It's More Than Just Fidgets: Treating BFRBs with SCAMP

Julia Bickerstaff
3 days ago
4 min read

Lots of acronyms in our title, let's explore it!

Do you pull your hair, bite your nails, chew on your lip, etc.? Has anyone ever told you to "just stop it" or downplayed the experience by telling you to just grab a fidget?

While fidgets can be helpful, they are often treated as the only option to treat these behaviors, which just isn't the case.

It can be incredibly frustrating when these behaviors are generalized to "just be anxiety" or a "bad habit" that only willpower alone should fix, especially when treatment is a lot more complex than that.

It's important to understand what BFRBs are and to treat them with evidence-based practices, otherwise the client is left feeling discouraged or ashamed of the behavior.

So for starters...

What is a BFRB?

Body-focused repetitive behaviors (BFRBs) are defined by the TLC Foundation for BFRBs as:

"Any repetitive self-grooming behavior that involves biting, pulling, picking, or scraping one’s own hair, skin, lips, cheeks, or nails that can lead to physical damage to the body and have been met with multiple attempts to stop or decrease the behavior.” (1)

Common BFRBs can include, but aren't limited to:

» Trichotillomania (hair-pulling)

» Excoriation Disorder (skin-picking)

» Lip picking

» Nail biting

» Tongue chewing

BFRBs are not self-harm, as the damage caused by the behavior is not intentional. They are driven by neurobiological factors including dysregulation in brain systems, particularly reward loops (3).

BFRBs fall under the OCD umbrella due to the compulsive nature of the problem behavior (picking, pulling, biting, etc.). However, it's important to note that BFRBs are not the same as OCD, although they often co-occur for a lot of people.

Treatment for BFRBs

Cognitive behavioral therapy (CBT) is the gold-standard approach for treating BFRBs. Underneath that CBT umbrella, we have our two main modalities to specifically treat BFRBs: Habit Reversal Training (HRT) and the Comprehensive Behavioral Model (ComB Model) (2).

HRT was the initial treatment for BFRBs created in the 70s. It was very promising at first, but effectiveness and durability decreased over time. The ComB Model was created in the 90s to provide more individualized care and address areas that were neglected in HRT (2).

The ComB Model is based on the idea that there are five domains that trigger and maintain BFRBs, and the behaviors are usually the result of an unmet need in that area. These domains are known as SCAMP (Sensory, Cognition, Affective, Motoric, Place) (4).

Once we build awareness of what occurs within these SCAMP domains, we are then able to generate interventions to address each trigger and minimize the behavior.

SCAMP Domains (4)

As previously mentioned, in order to provide thorough, effective care, we need a deep dive into all the areas that influence and maintain BFRBs. Here are some questions that are typically asked in therapy to gather information and generate intervention ideas:

Sensory

» Were you feeling a sensation in your fingers or at the site that made you want to pick/pull? Tingling, need to fiddle, itchy, etc.?

» What sensory input influenced the behavior? Did you see a hair out of place, feel a blemish on your cheek, do you like the sound of a hair leaving the follicle, did you notice a different texture, etc.?

Interventions can include finding ways to meet that sensory need without picking or pulling:

» Fidgets, Calm Strips, scalp massager, tinted moisturizer, dimming lights, etc.

Cognitive

» What were you thinking about that made you want to pick or pull? “Just one more time then I’ll stop, I just need to even this out, I already broke my streak,” etc.?

» What are your beliefs about appearance that might influence the behavior? "I should never have a blemish, hair of different textures is gross," etc.?

Interventions include modifying these beliefs and finding ways to respond differently to these thoughts:

» Cognitive restructuring, rebuttals, cognitive defusion, mindfulness, self-compassion, etc.

Affective

» What mood were you in when the picking/pulling occurred? Anxious, frustrated, sad, bored, etc.?

Interventions include finding ways to navigate these feelings in healthier ways, not with picking or pulling:

» Journaling, mindfulness meditation, grounding skills, values-based activities, etc.

Motoric

» Did the picking/pulling happen automatically/out of one’s awareness, was it focused/done intentionally, or both? Started automatic, then became focused?

» What was the position of your body that may have influenced the behavior? Hand propping up your face, etc.?

Interventions include finding ways to build awareness of the automatic behavior and keep your hands busy once awareness occurs:

» Barriers such as bandaids, tape on fingertips, hats, hair masks/oils, gloves, Vaseline, etc.

Place

» Where were you when you were pulling/picking? Driving, at work, in bed, in front of the mirror, watching TV, on your phone, etc.?

Interventions include making these environments less pick/pull friendly, and keeping interventions within arm’s reach:

» Getting rid of implements such as tweezers, keeping fidgets in the car, keeping lights low in the bathroom, etc.

As you can probably tell, fidgets aren't going to be the answer for every single domain (or person), and that's the beauty of the ComB Model: interventions are created to meet each person's individual needs and preferences. Comprehensive care is necessary in order to see genuine results and progress.

Resources

You can learn more about BFRBs and their treatment, as well as search for specialized clinicians, at:

The TLC Foundation for Body-Focused Repetitive Behaviors (TLC)

https://www.bfrb.org/

International OCD Foundation (IOCDF)

https://iocdf.org/

Anxiety & Depression Association of America (ADAA)

https://adaa.org/

BFRB Changemakers

https://bfrbchangemakers.org/

Picking Me Foundation

https://pickingme.org/