Review of Management Considerations for Excoriation Disorder in Older Adults.

Excoriation disorder (ED) is defined as compulsive skin picking that results in skin damage and emotional distress. Optimal management of ED includes individualized treatment plans consisting of psychotherapies, behavioral and pharmacologic interventions. Compared with younger populations, older adults are at increased risk for poor outcomes, such as infection and hospitalization, and require unique management considerations. Risk factors that contribute to disease burden include age-related changes to the skin and underlying medical and psychiatric comorbidities. A literature review was conducted on ED yielding limited evidence exclusive to older adults. The authors suggest a therapeutic approach to ED in older adults based on available evidence and experience from inpatient and outpatient psychiatric settings. Finally, opportunities for future research are highlighted.

Prevalence of body-focused repetitive behaviors in a diverse population sample - rates across age, gender, race and education.

BACKGROUND: Prevalence estimates for body-focused repetitive behaviors (BFRBs) such as trichotillomania differ greatly across studies owing to several confounding factors (e.g. different criteria). For the present study, we recruited a diverse online sample to provide estimates for nine subtypes of BFRBs and body-focused repetitive disorders (BFRDs). METHODS: The final sample comprised 1481 individuals from the general population. Several precautions were taken to recruit a diverse sample and to exclude participants with low reliability. We matched participants on gender, race, education and age range to allow unbiased interpretation. RESULTS: While almost all participants acknowledged at least one BFRB in their lifetime (97.1%), the rate for BFRDs was 24%. Nail biting (11.4%), dermatophagia (8.7%), skin picking (8.2%), and lip-cheek biting (7.9%) were the most frequent BFRDs. Whereas men showed more lifetime BFRBs, the rate of BFRDs was higher in women than in men. Rates of BFRDs were low in older participants, especially after the age of 40. Overall, BFRBs and BFRDs were more prevalent in White than in non-White individuals. Education did not show a strong association with BFRB/BFRDs. DISCUSSION: BFRBs are ubiquitous. More severe forms, BFRDs, manifest in approximately one out of four people. In view of the often-irreversible somatic sequelae (e.g. scars) BFRBs/BFRDs deserve greater diagnostic and therapeutic attention by clinicians working in both psychology/psychiatry and somatic medicine (especially dermatology and dentistry).

Prevalence and predictors of hair pulling disorder and excoriation disorder in Tourette syndrome.

Trichotillomania/hair pulling disorder (HPD) and excoriation/skin picking disorder (SPD) are childhood-onset, body-focused repetitive behaviors that are thought to share genetic susceptibility and underlying pathophysiology with obsessive-compulsive disorder (OCD) and Tourette syndrome (TS). We sought to determine the prevalence of DSM-5 HPD and SPD in TS patients, and to identify clinical factors most associated with their co-morbidity with TS. Participants included 811 TS patients recruited from TS specialty clinics for a multi-center genetic study. Patients were assessed using standardized, validated semi-structured interviews. HPD and SPD diagnoses were determined using a validated self-report questionnaire. HPD/SPD prevalence rates were calculated, and clinical predictors were evaluated using regression modeling. 3.8 and 13.0% of TS patients met DSM-5 criteria for HPD and SPD, respectively. In univariable analyses, female sex, OCD, and both tic and obsessive-compulsive symptom severity were among those associated with HPD and/or SPD. In multivariable analyses, only lifetime worst-ever motor tic severity remained significantly associated with HPD. Female sex, co-occurring OCD, ADHD, and motor tic severity remained independently associated with SPD. This is the first study to examine HPD and SPD prevalence in a TS sample using semi-structured diagnostic instruments. The prevalence of HPD and SPD in TS patients, and their association with increased tic severity and co-occurring OCD, suggests that clinicians should screen children with TS and related disorders for HPD/SPD, particularly in females and in those with co-occurring OCD. This study also helps set a foundation for subsequent research regarding HPD/SPD risk factors, pathophysiology, and treatment models.

