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Beneath the Surface: Confronting the Hidden World of Skin Picking and Hair Pulling

Body-focused repetitive behaviours, often shortened to BFRBs, represent a group of conditions where individuals repeatedly touch their hair or body in ways that cause physical damage. These are not simply nervous habits like occasionally twirling hair or biting a fingernail. Instead, BFRBs involve intense urges leading to actions like compulsive skin picking (dermatillomania or excoriation disorder), hair pulling (trichotillomania), nail biting (onychophagia), cheek biting (morsicatio buccarum), or skin biting (dermatophagia). While many people might engage in these behaviours mildly or infrequently, for those with a BFRB disorder, the actions are difficult to control, recurrent, and cause significant distress or impairment in daily life, despite repeated attempts to stop. These behaviours often serve as coping mechanisms for difficult emotions like stress, anxiety, boredom, or unhappiness, providing temporary relief but ultimately leading to harm.

The Grip of Shame and Secrecy

Experts estimate that clinically significant BFRBs affect between 1.5% and 5% of the global population, though some studies suggest milder forms are far more common, potentially affecting up to 60% of people at some point. Sarah Redzikowski, a 40-year-old woman, recently brought her own decades-long struggle with dermatillomania into the light via TikTok. Her tearful videos showed the raw reality of the disorder: inflamed skin, bleeding, and scarring. She lamented the countless hours lost to the compulsion. This act of vulnerability highlights a core challenge for those with BFRBs – the overwhelming shame and secrecy surrounding the condition. Psychologist Suzanne Mouton-Odum confirms this, noting that intense shame often prevents individuals from disclosing their behaviours, even in confidential surveys, significantly hindering diagnosis and recovery.

Childhood Roots and Hidden Struggles

For Ms. Redzikowski, skin picking began in childhood. It offered a sense of solace and control amidst family difficulties. This pattern is not unusual; BFRBs often emerge in late childhood or early adolescence. Throughout her teenage years, hiding the condition became paramount. She employed clever tactics like specific hairstyles and concealing clothing to mask the physical evidence. This experience resonates with Saharra Dixon, a 29-year-old health coach and doctoral candidate. Her hair-pulling behaviour, trichotillomania, started with pubic hair but shifted to her scalp after family members criticised her, intensifying feelings of self-consciousness and the need for secrecy. These personal accounts underscore how BFRBs can deeply intertwine with early life experiences and self-perception.

The Weight of Stigma

The intense stigma associated with BFRBs adds another layer of difficulty. Dr. Mouton-Odum illustrates this starkly, sharing instances where parents, struggling to comprehend their child's hair-pulling, have attributed the resulting hair loss to serious illnesses like cancer. This highlights the profound lack of understanding and the immense societal pressure that individuals with BFRBs face. They often internalise this stigma, leading to feelings of isolation and self-blame. Breaking through this stigma requires increased public awareness and open conversation, moving away from judgment towards empathy and understanding. The secrecy born from stigma prevents many from seeking help, perpetuating a cycle of suffering.

Image Credit - NY Times

A Mask and a Career

Ms. Redzikowski developed considerable skill in makeup application. This talent eventually led her to a career as a beauty influencer and makeup artist. Ironically, the very skill that provided a professional path also served as a crucial tool for masking the physical signs of her dermatillomania. This created a complex duality in her life. While her expertise allowed her to present a flawless image to the world, the constant fear of judgment, especially from clients after particularly intense picking episodes, generated enormous emotional distress. This internal conflict, the pressure of maintaining an image while battling a hidden compulsion, took a severe toll, contributing to a period of intense despair.

The Crisis Point and Seeking Help

The immense pressure of concealing her condition while working in the beauty industry ultimately became unbearable for Ms. Redzikowski. The fear of exposure and the internal struggle culminated in a devastating crisis: a suicide attempt. This critical point marked a desperate need for intervention. It underscored the severe mental anguish that can accompany BFRBs when left unaddressed or hidden due to shame. Reaching this low point, however, became a catalyst for seeking professional help, paving the way for diagnosis and the beginning of a structured treatment journey. It highlights the potential severity of BFRBs and the urgent need for accessible, effective support.

