This article was published on: 10/1/21 4:23 PM
As the success of Dr. Pimple Popper (dermatologist Dr. Sandra Lee, known for her YouTube channel squeezing blemishes) shows, people love to see a perceived imperfection removed. What happens when these normal grooming behaviors get out of control? Body-focused repetitive behaviors (BFRBs) are a group of related disorders that cause people to repeatedly touch their hair or body in ways that result in damage. Hair-pulling disorder (trichotillomania) and skin-picking disorder (dermatillomania) are the two BFRBs currently recognized by the American Psychological Association, but many other behaviors fall under this umbrella term, such as nail-biting and cheek-biting.
BFRBs are often accompanied by intense feelings of shame. Shame is a self-evaluation of inadequacy, triggered by a discrepancy between a negative self-evaluation and the ideal self (Miceli & Castelfranchi, 2018). A person experiencing shame believes themself inadequate to meet their desired standards, often leading to other unpleasant emotions such as disappointment, helplessness, and hopelessness.
People with BFRBs may experience “the shame of engaging in problem behaviors that are both visible and self-inflicted” (Mansueto, Vavrichek, & Golomb, 2019). Shame about pulling or picking impacts self-esteem, relationships, and occupational or academic performance. People with BFRBs may believe that their behaviors make them deeply flawed, avoid relationships due to fear of discovery of their condition, or struggle to complete tasks because of time spent picking, pulling, or disguising resultant damage.
Noble et al. (2017) assessed the relationship between maladaptive perfectionism, shame, and hair pulling severity. Anderson & Clarke (2019) analyzed the content of posts on an online support forum for individuals who pick their skin. Both studies identified three themes of BFRB-related shame:
Bodily shame (e.g. “I am ashamed about my body and my appearance,” “The damage from my skin picking is disgusting”)
Behavioral shame, or symptom shame (e.g. “I am ashamed of the behaviors I do,” “What I do is disgusting”)
Characterological shame, or global shame (e.g. “I am ashamed because I am a ‘bad’ person,” “I am faulty”)
Paradoxically, shame can increase hair pulling and skin picking, perpetuating a cycle of negative affect and maladaptive coping behaviors. Those who struggle with BFRB-related shame may find the following strategies helpful.
1. Challenge perfectionism.
Striving for “perfection” in skin and hair quality can lead to picking or pulling (Mansueto, Vavrichek, & Golomb, 2019). Efforts to correct perceived imperfections—including asymmetries, blemishes, split ends, and other variations—often result in skin and hair looking worse than when we began. Beliefs that hair and skin should grow back quickly and “normally” can also undermine recovery. Accepting that skin and hair vary in appearance throughout one’s lifetime can reduce bodily shame about these “flaws” and the pulling and picking that frequently follow.
Lapses, setbacks, and slow progress are especially detrimental to people with BFRBs who strive for perfection in their own behavior (Mansueto, Vavrichek, & Golomb, 2019). Perfectionistic thoughts like “I’ve already pulled a little today, so I might as well keep going” or “I’ll never completely stop picking, so I shouldn’t even try” serve as permission-giving statements that enable BFRBs, turning minor episodes into major damage.
Slips are a normal part of treatment. Treating slips as broken streaks (“I was doing so well and now I’m back at square one”) reinforces perfectionistic thinking and behavioral shame. Instead, reframe slips as a sign of a high score or personal best: “Now I know I can go at least one week without pulling my hair. If I did it once, I can do it again.” Learning to manage a BFRB is a marathon, not a sprint, and consistent strategy use is the best way to build up stamina.
2. Practice self-compassion.
Many people view their BFRB as the result of a personal failing or an indication that they lack the willpower needed to overcome the behavior (Mansueto, Vavrichek, & Golomb, 2019). They may beat themselves up for small instances of pulling or picking, view themselves as inherently flawed, or buy into the idea that recovery is not possible for them. This, of course, only leads to more intense unpleasant emotions and increases pulling and picking.
Practicing self-compassion means treating oneself with warmth, understanding, caring, and a desire to help (Neff & Germer, 2018). Self-compassion also recognizes that suffering, failure, and imperfection are all part of the human experience. The quintessential question of self-compassion is “What do I need to help alleviate my suffering?” Sometimes, self-compassion requires action: not only accepting oneself in the moment, but planning to make changes to alleviate future suffering. Perhaps pulling or picking would alleviate discomfort in this moment, but the long-term consequences of the behavior increase suffering.
Addressing negative self-beliefs is one way to reduce characterological shame and thus future suffering. One way of addressing negative self-beliefs is adaptive self-talk, which involves “talking to yourself in positive ways that are encouraging—like a best friend would” (Mansueto, Vavrichek, & Golomb, 2019).
3. Connect with other people with BFRBs.
An estimated 2-4% of the population meet criteria for hair-pulling disorder, and 2-5% of the population meet criteria for skin-picking disorder (The TLC Foundation for BFRBs, 2021). Communicating with other people with BFRBs and hearing their stories can reduce shame by normalizing these experiences.
The TLC Foundation for Body-Focused Repetitive Behaviors (https://www.bfrb.org/) is a fantastic resource. Whether one wants to find a therapist, start or join a support group, read personal stories from the BFRB community, or learn about the latest BFRB research, the TLC Foundation has an answer.
Picking Me Foundation (https://pickingme.org/) invites members to share their experiences with skin picking through art, poetry, and affirmations. Picking Me also provides resources to help manage skin picking and hosts an online support group for people with all BFRBs.
Other organizations supporting BFRB clinicians and/or experiencers include the International OCD Foundation (https://iocdf.org/) and the Anxiety and Depression Association of America (https://adaa.org/).
References
Anderson, S. & Clarke, V. (2019). Disgust, shame and the psychosocial impact of skin picking: Evidence from an online support forum. Journal of Health Psychology, 24(13), 1773-1784. https://doi.org/10.1177/1359105317700254
Mansueto, C. S., Vavrichek, S. M., & Golomb, R. G. (2020). Overcoming Body-Focused Repetitive Behaviors: A Comprehensive Behavioral Treatment for Hair Pulling and Skin Picking. New Harbinger Publications.
Miceli, M. & Castelfranchi, C. (2018). Reconsidering the Differences Between Shame and Guilt. Europe’s Journal of Psychology, 14(3), 710-733, doi: 10.5964/ejop.v14i3.1564
Neff, K. & Germer, C. (2018). The Mindful Self-Compassion Workbook: A Proven Way to Accept Yourself, Build Inner Strength, and Thrive. Guilford Press.
Noble, C. M., Gnilka, P. B., Ashby, J. S., & McLaulin, S. E. (2017). Perfectionism, Shame, and Trichotillomania Symptoms in Clinical and Nonclinical Samples. Journal of Mental Health Counseling, 39(4), 335-350. https://doi.org/10.17744/mehc.39.4.05
The TLC Foundation for Body-Focused Repetitive Behaviors (2021). https://www.bfrb.org/
written by Sophia Alapati, LCPC, Clinical Associate
The Maryland Anxiety Center was founded by Andrea G. Batton, LCPC with a vision of creating a practice where clinicians and staff work cohesively and collaboratively with patients to provide optimal psychological care. The Maryland Anxiety Center specializes in the treatment of anxiety and related disorders from a cognitive behavioral perspective, the gold-standard and most effective treatment for such conditions.