Impulsivity in body-focused repetitive behavior disorders: Disparate clinical associations between three distinct measures.

OBJECTIVE: Research on trichotillomania (TTM) and excoriation (skin-picking) disorder (SPD) has suggested that impulsivity may be an important cognitive underpinning of the behavior, but many studies have produced mixed results. This analysis assessed impulsivity in TTM and SPD using three measures: the Barratt Impulsiveness Scale (BIS), the Eysenck Impulsiveness Questionnaire (EIQ), and the Stop-Signal Task (SST). METHODS: Two hundred and eighty three subjects with TTM or SPD completed measurement of impulsivity as a part of participation in several research studies. Subjects scoring one standard deviation above or below measure means were included in the analysis for that scale (SST: N = 45; EIQ: N = 32; BIS: N = 34). High and low impulsive groups were compared within measures on demographic, clinical, and behavioral variables. RESULTS: Results differed by group, with domains of the BIS showing associations with clinical severity, quality of life, and anxiety, and the SST showing several differences, but not clinical severity. The EIQ domains showed no significant differences. No groups differed demographically. CONCLUSIONS: These results suggest that the EIQ, BIS, and SST assess distinct characteristics. Notably, only the attentional domain from the BIS predicted higher severity scores. Future research needs to clarify the ideal utility for these scales as they relate to TTM and SPD. Key points The BIS, EIQ, and SST domains are associated with distinct clinical differences between high and low impulsivity groups. Only the subjects in the high attentional impulsivity domain of the BIS showed significantly elevated symptom severity. The high and low impulsivity groups within the EIQ domains did not show any significant differences. These disparate associations may indicate the need for better subtyping of impulsivity, as different measures of specific domains appear to show associations with distinct features.

Body-Focused Repetitive Behaviors in Patients with FOXP1 Syndrome: An International Cross-Sectional Survey-Based Study.

Introduction: FOXP1 syndrome is a rare neurodevelopmental disorder due to forkhead box protein 1 (FOXP1) gene mutations and is associated with intellectual disability, dysmorphic features, and autism spectrum disorder. We aimed to assess body-focused repetitive behavior (BFRB) prevalence in this patient population using a cross-sectional survey-based study. Methods: A validated survey assessing for BFRBs was administered to parents attending the International FOXP1 Foundation conference on June 21, 2023, and was sent to a FOXP1 syndrome listserv. Results: Excoriation disorder, onychophagia, onychotillomania, and trichotillomania were reported by 58.6%, 38.6%, 29.7%, and 10.0% of subjects, with 63.4%, 59.3%, 54.5%, and 14.3% having moderate to severe disease, respectively. Overall, 28.6%, 30.0%, and 10.0% had one, two, and three BFRBs, respectively. Conclusion: Prevalence of BFRBs is high among FOXP1 syndrome patients surveyed, affecting quality of life for patients and their families and causing significant sequelae.

Is Self-Help Dangerous? Examination of Adverse Effects of a Psychological Internet-Based Self-Help Intervention for Body-Focused Repetitive Behavior (Free From BFRB).