Diagnosis and Initial Treatment Steps

In 2021, while undergoing treatment for depression, Ms. Redzikowski finally received a formal diagnosis of dermatillomania. This acknowledgement was a crucial step. Her initial treatment plan involved medication, specifically N-acetylcysteine (NAC), an amino acid derivative thought to modulate glutamate levels in the brain, potentially reducing compulsive behaviours. Behavioural modifications were also introduced. While these interventions offered some measure of relief, her psychiatrist primarily focused on managing the depression. According to Dr. Mouton-Odum, this highlights a common challenge: effective BFRB treatment requires addressing the specific underlying drivers of the repetitive behaviour itself, not just co-occurring conditions like depression or anxiety, although managing those is also important.

Understanding N-Acetylcysteine (NAC)

N-acetylcysteine (NAC) has emerged as a promising, though not universally effective, treatment avenue for some individuals with BFRBs. It is an over-the-counter supplement, an amino acid derivative known primarily as an antidote for paracetamol overdose and as a mucolytic agent. Research suggests NAC functions as a glutamate modulator and antioxidant. Glutamate is a key neurotransmitter, and imbalances in its system are implicated in obsessive-compulsive spectrum disorders. NAC is thought to restore glutamate balance, potentially reducing the urge driving compulsive behaviours like skin picking or hair pulling. It may also reduce oxidative stress in the brain, which could play a role in mitigating compulsions. Doses typically range from 600mg to 2400mg daily, sometimes higher, often used alongside therapy.

Exploring Deeper Causes in Therapy

Through continued therapy, Ms. Redzikowski began to connect her skin-picking behaviour more directly to her turbulent upbringing. This insight shifted the understanding of the behaviour from a mere "bad habit" to a deeply ingrained coping mechanism developed in response to early life stress. Today, picking still provides a form of comfort during stressful periods, such as the anxiety provoked by recent wildfires near her Los Angeles home. However, the urge is not solely stress-related; any perceived imperfection on her skin can also act as a powerful trigger. This highlights the complex interplay of emotional regulation and sensory triggers often present in BFRBs. Therapy helps unravel these connections.

The Sensory Experience of BFRBs

For many individuals with BFRBs, there is a distinct sensory component to the behaviour. Barbara Lally, a 33-year-old documenting her trichotillomania journey online, describes the impulse as akin to an unbearable itch. Relief and satisfaction come only upon finding and extracting a specific, targeted hair. This resonates with many who experience skin picking or hair pulling – there is often a focused search for a particular "imperfection," scab, or hair follicle that feels "wrong" or "out of place." The act of removing it provides a brief, intense release of tension or a feeling of "rightness," reinforcing the behaviour despite the subsequent damage and distress.

Image Credit - NY Times

The Power of Community and Peer Support

Finding others who understand the unique struggles of BFRBs can be profoundly healing. Jason Yu, 31, battled skin picking for a decade, trying numerous physical deterrents with limited success. Real progress began when he joined a peer support group. Sharing experiences and strategies with others who truly "got it" helped reduce his sense of isolation and shame. This positive experience inspired him to launch a podcast dedicated to BFRBs, further breaking the silence. Peer support provides validation, practical coping strategies, and crucial emotional encouragement, reminding individuals they are not alone. Groups like those facilitated by the TLC Foundation for BFRBs or UK-based organisations offer vital connections.

Reframing the Narrative

A significant shift for Mr. Yu involved reframing his picking behaviour. Instead of viewing it solely as a failure or something shameful, he learned to see it as a signal from his body indicating heightened anxiety or unmet needs. This cognitive shift, often facilitated by therapy and peer support, is crucial for long-term management. While he is not entirely pick-free, the behaviour is greatly reduced. Now, when the urge arises, it serves as a valuable cue to check in with his emotional state and employ healthier coping strategies. This reframing transforms the behaviour from a source of self-criticism into a tool for self-awareness.

