Coronavirus & BFRBs: The Additional Challenges of Staying Healthy Erin Follow Mar 6 · 6 min read

I have diagnosed trichotillomania (trich) and undiagnosed dermatillomania (derm). I pulled my first few eyelashes around the age of 5. For a long time, the behavior went away. I didn’t understand it at that age anyway. When I was 13, it briefly resurfaced and led to a few gaps in my eyelashes but nothing too noticeable. Again, it went away for a few years. Then, when I was 17, I pulled them all out in one awful day. It’s been almost 8 years now, and I’ve essentially been eyelash-less for that entire period. Unfortunately, though I continue to try new and old methods of recovery, there doesn’t appear to be a end in sight in the near future and (especially not while I’m getting my PhD — way too much stress) and this will likely be something I continue to struggle with.

I know this is an incredibly familiar story for those in the BFRB (body-focused repetitive behavior) world, and there are lots of other personal stories you can read to try and understand these emotional, challenging, and often shameful (as in, we feel immense amounts of shame for the behavior, our appearances, and not being able to stop) disorders. So, I don’t want to spend much time focusing on my personal story. What I do want to draw attention to, however, is the paucity of discussion (and research) on the associated health risks of BFRBs, particularly infection; even more particularly, COVID-19, aka, coronavirus.

We know COVID-19 is still spreading, and will likely to continue to spread. We also know that both viral and bacterial infections can be transmitted through bodily fluids such as nasal and saliva droplets, as well as tiny molecules secreted from our eyes. These droplets spread through the air and land on any and everything, from doorknobs to shopping carts. We then touch these common items, and proceed to transfer them to our nose, mouth, and, yes, even our eyes. This happens to every single person on the planet and is not unique to those with BFRBs. So, why are BFRBs relevant when discussing the spread of infections?

Trichotillomania affects about 1–2% of the US population. Although many individuals with trich pull hair from the scalp, an estimated 73% pull from their eyelashes and 72% pull from their eyebrows. Not only does this result in shame and embarrassment related to appearance, it also puts us at an increased risk for a number of eye issues. Between trich and wearing contact lenses, I still wonder how in the world I’ve never gotten an eye infection (knock on wood). But I do have blepharitis, or inflammation of the eyelids, as a result of the oil in my eyelids not having anywhere to go (it’s usually dispersed along the eyelashes and lubricates the eyeball). I’m immensely grateful for the optometrist I saw last year that actually took the time to acknowledge my trich and help me find ways of dealing with my dry eyes. I could get on a soapbox about how little attention eye professionals seem to pay to trich or really flat out ignore it, but I’ll save that for another day.

Anyway, dermatillomania, or compulsive skin-picking, is another area of concern. Beyond clinical skin-picking, an estimated 63% of individuals engage in some form of skin picking (Lang et al., 2016). An estimated 1.4% of the population in the US are affected by dermatillomania. One source reports that around 32% of people with derm pick at skin on the face. For me, I find myself constantly picking at my lips. Unlike my trich, this has never waxed and waned — I’ve done this for as long as I can remember and I’m sure it has resulted in some of the common colds I’ve had over the years.

In both scientific literature and regular internet articles, there is little information on how often BFRBs result in infection or other illnesses. I attribute this more to the overwhelming lack of research on BFRBs rather than the idea that they are not related. Of course, COVID-19 is brand new and there certainly would not be any information on how it affects people with BFRBs. Beyond this current pandemic, though, I have wondered so often how the behaviors associated with trich and derm are related to our immune system and risk of illness.

Most of the advice I have seen about preventing contraction of the virus has been twofold:

“WASH YOUR HANDS!” Okay, easy enough. “Keep your hands away from your nose, mouth, and eyes.” Yikes…

While I’ve been going through hand sanitizer like nobody’s business and actually washing my hands for a whole 20 secs (I sense your judgment, but I also know 95% of y’all don’t usually do this either!), I quite literally cannot keep my hands away from my face. As much as I try to be consistent with hand sanitizing and washing, I know there are plenty of occasions when I forget. It’s also just simply not possible to do 24/7. Combine that with the fact that I work in a shared office in the student health building on a campus of 60,000 students and… my anxiety just thinking about it makes me want to pull!

All jokes aside, this issue really does weigh heavily on my mind, and it’s an issue that not a lot of people I am around can relate to. On campus, we joke about the virus and how we’ve recently changed our behaviors — I joke along of course, but inside I feel dread knowing I’m putting myself at a higher risk of contracting many infections besides COVID-19.

It would be easy to ignore this issue entirely given that BFRB’s are considered a “rare” disorder. And it’s true that only about 2% of people have trich and 5% have derm. But what that actually amounts to is over 6.6 million individuals with trich and over 16.5 million people with derm. Personally, I consider that A LOT of people. It’s something that we (both the scientific community and the general public) should pay attention to. As I mentioned before, the research on BFRBs is so scarce, and there certainly doesn’t appear to be any focused on BFRBs and risk of infection. How do we develop solutions to our questions about safety and health in these disorders without further investigation?

When I started writing this post, I hoped some novel and brilliant ideas of how to stay healthy with BFRBs would come to me. Unfortunately, I got nothin’. As far as treatment for BFRBs, Cognitive Behavioral Therapy (CBT) and habit reversal methods are thought to be somewhat effective, and there’s a tiny bit of support for the over-the-counter supplement N-acetyl cysteine (NAC) and selective serotonin reuptake inhibitors (SSRIs) which are used primarily for treatment of depression, anxiety, and OCD. However, these treatments take an immense amount of time, money, and effort; and in my experience thus far, they don’t work. So, while an argument to this issue could be, “Well, just get your BFRB treated!” that’s not really a quick, affordable, easy, or helpful solution.

For now, all we can do is keep washing and sanitizing our hands, hoping that is enough when our hands inevitably return to our faces. If someone in your life has a BFRB, let them know you see them, you’re there for them, and you’ve thought about how staying healthy may be a source of anxiety for them. Honestly, I’m worried about COVID-19. I also worry about my overall health and especially my eye health. My goal in writing this piece is to start a discussion about the additional health risks of BFRBs, particularly the spread of infection, to encourage new research, and to offer a sense of community to other BFRB-ers who may be worrying about the same things.

And to my fellow mental and public health researchers: let’s do something about this.

Additional References and Informational Sites:

Lang R, Didden R, Machalicek W, Rispoli M, Sigafoos J, Lancioni G, Mulloy A, Regester A, Pierce N, Kang S (2010). “Behavioral treatment of chronic skin-picking in individuals with developmental disabilities: a systematic review”. Research in Developmental Disabilities. 31 (2): 304–15.