AssessmentsBody focused repetitive disorders
Body focused repetitive disorders
USMLE® Step 1 style questions USMLE
A 25-year-old woman who is in the surgical ward after an appendectomy is being evaluated for an erythematous excoriation with a serosanguinous crust on her right antecubital fossa where an IV line was placed. The nurse says that the patient has been picking at that area continuously despite being urged to stop. Physical examination shows dozens of hypertrophic, hyperpigmented scars on her chin, cheeks, and forearms. The patient says that she has caused them herself since her teenage years because she has not been able to break the stress habit, even after several infections. Which of the following is the most likely diagnosis?
Body-focused repetitive disorders is an umbrella term in the DSM-5 for disorders where individuals compulsively damage their physical appearance.
These used to be classified as impulse-control disorders, but now belong in the family of obsessive-compulsive disorders.
Obsessive-compulsive disorders are usually defined by psychological obsessions—thoughts, urges, and images that are unwanted, intrusive, and recurrent—as well as behavioral compulsions exhibited physically in response to the obsessions.
For body-focused repetitive disorders, though, the self-damaging behavior isn’t usually related to a conscious psychological obsession, but occurs instead when a person feels stressed, anxious, or even bored.
Once a person starts engaging in the self-damaging behavior, there’s usually a strong urge to keep doing it over and over again.
This can happen in multiple short episodes throughout the day, or during single long sessions that can last for hours at a time.
People with body-focused repetitive disorders aren’t always fully aware of their behavior while engaged in the compulsion, making it difficult to stop.
These behaviors are distinct from intentional behaviors aimed at improving physical appearance, like plucking one’s eyebrows.
Body-focused repetitive disorders don’t include compulsions resulting from other mental disorders, like picking at skin during a tactile hallucination, when someone thinks bugs are crawling under their skin.
They’re unrelated to behaviours made in response to irritating stimuli from other illnesses, like scratching at an itchy scabies rash.
Finally, body-focused repetitive disorders aren’t related to side-effects from medication.
Trichotillomania is one type of body-focused repetitive disorder where people feel an irresistible urge to pull out their hair.
Trich- derives from the Greek word for hair, -tillo is related to the Greek phrase for pull, and mania refers to a frenzy.
Because the hair-pulling sites can vary, trichotillomania isn’t always as visible as you might think.
Having said that, the most common area for hair-pulling is the scalp, especially the hair around the crown of the head, which can result in a very distinctive, circular pattern of hair loss referred to as a “Friar Tuck” appearance, named after the monk in Robin Hood.
People with trichotillomania generally feel embarrassed by their behavior and often make repeated attempts to hide it or stop altogether.
Sometimes, this hair-pulling is associated with specific, ritualized behaviors, like only pulling out hairs in a specific way, like with tweezers, or with the root still intact.
Regardless of how the hairs are pulled, as the behavior continues, it can lead to permanent damage of the underlying skin and affect future hair growth.