New research released this month about the prevalence of body-focused repetitive behaviors (BFRBs) suggests that these disorders are more common than previous research stated.
Prevalence? What’s prevalence?
Prevalence is a term used in epidemiology to describe a proportion of a population that has a condition. Mostly, it refers to the commonality of something. The numbers usually represent a fraction of a percentage of cases per 100,000 people but are specific to a given period.
While prevalence often suggests that the percentage provided is a real number, it is based on a sample population. Sample populations are smaller versions of the entire population which mean that even if there is the prevalence of 10% indicated for a condition, it does not mean that 10% of people have it. Instead, it means 10% of a sample population has it which implies that percentage reflects the general population.
In college research classes, professors caution students about social science statistics and teach them to critically evaluate the information presented before applying that research. Here’s why. Remember that prevalence is a number that refers to how common a condition is within a sample at a given point in time. The DSM-5, for example, states “In the general population, the lifetime prevalence for excoriation disorder in adults is 1.4% or somewhat higher” (p. 255). First, the DSM-5 was published in 2013 which means the research used to provide these statistics was conducted before that. Therefore, this data is over five years old, and a lot can change in five years. Second, it states “general population” so does that mean researchers surveyed the entire population to determine those numbers? No, they did not. It is more likely that clinical samples were used to create them since most of the research done to create diagnostic criteria uses research work teams. Clinical samples are groups of people who seek treatment. Therefore, if people do not seek treatment, they are not included in the clinical sample.
New research indicates that more people experience BFRB’s than the old research indicates. This study invited undergraduate students at a large university to fill out an electronic survey about BRFB’s. Over 4,400 people filled out the survey. Keep in mind that is a lot of people, but it is still limited to a sample within an age group consistent with undergraduate attendance at a university. The interesting thing is that 12.27% of the respondents met criteria for a BFRB that would meet diagnostic criteria for a disorder, and 22.19% of them said they engaged in BFRBs, but the level was considered “subclinical” meaning the behaviors were problematic, caused distress, and resulted in physical damage but did not meet the diagnostic criteria of functional impairment.
Narrowing the focus to people with skin picking behaviors, the new data reported 5.7% of respondents met criteria for excoriation disorder and another 23.9% engaged in skin picking behaviors at the subclinical level. Compare these numbers to the 2013 version in the DSM-5 which stated 1.4% of the general population met criteria for skin picking disorder. Previous research from 2000 indicated that compulsive skin picking affects 3.8% of college students.
People who struggle with BFRBs also experience a great deal of shame and embarrassment as well which means some many people never seek treatment or tell anyone about it. This study is important because, with the anonymity of an electronic survey, a more accurate picture develops of how many people are affected by these disorders. Perhaps they are not as rare as once thought.
The researchers also suggested that while the prevalence of BFRBs meeting diagnostic criteria is still relatively low, there is a significant percentage of the participants who sub-clinically struggle with BFRBs. Just because there is not “functional impairment” does not mean a person is negatively affected by the behaviors as indicated by the levels of distress reported which begs the question about assessment and treatment for those people with BFRBs of decreased severity.
First, and probably the most important, is that people with compulsive skin picking are not alone as they think they are. Perhaps knowing that other people deal with it too will help eliminate the shame and stigma that accompanies the disorder. By reducing shame and stigma, more people will feel comfortable talking about it and asking for help.
Second, clinicians base diagnostic assessments on what a client reports as the problem as well as what the most common disorders are within a certain spectrum of symptoms. For example, as a therapist, if someone came in complaining of depression, the next question is to ask about anxiety because depression and anxiety often occur together. If someone reports having depression and anxiety, the next question might be whether the person has a history of trauma because research suggests trauma is one of the main causes for depression and anxiety, so if there is trauma, it may actually be PTSD. A clinician will go through a diagnostic interview in that manner, trying to hone in on a diagnosis which will drive the treatment plan.
With this new research about BFRBs, clinicians have a responsibility to include questions about them during intake assessments because there are likely people who experience BFRBs but are too afraid to say anything. If a clinician knows they are more common than originally thought, they are more likely to ask about it. Additionally, this research has implications for future research on the factors that influence BFRBs and whether they are part of normal behavior patterns that sometimes become maladaptive or develop into compulsions.
Many sources that describe compulsive skin picking share the rarity of the disorder. I’ve written about the low prevalence rates myself. However, new research indicates disparities in prevalence rates meaning it may be more common than we thought. That means people with compulsive skin picking are not as rare or alone as they thought, which will hopefully reduce the shame and stigma attached to the disorder. Lastly, it encourages clinicians to ask about them within the context of assessment as usual thereby inviting people to talk about BFRBs and get the help they need even if they do not meet diagnostic criteria.
Houghton, D.C., Alexander, J.R., Bauer, C. C., & Woods, D. W. (2018). Body-focused repetitive behaviors: More prevalent than once thought? Psychiatry Research, 270, 389-393. https://doi.org/10.1016/j.psychres.2018.10.002