Despite the proven effectiveness of psychotherapy for psychiatric disorders, adverse events or unwanted effects may occur. Unwanted effects, however, are rarely assessed. In self-help interventions, which usually are not supported by a therapist, such effects have received even less attention even though special caution is needed regarding unwanted effects such as those related to misapplication. For the present study, we present the newly developed Positive and Negative Effects of Psychotherapy Scale for Internet-Based Intervention (PANEPS-I) and examine possible unwanted effects of an internet-based self-help intervention in individuals with body-focused repetitive behaviors (BFRBs), aggregating three different techniques: habit reversal training (HRT), decoupling (DC), and decoupling in sensu (DC-is). Some HRT users have expressed concern that the suppression of the problematic behavior could lead to rebound effects, but this has not been examined rigorously. Following baseline assessment, 141 participants with at least one BFRB were randomly assigned to two intervention groups that differed only with respect to the delivery mode (video, manual); the content was the same. After 6 weeks, a post-assessment was conducted. Unwanted effects were assessed using the PANEPS-I. A total of 70% of the participants (both treatment groups combined) reported at least one positive effect of the intervention. Negative effects were reported by 14-92% of participants, depending on the effect. The highest agreement rates were found for "no positive goal orientation" (52.5%), "did not address personal problems" (48.8%), "time/performance pressure" (20.9%), shame (16.3%), and concerns about data privacy (14.3%). Participants in the manual intervention group reported unethical procedures (e.g., data privacy concerns) more often (Cohen's d = .44) than those in the video intervention group. Responders reported more positive effects and nonresponders more malpractice (|d| = .80, .54, respectively). HRT users (self-report) showed no significant differences compared to nonusers regarding negative effects. Stepwise hierarchical regression analyses indicated a dose-response relationship for reported positive effects and malpractice. Side effects may occur in any kind of intervention. Usage of HRT did not lead to more reported negative effects compared to nonusage. To improve the quality and effectiveness and ensure the safety of the user, especially those using digital self-help interventions, it is important to regularly assess unintended effects since there is no supervision of the patient in unguided self-help interventions.

Comparing the 'When' and the 'Where' of Electrocortical Activity in Patients with Tourette Syndrome, Body-Focused Repetitive Behaviors, and Obsessive Compulsive Disorder.

Background/Objectives: Tourette Syndrome (TS), Obsessive Compulsive Disorder (OCD), and Body-Focused Repetitive Behaviors (BFRB) are three disorders that share many similarities in terms of phenomenology, neuroanatomy, and functionality. However, despite the literature pointing toward a plausible spectrum of these disorders, only a few studies have compared them. Studying the neurocognitive processes using Event-Related Potentials (ERPs) offers the advantage of assessing brain activity with excellent temporal resolution. The ERP components can then reflect specific processes known to be potentially affected by these disorders. Our first goal is to characterize 'when' in the processing stream group differences are the most prominent. The second goal is to identify 'where' in the brain the group discrepancies could be. Methods: Participants with TS (n = 24), OCD (n = 18), and BFRB (n = 16) were matched to a control group (n = 59) and were recorded with 58 EEG electrodes during a visual counting oddball task. Three ERP components were extracted (i.e., P200, N200, and P300), and generating sources were modelized with Standardized Low-Resolution Electromagnetic Tomography. Results: We showed no group differences for the P200 and N200 when controlling for anxiety and depressive symptoms, suggesting that the early cognitive processes reflected by these components are relatively intact in these populations. Our results also showed a decrease in the later anterior P300 oddball effect for the TS and OCD groups, whereas an intact oddball effect was observed for the BFRB group. Source localization analyses with sLORETA revealed activations in the lingual and middle occipital gyrus for the OCD group, distinguishing it from the other two clinical groups and the controls. Conclusions: It seems that both TS and OCD groups share deficits in anterior P300 activation but reflect distinct brain-generating source activations.

Habit Reversal Training and Variants of Decoupling for Use in Body-Focused Repetitive Behaviors. A Randomized Controlled Trial.

