Written by: Hannah Sommer Garza, PhD
What are Body-Focused Repetitive Behaviors (BFRBs)?
BFRBs refer to a group of related behaviors where the individual repetitively touches specific parts of the body (e.g. hair, nails, skin) in a way that can cause damage. BFRBs are not tics. Common BFRBs include hair-pulling disorder (trichotillomania), skin-picking disorder (excoriation), nail-biting (onychophagia), and knuckle-cracking. Individuals may engage in a single type of BFRB (e.g. hair-pulling) or a combination of them throughout their lifetime. These behaviors tend to cluster together within families, suggesting a genetic component to their presentation. For more information, check out this website. Fortunately, all BFRBs can generally be treated very similarly. This blog focuses on one particular evidence-based treatment for BFRBs, the Comprehensive Model for Behavioral Treatment (ComB).
The ComB model was developed by Charles Mansueto, PhD and his colleagues at the Behavior Therapy Center of Greater Washington. It is one of the leading cognitive behavior therapy (CBT) approaches to treating BFRBs, by identifying the function of the target behavior (e.g. hair-pulling or skin-picking) and creating a targeted replacement for it. The ComB model is also endorsed by the Trichotillomania Learning Center (TLC) Scientific Advisory Board, a board of BFRB expert researchers and clinicians. The ComB model assesses five functional domains known to be associated with the promotion of the BFRB. The five domains are: Sensory, Cognitive, Affective, Motor, and Place. The common acronym for them is SCAMP. I will outline each of the domains below.
The Sensory domain encompasses any sensory experience that promotes the BFRB. More specifically, any visual, auditory, tactile, oral, or olfactory experience that occurs before, during, or after the BFRB that promotes engagement in the BFRB. Check out this video on the Sensory domain from a BFRB expert, Suzanne Mouton-Odum, PhD.
One theory suggests that people engage in BFRBs as a way to soothe their central nervous systems. Throughout a given day, there are various and ever-changing sensory experiences we encounter. This can throw our central nervous system out of whack, so we do our best to self-regulate. One method of self-regulating could be through using BFRBs to either amp up the nervous system or to calm it down in response to environmental or internal experiences and to try to reach a form of homeostasis.
The assessment of this domain involves identification of sensory experiences associated with the target behavior. For instance, an individual with trichotillomania may notice hair-pulling sensory experiences that promote pulling to be: noticing a hair out of place (visual), feeling a kinky or coarse hair (tactile), enjoying the sound of the eyelid slapping back after pulling eyelashes (auditory), rubbing the pulled hair on the lips or sucking on the bulb (oral), or enjoying the smell of the bulb after pulling (olfactory). Examples of sensory experiences that promote skin-picking include: seeing a pimple (visual), feeling the dry or flaky part of a scab (tactile), enjoying the sound of skin flaking from a scab (auditory), swallowing picked skin (oral), or enjoying the smell of the picked blackhead (olfactory).
Once the triggering and maintaining sensory factors have been identified, the goal is to develop a functional replacement of those sensory experiences to have in place of the BFRB or to prevent the sensory trigger from occurring. That’s where a significant bulk of the treatment work comes in, involving a series of “experiments” to find a helpful combination of sensory replacements that will work for you specifically. Be a detective in your experiments. If a strategy is or is not working, find out why or why not. That will help you to get more targeted in finding the sensory interventions that will work best for you.
Some ideas for preventing sensory triggers could include dimming bathroom lights and covering mirrors to reduce visual exposure to hairs out of place or pickable skin. One could also preventatively use some sensory strategies to get ahead of BFRB urges. In terms of developing a functional replacement of the sensory experience, it’s best to try to recreate the enjoyable sensory experiences associated with the BFRB by finding the perfect fidget toy or tactile distraction. The ideal fidget will be one that most closely mimics the sensory experience associated with the BFRB. Oriental Trading Company has some great options for fidgets, but you can also get creative with household items. For example, makeup or paint brushes can usually mimic real hair at various lengths. If short, stubby hairs provide an enjoyable sensory experience, try cutting the paint brush bristles to be shorter in length, or try using a toothbrush or eyebrow brush to recreate the coarse hair sensation. Chewing gum or having suckers can be strategies for oral sensory experiences. Popping bubble wrap can also be a great way to create an auditory sensory experience. Ultimately, get creative with what you can use to recreate your sensory experience instead of engaging in your BFRB.
The second domain in the ComB model is Cognitive. Cognitive is just another word for thoughts. In terms of BFRB assessment and treatment, we’re specifically talking about thoughts that cue BFRBs or promote BFRBs in some way. Check out this video for more information on how thoughts relate to BFRBs in the ComB model.
The assessment of this domain involves identifying thoughts that occur before, during, or after the BFRB that are associated with the BFRB. These could be thoughts that enhance the desirability of engaging in the BFRB. For instance, “this hang-skin is uneven so I need to ‘fix’ it,” “I will only pull a few more hairs and then I will stop,” “picking helps me feel better,” or “it’s too much effort to get my strategy.” Other thoughts could be those that reward BFRB engagement, such as “yes, I got out the whole hair bulb” or “now my gray hairs are gone and that’s much better.”
