Body Focused Repetitive Behaviors: Helping Teens and Young Adults Manage Stress and Anxiety

Rachel Strohl, Psy.DPresenter: Rachel Strohl, Psy.D.

View the webinar’s corresponding slide presentation here
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Dr. Strohl discussed ways teens and young adults who have trichotillomania or other related body focused repetitive behaviors (BFRBs) to learn to improve their management of stress and worries. She also spoke about stress management tools, such as relaxation paced breathing, sensory grounding, cognitive therapy, and exposure tasks to decrease symptoms of stress and worry.


  1. NJCTS says:

    In DSM V, OCD has been removed from Anxiety category and placed into it’s own, new category. 1) I have always been taught that Anxiety must exist for OCD to be present? Is this still considered a correct paradigm? 2) can you generally discuss the OCD category change and it’s implications in diagnosis and treatment?

    • Dr.Strohl says:

      Yes, anxiety must exist for OCD to be present. Obsessions are bizarre, intrusive thoughts that cause anxiety and distress, while compulsions are behaviors or mental acts designed to neutralize the anxiety. My understanding with DSM V is that since there are so many OC Spectrum Disorders, they decided to group them together. This should not change the empirically based treatments for OC Spectrum Disorders, such as Trich and Excoriation (skin picking).

  2. NJCTS says:

    I thought DSM IV had Trich as OCD and they finally moved it. You just said the opposite. I am an adult with Trich but I teach middle schoolers so I am watching for multiple reasons.

    • Dr.Strohl says:

      No, actually DSM IV TR put OCD under the Anxiety Disorder category and put Trichotillomania into the Impulse Control Disorders Not Otherwise Specified. Anecdotally, those of us in the field of Trich did not believe this was an appropriate category for the disorder, since it’s more related as an OC Spectrum Disorder.

  3. NJCTS says:

    Are there suggestions to helping ease the stress and anxiety of a student with disabilities into a new school/classroom in the middle of the school year?

    • Dr.Strohl says:

      Absolutely! Make contact with the support personnel in the school, whether the school psychologist or guidance counselor, and they can assist with the transition. Depending if your child has a 504 plan or IEP, there are accommodations that should be put into place in the classroom, lunchroom, with homework, that can assist your child. In general, make sure your child has positive coping skills to manage their own anxiety, such as relaxation breathing, sensory grounding tools, detective thinking skills, and exposure tasks to face the fears one step at a time.

  4. NJCTS says:

    Is trichotillomania an obsessive-compulsive D/O? If not, what is the difference.

    • Dr.Strohl says:

      Trich is not considered an obsessive compulsive disorder. Trich is considered an OC Spectrum Disorder, meaning a “cousin” of OCD. Although the new DSM V categorizes the two disorders under the same category, they should be considered different disorders. For treatment, the OCD treatment of choice is ERP (exposure and response prevention). For trich or BFRBs, the treatment of choice is the behavioral ComB Method (SCAMP)or Fiddling SHEEP (see slides of presenation for more details on treatment).

  5. NJCTS says:

    Please address the link between stress and anxiety and being unable to attend school. what might trigger a student to suddenly become completely immobilized to the point where he has trouble even discussing school.

    • Dr.Strohl says:

      The link between stress and anxiety and school refusal can greatly vary for students. It’s important to have an accurate anxiety diagnosis to understand the associated fear in school and subsequent refusal. For instance, a student with OCD may fear contamination at school. A student with social anxiety may fear negative judgment from peers. A student with trich or BFRBs may avoid school because concern that others will notice his/her bald spots or skin wounds. Once the fear is identified, a plan to reenter school can be put into place with a hierarchical approach (one step at a step, eg. student goes to guidance before class in the morning).

      • Dr.Strohl says:

        For further information on this topic, please access NJ CTS archived webinars on school refusal: Dr. Robert Zambrano, Oct 2013, and Dr. Brian Chu, April 2010.

  6. NJCTS says:

    Please provide some examples of what ERP treatment for OCD looks like.

    • Dr.Strohl says:

      Exposure and response prevention (ERP)is the empirically validated therapy for OCD. The goal is to assist a person with OCD to break the reinforcing loop that his/her anxiety increases with obsessions, and decreases with rituals… leading to short term relief, long term suffering. ERP proposes ST discomfort for LT relief. For instance, people whose obsessions involve fear of harm to their family would (for example)check that the doors to their house are locked over and over. ERP would assist a person not check the locks, or in a gradual manner, check the locks less. The exposure would involve creating scripts that involve because they left the door unlocked, some harm came to their family. The goal is to habituate to the obsessions of harm, not the content (a person will always feel concerned that harm could come to their family, but with ERP, the goal is that they’re now bored of the obsession).

  7. NJCTS says:

    As a parent what how can I best support my teenager with trich/bfrbs?

    • Dr.Strohl says:

      Great question! I would first start by asking your teen. Some teens are looking for a coach… someone to guide them through the strategies to reduce their pulling. They rely on their parents to assist with increased awareness of the pulling behavior. I often instruct parents to never say “stop pulling;” instead, “use your strategies” as a reminder. Some teens are looking for a cheerleader… they want their parents to support them, cheer for them, empathize with them, but they don’t want to be told what to do. And then other teens are looking for complete independence regarding trich and their parents. They want to do the therapy on their own, or they are not motivated to change their pulling behavior at this time.

  8. NJCTS says:

    Expand a little more on what role the educator plays in support a student with bfrbs.

    • Dr.Strohl says:

      Educators play a large role in the identification of the problem. I often tell teachers that it’s not their job to change the BFRBs, but perhaps discuss with the student if it’s a problem for them. The teacher may be the first individual to name the problem for the student, and in turn, talk to the parents about seeking therapeutic help if necessary. The teacher can convey their knowledge that effective therapies exist, and direct them to referral sources, such as the Trichotillomania Learning Center, http://www.trich.org. School psychologists and members of the child study team may play a more involved role in the student’s emotional well being, but again, identification and referral to the expert is key.