Background: Behavioral interventions hold promise in improving body-focused repetitive behaviors (BFRBs), such as hair pulling and skin picking. The effect of combining different treatment techniques is currently unknown. Methods: In the framework of a randomized controlled crossover trial, 334 individuals with at least one BFRB were allocated either to a waitlist control or to three experimental conditions (1:1:1:1). Participants in the experimental condition received self-help manuals teaching habit reversal training (HRT), decoupling (DC) and decoupling in sensu (DC-is) during a six-week period. Treatment conditions differed only in the order of manual presentation. We examined whether applying more than one technique would lead either to add-on or interference effects. Results: The three treatment conditions were significantly superior to the waitlist control group in the improvement of BFRBs according to intention-to-treat analyses at a medium effect size (all p ≤ 0.002, d = 0.52 - 0.54). The condition displaying DC first significantly reduced depressive symptoms (p = 0.003, d = 0.47) and improved quality of life (p = 0.011, d = 0.39) compared to the waitlist control. Those using more techniques concurrently showed the strongest decline in BFRB symptoms, even after controlling for days practiced. Participants rated all manuals favorably, with standard DC and HRT yielding greatest acceptability. Discussion: Results tentatively suggest the concurrent application of different behavioral treatments for BFRBs leads to add-on effects. Results were superior when DC was practiced first, with positive effects extending to depressive symptoms and quality of life. Integrating the three techniques into one self-help manual or video along with other treatment procedures (e.g., stimulus control techniques) is recommended.

A Head-to-Head Comparison of Three Self-Help Techniques to Reduce Body-Focused Repetitive Behaviors.

Body-focused repetitive behaviors (BFRBs) include skin picking, trichotillomania, nail biting and cavitadaxia/lip-cheek biting, among other behaviors. For the first time, we compared three different self-help techniques aimed at reducing BFRBs. We explored the acceptance and preliminary efficacy of the approaches and whether the techniques exerted differential effects depending on BFRB-type.A total of 113 participants with at least one BFRB were randomly allocated to either habit reversal training (HRT; active elements: awareness and competing response training), decoupling (DC) or decoupling in sensu (DC-is). Reassessment was conducted 4 weeks later. The Generic Body-Focused Repetitive Behavior Scale (GBS) served as the primary outcome. The completion rate was best for DC-is (68.6%) as compared to HRT (57.1%) and DC (53.5%). A total of 34.8% of completers in the DC group showed an improvement of at least 35% on the GBS compared to 10.0% in the HRT and 23.3% in the DC-is group. In accordance with previous work, moderator analyses showed that improvement under DC is best for non-skin-pickers. A dose-effect relationship emerged, particularly for HRT. Subjective appraisal ratings were more favorable for DC-is and HRT than for DC. With respect to completion rate, subjective appraisal and symptom improvement, DC-is yielded consistently satisfactory results, whereas HRT showed good subjective but rather poor objective improvement. Those who performed DC, especially non-skin-pickers, showed good improvement but overall completion and subjective efficacy were low. Future studies should investigate whether the three techniques exert add-on effects when combined and whether demonstration via new media (e.g., video) will augment comprehensibility and thus efficacy of the techniques.

Associations between disordered eating and body focused repetitive behaviors in college students.

Objective: College students with disordered eating (DE) are at increased risk of body focused repetitive behaviors (BFRBs). Both DE and BFRBs are described as impulsive and compulsive. However, the associations of impulsive DE with impulsive BFRBs and compulsive DE with compulsive BFRBs have not been examined.Methods: 191 college-aged students completed a survey of BFRBs and DE.Results: Participants who reported hair pulling were twice as likely to report clinically significant DE than those who denied hair pulling (p = .022). Participants who endorsed distressing hair pulling (p = .026), skin picking (p = .052), and nail biting (p = .094) were twice as likely to report clinically significant DE than those who were not distressed by these behaviors. Evidence did not support the association of BFRBs and DE along an impulsive/compulsive continuum.Conclusions: Results suggest that BFRBs and DE often co-occur, and the role of impulsivity and compulsivity in these behaviors is complex.

Development of the social concerns in individuals with body-focused repetitive behaviors (SCIB) scale.