Treatment within the cognitive domain involves targeted challenging and changing of those thoughts that promote the BFRB. Start to challenge the thought by looking at realistic evidence. Is the hang-skin really uneven? Is picking it really going to fix it? What are the costs to picking it? Is there another way to address it without picking it? You can also find motivating and helpful thoughts to cope with tough urges. For instance, “this urge is at its peak, but it will pass,” “this urge is hard to resist, but you can do it,” “I have found success with strategy X and can easily get/use it right now,” or “you’re making so much progress already, keep it up.”
The third ComB domain is Affective. Affect just means emotions or feelings. Oftentimes, people engage in BFRBs as a way to regulate emotions like nervousness, anxiety, frustration, or sadness. People may also experience certain emotions after BFRB episodes, like satisfaction, or even guilt, embarrassment, or shame. Check out this video for more information on the ComB affective component.
Assessment involves identifying emotions that may trigger the BFRB as well as those experienced after engaging in the BFRB. The first step is to build awareness of emotional experiences and how they relate to picking or pulling. Some people are already pretty good at noticing and labeling emotions as they are experienced, but for many people, this can be challenging. If you are someone who is wanting to increase your awareness of emotional experiences, try first paying attention to physical changes in your body. Do you notice your heart race increase, becoming physically hot, or having an upset stomach? Sometimes, these physical experiences are more readily captured, and can be neon sign reminders to connect them to an emotion. Additionally, you can pay attention to big changes in your behavior to try to capture feelings. If you notice that you are crying, avoiding something important, or are yelling at a family member, these could be signs that you have an associated emotional reaction. Ultimately, listen to your body cues or behaviors to get better at understanding what you’re feeling. As you better understand what you’re feeling and what kinds of situations you tend to feel that way, you may start to notice if your BFRB serves some sort of self-soothing or emotionally-regulating function. If so, then you can use affective coping strategies for managing BFRBs.
For many people, they engage in BFRBs when they feel stressed or overwhelmed. Affective coping strategies are designed to help manage the feelings associated with the BFRB. Therapy can help you learn healthy coping strategies for managing emotions. Some examples of affective strategies are: taking a bubble bath, going for a walk or run, deep breathing, yoga, journal writing, talking with friends, listening to soothing music, addressing procrastination, or managing interpersonal conflict. Some medications have also been found to reduce emotional distress.
The fourth domain of the ComB Model is Motor. The Motor domain captures the person’s awareness of and ease of engaging in the BFRB. Awareness is HUGE for addressing all of the other domains. Otherwise, it’s like playing darts in the dark in terms of selecting targeted interventions and strategies. Check out this video on the ComB motor domain.
The key here is keeping wandering hands busy and/or making it a little more difficult to engage in the BFRB. One of my first suggestions to people when they start BFRB treatment is to wear some kind of block. This may look a little different for different people and depending on the BFRB, but the idea is to wear something that blocks your ability to do the BFRB outside of your conscious awareness. Wearing blocks can be an especially helpful way to notice features of the other ComB domains that are able to be targeted for intervention. For many people, it also makes it nearly impossible to engage in the BFRB when wearing a block. Some examples of blocks are: wearing finger bandages, wearing a hat, wearing band-aids over cuts or scabs, wearing long sleeves or pants, and wearing gloves. Other motor strategies that keep wandering hands busy are: throwing away tweezers, staying active, using a fidget toy, putting on lotion, and knitting or other crafts.
The fifth and final domain of the ComB Model is Place. The Place domain encompasses the environment, location, time of day, and activity that promotes the BFRB. Check out this video for more information on the Place domain of the ComB model.
Assessment the kinds of places where BFRBs occur. Are there certain places where you tend to pick or pull? Do you primarily engage in the BFRB alone, or also when around other people? Do you find that you almost always engage in your BFRB when feeling tired or at the end of the day? Are there certain activities you’re doing where you notice more BFRB action, like checking email, writing a paper, doing homework, or watching TV?
Once you’ve identified certain places where BFRBs are more likely to occur, treatment in the Place domain involves tweaking those environments to make it more difficult for you to do the BFRB. Some examples may include: dimming the bathroom lights, covering mirrors, wearing make-up, wearing hair pulled back, or placing reminder notes in high-risk areas. If you notice patterns in the types of environments where you engage in your BFRB, then you would benefit from having preventative strategies in place for better managing those situations without picking or pulling.
How Treatment Can Help
Behavior change is hard!! While some people can make progress treating their BFRB alone, there are many powerful benefits of going to therapy for your BFRB. Through working with a specialist, you can build skills for identifying triggers and coming up with successful interventions that are supported by scientific research. The therapist can also help you to work through tough issues or barriers that may be getting you stuck. It can also be helpful to bounce intervention ideas off another person with experience treating BFRBs. Together, you can find strategies that will be realistic for you to use in your life. For instance, your therapist can work with family members to help educate them about BFRBs and to learn ways to be more supportive of your treatment efforts. Also, for many people, therapy is one of the first times they’ve felt able to talk openly about their BFRB without being judged for it. Ultimately, through support in therapy and some hard work, you may be better able to learn ways to change your BFRB behaviors. You are not alone, and help is out there!
Mansueto, C. S., Goldfinger Golomb, R., McCombs Thomas, A., & Townsley Stemberger, R. M. (1999). A Comprehensive Model for Behavioral Treatment of Trichotillomania. Cognitive and Behavioral Practice, 6, 23-43.