Trichotillomania (TTM) and skin-picking disorder (SPD) have been characterized as body-focused repetitive behavior disorders (BFRBs). Because BFRBs frequently co-occur, we sought to discover the similarities and differences for individuals having both TTM and SPD as opposed to 1 of these disorders. Participants with primary TTM (N = 421) were evaluated regarding the comorbidity of SPD, and participants with primary SPD (N = 124) were evaluated regarding the comorbidity of TTM. The effects of comorbidity overlap on demographic and clinical measures were evaluated. Of the 421 participants with primary TTM, 61 (14.5%) had co-occurring SPD. Of 124 participants with primary SPD, 21 (16.9%) had comorbid TTM. Participants with primary TTM and comorbid SPD had significantly more severe trichotillomania symptoms and were more likely to have major depressive disorder than those with TTM alone. Participants with primary SPD and comorbid TTM reported significantly more severe skin-picking symptoms than those who had only SPD. Individuals with co-occurring TTM and SPD may have more problematic symptoms with the primary repetitive behavior. Hair pullers with comorbid SPD were more likely to have comorbid depression. Evaluating patients for multiple BFRBs may be important to assess the severity of symptoms and may have treatment implications.