Prevalence and Influencing Factors of Body-focused Repetitive Behaviors in Turkish Medical Students

Year 2024, Volume: 34 Issue: 5, 681 - 689, 30.10.2024

Şükrü Alperen Korkmaz

https://doi.org/10.54005/geneltip.1505724

Abstract

Background/Aims: Body-focused repetitive behaviors (BFRBs) such as skin-picking, trichotillomania, nail-picking, nail-biting, lip-biting and skin-biting have adverse physical and psychological effects. This study aimed to investigate the prevalence and associated factors of BFRBs in a sample of Turkish medical students.

Methods: An online survey was used to investigate the prevalence of six BFRBs —skin-picking, trichotillomania, nail-biting, nail-picking, lip-biting and skin-biting-- and psychological factors such as anxiety, depression, stress levels, impulsivity and difficulties in emotional regulation (DER) in a sample of 200 medical students. Skin Picking Scale-Revised (SPS-R), Massachusetts General Hospital Hairpulling Scale (MGH-HPS), Depression Anxiety Stress Scales-21 (DASS-21), Barratt Impulsiveness Scale–Short Form and Difficulty in Emotion Regulation Scale—Brief Form and specific questions for four BFRBs (nail-picking, nail-biting, lip biting and skin biting) were administered.

Results: The prevalence of at least one BFRB disorder was 28.0% (n=56). The most common diagnoses were skin-picking (17.0%) and trichotillomania (10.5%), followed by skin-picking (9.0%), lip biting (8.5%), nail-picking (7%) and nail-biting (5.0%). The gender difference was found only in skin-picking disorders (females=22.9%; males=8.5%). Students with BFRB disorder (n=56) were found to have higher levels of anxiety, depression, stress, impulsivity and DER. Students in 2nd, 3rd and 5th grade are more likely to have BFRB disorders than interns. DER was a partial mediating variable between impulsivity and the presence of BFRB disorder.

Conclusions: The findings of the study suggest that BFRBs are common among medical students and that these behaviors are associated with psychological factors such as depression, anxiety, stress levels, impulsivity and difficulties in emotion regulation. Screening programs and intervention strategies for BFRBs in medical students should be developed, and it is recommended that psychological factors should be considered in these interventions, emotion regulation and stress management skills should be significantly improved, and comorbid depression and anxiety should be treated.

Keywords

BFRBs, university student, prevalence, co-morbidity, skin picking, trichotillomania, impulsivity

Ethical Statement

The study protocol was approved by the Çanakkale Onsekiz Mart University Faculty of Medicine NonInterventional Clinical Research Ethics Committee (protocol number: 24/03-14, 08.05.2024).