Body-focused repetitive behaviors (BFRBs) include such disorders as compulsive hair pulling, skin picking, nail biting, and cheek biting, which can lead to significant psychosocial impairment (American Psychiatric Association, 2013). As such, social concerns (i.e., concerns about how others view their behavior or affected body sites) are common in these individuals, and may significantly associate with BFRB symptomology (Snorrason et al., 2012). Currently, there are no measures to adequately assess social concerns specific to BFRBs. To this end, we developed a new self-report measure called the Social Concerns in Individuals with BFRBs (SCIB) that aimed to assess these concerns using two independent samples of individuals reporting elevated BFRB symptoms. Results showed that the overall level of social concerns reported on the SCIB significantly explained the variance in hair pulling and skin picking symptom severity even after controlling for the influence of other general social concern and emotional distress measures. Exploratory and confirmatory factor analyses provided psychometric evidence for the two-factor structure of the SCIB: (1) Concern about Physical Unattractiveness and (2) Concern about Social Disapproval, which were found to assess distinguishable aspects of BFRB-relevant social concerns. Overall, the findings suggest that the SCIB is a useful measure that can be used to evaluate social concerns in those with BFRB disorders.

"Shame on you": The impact of shame in body-focused repetitive behaviors and binge eating.

Body-focused repetitive behaviors (BFRBs), such as hair-pulling, skin-picking, and nail-biting, have been associated with difficulties in emotion regulation. Studies have suggested that aversive emotions are important triggers for impulsive behaviors such as BFRBs and binge eating. In particular, shame has been hypothesized to be a key emotion before and after these behaviors, but no experimental studies yet have investigated its impact on BFRBs. We aimed to evaluate the role of shame in BFRB and binge eating episodes and the presence of shame following these behaviors. Eighteen women with BFRBs, 18 with binge eating, and 18 community controls participated in the study. Results showed that an experimental shame condition triggered more shame in the binge eating and BFRB groups than in the control group. In addition, the shame induced condition increased the urge to engage in BFRBs, but not in binge eating. Results showed that participants from the BFRB and the binge eating groups reported more shame after engaging in their pathological behaviors compared to following the neutral condition. Future studies should replicate these findings with larger samples and different shame-inducing conditions.

Evaluating the role of Approach-Avoidance Training on action-tendencies in individuals with skin-picking disorder: A preliminary randomized experiment.

BACKGROUND AND AIMS: Pathological skin-picking (PSP) or excoriation disorder is a destructive behavior that affects 1-2% of the general population. The purpose of this pilot study was to evaluate the effect of a computerized behavior modification task on action-tendencies (i.e., approach or avoidance) in adults with PSP. We aimed to modify these action-tendencies by having participants with PSP complete the Approach-Avoidance Training (AAT) task, using a joystick to simulate an approach (=pull) or avoidance (=push) response. METHOD: Forty-five participants diagnosed with PSP were randomized to one of three training conditions: (1) Avoidance Training (AvT; n = 15), (2) Approach Training (ApT; n = 15), or (3) Placebo Training (PT; n = 15). We hypothesized that after training, those in the AvT would have the greatest reduction in behavioral approach (i.e., their overall reaction time [RT] to approach pictures of irregular skin stimuli). RESULTS: Results of the pre-training assessment task revealed a positive correlation between behavioral approach to irregular skin stimuli and skin-picking severity as assessed by the Skin Picking Scale-Revised (SPS-R). After training, a lower behavioral approach and urges to pick were found in the AvT and PT groups, while those in the ApT reported higher behavioral approach and urges to pick. At two-week follow-up, no significant changes on the SPS-R were reported between groups. DISCUSSION: Our preliminary data suggest that the AAT is a promising avenue of research to develop as a cognitive intervention to address an excessive behavioral approach tendency that characterizes skin-picking problems.

Body-focused repetitive behaviors in school-going children and adolescents and its relationship with state-trait anxiety and life events.