Going Public: A Turning Point

Ms. Redzikowski made a transformative decision to reveal her condition on social media. She began with a courageous, barefaced video showing her routine for covering the marks left by picking. The vulnerability struck a chord. The video amassed nearly 400,000 views on TikTok, accompanied by an outpouring of comments. Countless individuals expressed gratitude, shared their own similar struggles, and thanked her for her honesty. This overwhelming response marked a significant turning point, not just for her personal recovery journey but also in contributing to broader awareness and de-stigmatisation of BFRBs. It demonstrated the immense power of shared vulnerability in fostering connection and reducing isolation.

Embracing Authenticity Online

Following her initial revelation, Ms. Redzikowski consciously chose to reject filters and embrace her authentic self as a beauty influencer. This meant showing her skin, including the effects of dermatillomania, without digital alteration. This bold move resonated deeply with her audience and attracted brand collaborations centred around her unedited reality. The substantial engagement she receives not only supports her career but also fuels her personal recovery. By presenting her true self, she challenges conventional beauty standards and normalises imperfections, creating a space where others feel less alone and more accepting of their own skin and struggles. Her journey exemplifies how authenticity can be empowering.

The Role of Supportive Relationships

Strong personal support systems play a vital role in managing BFRBs. Ms. Redzikowski's partner, Kimoon Kim, actively participates in her wellbeing. He assists with her skincare routine, applying strategies learned during consultations with her therapist. His support extends beyond practical help; he offers public affirmation through positive comments on her online posts, reinforcing her courage and self-acceptance. This demonstrates how understanding and non-judgmental support from loved ones can significantly bolster coping mechanisms and contribute to healing. Open communication and a willingness to learn about the condition are key components of supportive relationships for those with BFRBs.

Image Credit - NY Times

Continuing the Conversation: A Sense of Duty

Despite the potential triggers involved in constantly seeing her own face online, Ms. Redzikowski feels a strong sense of duty to continue sharing her story. She recognises the impact her openness has had on others living in silence. A powerful affirmation of this arrived unexpectedly via a video comment. A former model Ms. Redzikowski had worked with professionally confessed to experiencing similar struggles with skin picking throughout her career. This unforeseen exchange vividly illustrated the hidden prevalence of BFRBs, even among those perceived as embodying perfection. It reinforced Ms. Redzikowski's commitment to fostering open dialogue and challenging the secrecy surrounding these conditions.

Expanding the Definition: Types of BFRBs

While dermatillomania and trichotillomania are the most commonly discussed BFRBs, the umbrella term encompasses a wider range of behaviours. These include onychophagia (nail biting), onychotillomania (nail picking), dermatophagia (skin biting or chewing), morsicatio buccarum (cheek biting), morsicatio labiorum (inner lip biting), rhinotillexomania (compulsive nose picking), and even trichophagia (hair eating, sometimes following pulling). Some classifications also include bruxism (teeth grinding) and joint cracking. Recognising the breadth of these behaviours is important for accurate diagnosis and understanding the diverse ways BFRBs can manifest. Each behaviour, when repetitive, difficult to control, and causing distress or harm, falls under this category.

Understanding the Causes: A Complex Picture

The exact causes of BFRBs remain unknown, but research points towards a complex interplay of factors. Genetics likely play a role, as studies show BFRBs run in families, and twin studies suggest a significant inherited component for conditions like trichotillomania. Neurologically, differences in brain structure and function, particularly in areas involved in emotional regulation, reward processing, and impulse control (potentially involving neurotransmitters like serotonin, dopamine, and glutamate), may contribute. Temperament, environmental stressors, and early life experiences, such as trauma or family turmoil, are also considered significant contributing factors. BFRBs often emerge as maladaptive coping mechanisms for managing overwhelming emotions or sensory sensitivities.