Supporting Institution

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Project Number

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References

• Sampaio DG, Grant JE. Body-focused repetitive behaviors and the dermatology patient. Clin Dermatol. 2018; 36(6): 723–727.
• What is a BFRB? [Internet]. The TLC Foundation for Body-Focused Repetitive Behaviors. Available from: https://www.bfrb.org/your-journey/what-is-a-bfrb
• Flessner CA, Woods DW. Phenomenological Characteristics, Social Problems, and the Economic Impact Associated With Chronic Skin Picking. Behav Modif 2006; 30(6): 944–963.
• Odlaug BL, Grant JE. Trichotillomania and Pathologic Skin Picking: Clinical Comparison with an Examination of Comorbidity. Annals of Clinical Psychiatry 2008; 20(2): 57–63.
• Odlaug BL, Grant, JE. Clinical characteristics and medical treatment of pathologic skin picking. Curr Psychiatry Rep 2010; 12(4): 306-310. Grant JE, Potenza MN. Pathological grooming behaviors: Phenomenology and assessment in obsessive-compulsive spectrum disorders. J Psychosom Res 2006; 60(3): 337-344.
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 5th edition. American Psychiatric Association; 2013.
• Penzel F. The hair-pulling problem: A complete guide to trichotillomania. Oxford University Press; 2003.
• Snorrason I, Keuthen NJ, Lee HJ, Beard C, Björgvinsson T. Skin Picking Scale-Revised: Diagnostic accuracy and optimal cut-off scores in university and psychiatric settings. J Obsessive Compuls Relat Disord 2022; 34: 100743.
• Snorrason I, Ólafsson RP, Flessner CA, Keuthen NJ, Franklin ME, Woods DW. The Skin Picking Scale-Revised: Factor structure and psychometric properties. J Obsessive Compuls Relat Disord. 2012; 1(2): 133–137.
• Keuthen NJ, O’Sullivan RL, Ricciardi JN, Shera D, Savage CR, Borgmann AS, et al. The Massachusetts General Hospital (MGH) Hairpulling Scale: 1. Development and Factor Analyses. Psychother Psychosom 1995; 64(3–4): 141–145.
• Aydın EP, Kenar JG, Altunay İK, Deniz F, Özer ÖA, Karamustafalıoğlu, K. O. Massachusetts General Hospital hairpulling scale: validity and reliability study of the Turkish Form. Turk Psikiyatri Derg 2023; 34(1): 2.
• Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy 1995; 33(3): 335–343.
• Sarçam H. The Psychometric Properties of Turkish Version of Depression Anxiety Stress Scale-21 (DASS-21) in Community and Clinical Samples. J Cogn Behav Psychother Res 2018; 7(1): 19-30.
• Spinella M. Normative Data and a Short Form of the Barratt Impulsiveness Scale. International Journal of Neuroscience 2007;117(3):359–368.
• Tamam L, Gulec H, Karatas G. Short form of Barratt impulsiveness scale (BIS-11-SF) Turkish adaptation study. Noro Psikiyatr Ars 2013; 50(2): 130-135.
• Meule A, Michalek S, Friederich HC, Brockmeyer T. Confirmatory factor analysis of the Barratt Impulsiveness Scale–short form (BIS–15) in patients with mental disorders. Psychiatry Res. 2020; 284: 112665.
• Bjureberg J, Ljótsson B, Tull MT, Hedman E, Sahlin H, Lundh LG, et al. Development and Validation of a Brief Version of the Difficulties in Emotion Regulation Scale: The DERS-16. J Psychopathol Behav Assess 2016; 38(2): 284–296.
• Yiğit İ, Guzey Yiğit M. Psychometric Properties of Turkish Version of Difficulties in Emotion Regulation Scale-Brief Form (DERS-16). Current Psychology. 2019; 38(6): 1503–1511.
• Duke DC, Bodzin DK, Tavares P, Geffken GR, Storch EA. The phenomenology of hairpulling in a community sample. J Anxiety Disord 2009; 23(8): 1118–1125.
• Keuthen NJ, Koran LM, Aboujaoude E, Large MD, Serpe RT. The prevalence of pathologic skin picking in US adults. Compr Psychiatry 2010; 51(2): 183–186.
• Houghton DC, Alexander JR, Bauer CC, Woods DW. Body-focused repetitive behaviors: More prevalent than once thought? Psychiatry Res 2018; 270: 389–393.
• Solley K, Turner C. Prevalence and correlates of clinically significant body-focused repetitive behaviors in a non-clinical sample. Compr Psychiatry 2018; 86: 9–18.
• Grant JE, Dougherty DD, Chamberlain SR. Prevalence, gender correlates, and co-morbidity of trichotillomania. Psychiatry Res 2020; 288: 112948.
• Thomson HA, Farhat LC, Olfson E, Levine JLS, Bloch MH. Prevalence and gender distribution of trichotillomania: A systematic review and meta-analysis. J Psychiatr Res 2022; 153: 73–81.