BACKGROUND: Body-focused repetitive behaviors (BFRBs) are nonfunctional self-injurious behaviors. BFRBs fall under obsessive-compulsive and related disorders (OCRDs) and co-occur with anxiety disorders. AIM: The current study plans to assess the presence of BFRBs in schoolchildren and adolescents and find its relationship with state-trait anxiety and significant life events. MATERIALS AND METHODS: The study identified twenty-one students with BFRBs using the Modified Habit Questionnaire. Along with the 21 matched healthy controls, both the groups were evaluated on the State-Trait Anxiety Inventory for Children (STAIC) and Life Event Scale for Indian Children (LESIC). RESULTS: The study group scored significantly high on STAIC state score (P = 0.004), trait score (P = 0.014), and total score (P = 0.020). On five life events, the study group reported significantly high on stress. CONCLUSION: The study reports the presence of BFRBs in schoolchildren; state-trait anxiety and significant life events have a significant association with BFRBs.

Insights into recurrent body-focused repetitive behaviors: evidenced by New York Times commenters.

In September 2019, the New York Times (NYT) published the article "Fighting the Shame of Skin Picking," which discussed the cosmetic, social and emotional impacts of body-focused repetitive behaviors (BFRBs). BFRBs, including excoriation disorder, trichotillomania, onychotillomania, and onychophagia, are recurring actions that damage one's physical appearance. The aim of this study is to characterize the demographic information provided and themes raised in the 166 comments posted in response to the article. The most commonly reported condition was skin picking (38.2%), followed by trichotillomania and/or trichophagia (30.3%), onychotillomania (24.7%), and onychophagia (23.6%). All conditions had a female predominance. Treatment of body-focused repetitive behaviors was the most common topic of discussion, followed by shame and impact on appearance. Since commenters described significant impairments to quality of life, larger randomized controlled trials on skin picking, trichotillomania, onychophagia, and onychotillomania are necessary to provide evidence-based management to patients.

Visual Triggers of Skin Picking Episodes: An Experimental Study in Self-Reported Skin Picking Disorder and Atopic Dermatitis.

Background: Skin Picking Disorder (SPD) is a new diagnosis with limited information available about triggers of picking episodes. Itch can be induced via audio-visual stimuli and the effect of contagious itch is stronger for those affected by atopic dermatitis. We examined if picking-related visual stimuli can trigger the urge to pick skin in self-reported SPD. We compared itch and the urge to pick in a sample of AD and/or SPD-affected to controls without either. Method: Urge to pick skin and/or scratch when viewing 24 itch-related, picking-related or neutral online pictures was assessed in adult females, who self-report skin-picking (SPD-only, n = 147) and/or atopic dermatitis (AD-only, n = 47; AD+SPD, n = 46) as well as in skin healthy controls (HC, n = 361). Results: All participants reported a stronger urge to pick for picking-related pictures compared to neutral content (F[1, 597] = 533.96, p < .001, ηp2 = .472) and more itch for itch-related pictures compared to neutral stimuli (F[1, 597] = 518.73, p < .001, ηp2 = .465). SPD-all (SPD-only & AD+SPD) reported stronger urges to pick for picking-related vs. other stimuli compared to the AD-only and HC group (p < .001, ηp2 = .047). Likewise, AD-all (AD-only & AD+SPD) reported significantly stronger itching for itch-related vs. other stimuli compared to SPD-only and HC (p = .001, ηp2 = .019). Conclusions: Analog to visual provocation of itch, the urge to pick can be triggered by visual stimuli. Treatments for SPD and AD may profit from addressing visual stimuli.

Sensory symptoms in body-focused repetitive behaviors, restless legs syndrome, and Tourette syndrome: An overlap?

Tourette syndrome (TS) is a neurodevelopmental condition characterized by multiple tics. Sensory symptoms play a key role in the clinical phenomenology and pathophysiology of TS, as most patients report premonitory urges driving tic expression. Interestingly, sensory symptoms have also been reported in other conditions characterized by repeated behaviors. This review explores the nature of sensory symptoms reported by patients with body focused repetitive behaviors (BFRBs, especially trichotillomania and skin picking disorder) and restless legs syndrome (RLS) in comparison to TS. A sense of mounting inner tension and reinforcement mechanisms driven by gratification and relief on expression of the tic or repetitive behavior appear to be implicated across all conditions. Subjective urges can be temporarily suppressed by patients with TS and selected BFRBs, whereas patients with RLS tend to report dysesthesia more frequently than a suppressible urge to move. The observed similarities in the phenomenology of sensory symptoms across these conditions raise the possibility of a comparable underlying pathophysiology. Preliminary findings suggest an overlap of neural pathways encompassing the insula, basal ganglia (putamen), and posterior cingulate cortex.