Effective Treatment Approaches: Beyond Medication

While medications like NAC or sometimes SSRIs (Selective Serotonin Reuptake Inhibitors, primarily for co-occurring anxiety/depression) can offer support, psychotherapy is considered the cornerstone of effective BFRB treatment. Cognitive Behavioural Therapy (CBT) is a primary approach, focusing on identifying and changing problematic thoughts, feelings, and behaviours. Specific CBT techniques are highly effective. Habit Reversal Training (HRT), developed in the 1970s, involves awareness training (identifying triggers and early signs), competing response training (substituting the BFRB with a harmless action), and building social support. It remains a foundational treatment with strong empirical backing for reducing BFRB frequency and severity.

Comprehensive Behavioural (ComB) Model

A more individualised approach within CBT is the Comprehensive Behavioural (ComB) model. Developed by Dr Charles Mansueto and colleagues, ComB recognises the unique complexity of each person's BFRB. It involves a thorough assessment across multiple domains: Sensory (touch, sight, physical sensations), Cognitive (thoughts, beliefs, interpretations), Affective (emotions, moods), Motor (the physical actions involved), and Place/Location (environmental triggers). By identifying the specific factors driving the behaviour in each domain (summarised by the acronym SCAMP), therapists and clients collaboratively develop tailored intervention strategies. This model acknowledges that BFRBs serve different functions for different people and require personalised treatment plans targeting their specific "why, where, and how."

Acceptance and Commitment Therapy (ACT) and DBT Skills

Other therapeutic modalities often enhance CBT for BFRBs. Acceptance and Commitment Therapy (ACT) helps individuals increase acceptance of uncomfortable urges and emotions without acting on them impulsively. It focuses on observing thoughts and feelings non-judgmentally and committing to actions aligned with personal values, even when urges are present. Dialectical Behaviour Therapy (DBT) skills, particularly those focused on mindfulness, distress tolerance, and emotion regulation, can also be integrated. These skills equip individuals with healthier ways to manage the intense emotions or tension states that often precede BFRB episodes, providing alternatives to picking, pulling, or biting.

The Role of Awareness and Advocacy

Raising public awareness is crucial for reducing the stigma surrounding BFRBs and encouraging individuals to seek help. Organisations like the TLC Foundation for BFRBs (and associated UK/international groups) play a vital role through education, research funding, providing resources for sufferers and families, and training clinicians. BFRB Awareness Week (typically the first week of October) helps focus attention on these often-misunderstood conditions. Social media, while potentially triggering for some, has also become a powerful platform for awareness. Individuals sharing their stories, like Ms. Redzikowski, Ms. Lally, and Mr. Yu, create communities, reduce isolation, and challenge harmful misconceptions, fostering a more supportive environment.

Image Credit - NY Times

Living with BFRBs: Management and Self-Compassion

Recovery from BFRBs is typically viewed as a process of management rather than a complete "cure." While significant reduction or cessation of the behaviour is possible, urges may still arise, particularly during stressful periods. Long-term management involves ongoing use of learned coping strategies, relapse prevention planning, and continued self-awareness. Crucially, self-compassion is paramount. Learning to treat oneself with kindness, understanding, and acceptance, especially during setbacks, is essential. Shifting from self-criticism to self-support helps break the cycle of shame that often fuels the behaviour. Embracing authenticity and acknowledging the BFRB as a disorder, not a personal failing, fosters resilience and sustained wellbeing.

The Future of BFRB Research and Treatment

Research into BFRBs continues to evolve. Ongoing studies explore neurobiological underpinnings, genetic markers, and the effectiveness of various treatment combinations. Newer pharmacological agents, like memantine (a glutamate modulator), show promise in early trials but require further investigation. Improving access to trained therapists remains a challenge, highlighting the need for more specialised training programmes and accessible resources like online therapy platforms and evidence-based self-help tools. Continued research, coupled with increased public and professional awareness, holds the key to developing more effective, personalised treatments and ultimately improving the lives of the millions affected by BFRBs worldwide.