• Siddiqui EU, Naeem SS, Naqvi H, Ahmed B. Prevalence of body-focused repetitive behaviors in three large medical colleges of karachi: a cross-sectional study. BMC Res Notes. 2012; 5(1): 614.
• Grzesiak M, Reich A, Szepietowski J, Hadryś T, Pacan P. Trichotillomania Among Young Adults: Prevalence and Comorbidity. Acta Dermato Venereologica 2017; 97(4): 509–512.
• Mikhael E, Mekhael M, Rached G, Richa S. The prevalence of screened trichotillomania in medical students of Saint-Joseph University. Encephale 2022; 48(1): 31–37.
• Alonazi SD, AlHnake AW, Alahmari FS, Abahussain E, Alkahtani AH, Alharbi KA, et al. Prevalence and Factors Influencing Trichotillomania Among Healthcare Workers and Students in Saudi Arabia: A Cross-Sectional Analytical Study. Cureus 2023; 15(12): e51128.
• Bohne A, Wilhelm S, Keuthen NJ, Baer L, Jenike MA. Skin picking in German students. Prevalence, phenomenology, and associated characteristics. Behav Modif 2002; 26(3): 320–339.
• Calikusu C, Kucukgoncu S, Tecer Ö, Bestepe E. Skin Picking in Turkish Students. Behav Modif 2012; 36(1): 49–66.
• Odlaug BL, Lust K, Schreiber LRN, Christenson G, Derbyshire K, Grant JE. Skin picking disorder in university students: health correlates and gender differences. Gen Hosp Psychiatry 2013; 35(2): 168–73.
• Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med 2006; 81(4): 354–73.
• Chew-Graham CA, Rogers A, Yassin N. “I wouldn’t want it on my CV or their records”: medical students’ experiences of help-seeking for mental health problems. Med Educ 2003; 37(10): 873–80.
• Henning K, Ey S, Shaw D. Perfectionism, the imposter phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students. Med Educ 1998; 32(5): 456–64.
• Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0: improving student wellness through curricular changes. Acad Med 2014; 89(4): 573–577.
• Murphy YE, Flessner CA. An investigation of impulsivity in young adults exhibiting body-focused repetitive behaviors. J Obsessive Compuls Relat Disord 2017; 12: 34–40.
• Wang W. Reasons for the Emergence of Body-Focus Repetitive Behaviors in Students and the Impact of Body-Focus Repetitive Behaviors on Students. Advances in Social Science, Education and Humanities Research 2022; 664: 2353-2357.
• Grant JE, Redden SA, Leppink EW, Chamberlain SR. Trichotillomania and co-occurring anxiety. Compr Psychiatry 2017; 72: 1–5.
• Grant JE, Redden SA, Medeiros GC, Odlaug BL, Curley EE, Tavares H, et al. Trichotillomania and its clinical relationship to depression and anxiety. Int J Psychiatry Clin Pract 2017; 21(4): 302–306.
• Le JT, Li XR, Huang CC, Dong X, Agrawal H. The correlation between perceived stress and skin-picking in medical students. J Psychosom Res 2024; 179: 111651.
• Moritz S, Scheunemann J, Jelinek L, Penney D, Schmotz S, Hoyer L, et al. Prevalence of body-focused repetitive behaviors in a diverse population sample – rates across age, gender, race and education. Psychol Med 2024; 54(8): 1552–1558.
• Houghton DC, Maas J, Twohig MP, Saunders SM, Compton SN, Neal-Barnett AM, et al. Comorbidity and quality of life in adults with hair pulling disorder. Psychiatry Res 2016; 239: 12–19.
• Alexander JR, Houghton DC, Bauer CC, Lench HC, Woods DW. Emotion regulation deficits in persons with body-focused repetitive behavior disorders. J Affect Disord 2018; 227: 463–470.
• Hamed SA, Abdellah MM. The relationship between valproate induced tremors and circulating neurotransmitters: a preliminary study. International Journal of Neuroscience 2017; 127(3): 236–242.
• Roberts S, O’Connor K, Bélanger C. Emotion regulation and other psychological models for body-focused repetitive behaviors. Clin Psychol Rev 2013; 33(6): 745–762.
• Hayes SL, Storch EA, Berlanga L. Skin picking behaviors: An examination of the prevalence and severity in a community sample. J Anxiety Disord 2009; 23(3): 314–319.
• Römer M. Body-Focused Repetitive Behaviour: The influence of Alexithymia and Impulsivity. Behavioural. Management, & Social Sciences, Bachelor’s [thesis]. Twente: University of Twente; 2019.
• Billieux J, Gay P, Rochat L, Van der Linden M. The role of urgency and its underlying psychological mechanisms in problematic behaviours. Behaviour Research and Therapy. 2010; 48(11): 1085–96.