Body-focused repetitive behaviors: More prevalent than once thought?

Body-focused repetitive behaviors (BFRBs), such as hair pulling, skin picking, and nail biting are common habits, but their pathological manifestations have been considered rare. Growing evidence suggests pathological forms of these behaviors can be conceptualized as a class of related disorders. However, few previous studies have examined the collective prevalence of related pathological BFRBs. The current study examined the self-reported prevalence of current (past month) subclinical and pathological BFRBs in a large (n = 4335) sample of college students. The study also examined the chronicity and impact of these behaviors. Results showed that 59.55% of the sample reported occasionally engaging in subclinical BFRBs, and 12.27% met criteria for a pathological BFRB, suggesting these conditions may be quite common. Of the various BFRB topographies, cheek biting was the most common. Both subclinical and pathological BFRBs tended to be chronic (i.e., occurring for longer than 1 year). Although persons with pathological BFRBs were distressed about their behavior, few experienced functional impairment or sought help for the behavior. Implications of these findings for the conceptualization and treatment of body-focused repetitive behaviors are discussed.

Emotion regulation deficits in persons with body-focused repetitive behavior disorders.

BACKGROUND: Conceptualizations of emotion dysregulation (ED) and body-focused repetitive behavior disorders (BFRBDs) imply that ED may be a central component of BFRBDs as well as a factor that distinguishes BFRBDs from non-impairing, subclinical body-focused repetitive behaviors (BFRBs). The current study empirically tested these observations. METHODS: One hundred thirty-eight undergraduates (of 1900 who completed a screening survey) completed self-report measures assessing four emotion regulation (ER) deficits hypothesized to underlie ED (alexithymia, maladaptive emotional reactivity, experiential avoidance, and response inhibition when distressed); 34 of these participants had BFRBDs, 64 had subclinical BFRBs, and 42 were unaffected by BFRBs. RESULTS: Results indicated that participants with BFRBDs reported higher levels of maladaptive emotional reactivity, experiential avoidance, and response inhibition when distressed than participants with subclinical BFRBs and participants unaffected by BFRBs. These results held even when controlling for comorbidity and total number of reported BFRBs. Participants did not differ on alexithymia. LIMITATIONS: Limitations of the current study include the BFRB groups' different distributions of BFRB types (e.g., hair pulling versus skin picking), the sample's demographic uniformity, and the fact that negative affectivity was not controlled when exploring BFRB group differences on ER deficits. Future research should improve on these limitations. CONCLUSIONS: The current results suggest that ED is a factor that differentiates BFRBDs from subclinical BFRBs. Such results may be useful for generating hypotheses regarding mechanisms responsible for BFRBs' development into BFRBDs. Furthermore, these results may provide insight into factors that explain the efficacy of more contemporary behavioral treatments for BFRBDs.

Chronic Rhinotillexomania Leading to Unilateral External Nare Stenosis.

Compulsive nose picking (rhinotillexomania) is a commonly known condition to general practitioners and pediatricians and is often advised against. This case highlights a 29-year-old individual with a prolonged history of intermittent rhinotillexomania who presented with repetitive viral upper respiratory infections. Physical examinations showed an enlarged nasal turbinate unilaterally with an otherwise normal nasal architecture. Further imaging and investigations showed no abnormalities or evidence of greater pathology. It was hypothesized that the patient's rhinotillexomania induced repetitive inflammation and subsequent hyperplasia of the nasal tissue, narrowing the circumference of an external nare. This case highlights the risks of a common but potentially dangerous habit along with its management.