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. Copyright:

INTRODUCTION

Body-focused repetitive behaviors (BFRBs) refer to a group of problematic, destructive, and nonfunctional behaviors directed toward one's body.[1] These mainly include skin picking, hair pulling (trichotillomania), nail biting, and lip chewing; other BFRBs such as hair manipulation, nail biting, chewing gums, lips, and cheek are classified under the residual category of other BFRBs. BFRBs function as coping mechanisms during stress.[1] These difficult to suppress behaviors result in physical and psychological difficulties.[123] BFRBs become problematic when there is associated distress and impairment in day-to-day functioning. There is difficulty in resisting these behaviors and, on performing, results in relief. BFRBs persist for they ensure transient pleasant state, and they are negatively reinforced.[134] The typical onset and severity peaks during childhood and adolescence; it affects females more than males.[145] Hair pulling and skin picking are most prevalent of these conditions.[15]

Current conceptualization places BFRBs among obsessive–compulsive and related disorders (OCRDs) for their repetitiveness and other qualities of obsession-compulsion.[14] However, the use of BFRBs as a means to alleviate or relieve stress-related negative emotional states suggests an association with state and trait anxiety too.[146] BFRBs are a bit distinct from typical OCRDs, in that a cognitive phenomenon rarely precedes them, but instead may be preceded by sensory experiences.[47] However, their inclusion in the OCRD group suggests some evidence of their relatedness to obsessive–compulsive disorder (OCD) in terms of phenomenology, familial aggregation, and neurobiological mechanisms. BFRBs are related to OCD and adulthood excoriation disorder. The prevalence of OCD, obsessive–compulsive symptoms, depression, and anxiety disorders is reportedly high in individuals with BFRBs.[478]

A life event is a significant occurrence involving relatively abrupt change that may produce severe and long-lasting effects. Life event-related stresses may result in both physical and mental health problems. Researchers have found a significant excess of undesirable life events before the onset of anxiety spectrum disorders, including OCD.[910] Newer evidence suggests a link between anxiogenic parenting practices and the occurrence of BFRBs in the pediatric population.[11] When we think of insecurities in any form in the family environment leading to anxiogenic practices, adverse life events are not that far. This relationship needs further exploration.

There is evidence for BFRBs lying on a spectrum of self-harm.[12] BFRBs have also been referred to as nonsuicidal self-injury (NSSI), where moderate-to-severe NSSIs include cutting, burning, scraping-erasing skin, self-tattooing, and minor NSSI mostly include behaviors labeled under BFRBs. Some recent studies have reported an association between anxiety, life events, and NSSIs.[1314]

BFRBs, state-trait anxiety, and significant life events could be related, and studying their relationship with each other will help in understanding BFRBs, their progression, and their impact on associated mental morbidity. There is a dearth of research on BFRBs in the Indian subcontinent; in India, barring few anecdotal case reports, no research has been published as per our knowledge. The present study aimed at filling this research gap by evaluating the presence of BFRBs in school-going children and adolescents and assessing its relationship with state-trait anxiety and life events.

MATERIALS AND METHODS

The study was conducted in a public school in Ranchi, Jharkhand. Out of 978 students from standard 5th to 10th, 109 students and their guardians consented for the study. Responses on the Modified Habit Questionnaire (MHQ)[15] were collected for these students, of which 33 reported positive for BFRBs. MHQ[15] is a self-reported set of twenty questions, which includes four sections each dedicated to hair pulling, nail biting, mouth chewing, and skin picking. Each section has five subquestions related to the presence or absence of a particular BFRB, frequency, duration, extent of problem, and attempts made to reduce or stop the behavior. After rating these 33 students on General Health Questionnaire-12[16](GHQ-12), 12 students scoring more than a cutoff score of 4 were excluded. GHQ-12[16] was applied to rule out the clinical population from the study. The remaining 21 students became the study group, and the same number of age and educationally matched students with a GHQ-12[16] score <4 was taken as a control group from BFRB-negative students. Students of both the groups were assessed on the State-Trait Anxiety Inventory for Children[17](STAIC) and Life Event Scale for Indian Children[18](LESIC). STAIC[17] is a tool to assess anxiety in children between 6 and 14 years. It has self-reported scales for state anxiety and trait anxiety having twenty questions each rated as 1, 2, or 3 as per the severity. LESIC[18] is a tool to measure life event-related stress in Indian children. It is a set of fifty questions designed to assess the effect of positive and negative life events. The institutional ethics committee approved this study.

The results obtained were analyzed using the Statistical Package for the Social Sciences version 25.0 (SPSS-25.0) for Windows®, with an independent t-test for parametric measures and Chi-square test for nonparametric measures. Correlation analysis was conducted to understand the relationship between BFRBs, state-trait anxiety, and life events.

RESULTS

The average age of the study group and the control group was comparable at 12.8 ± 1.20 (mean ± standard deviation) and 12.4 ± 1.167 years, respectively. Out of 21 students identified to have BFRBs, 19% of the students had hair pulling, 52% had nail biting, 81% had mouth chewing, and 9% had skin picking. Thus, most of the students reported > one BFRB. Further, interference of day-to-day activity and associated distress was reported by the students affected. Table 1 shows that the study group scored significantly higher on STAIC state score (P = 0.004), trait score (P = 0.014), and total score (P = 0.020) than controls.

Table 1

Comparison of State-Trait Anxiety Inventory for Children scores between children and adolescents with and without body-focused repetitive behaviors (n=42)

Variables	Mean±SD		t (df=40)	P
	Cases (n=21)	Controls (n=21)
STAIC state score	32.19±5.759	26.67±5.782	3.102	0.004**
STAIC trait score	35.48±9.136	28.62±8.034	2.583	0.014*
STAIC total score	66.05±15.522	55.10±13.722	2.423	0.020*

*Significance at P<0.05 (two-tailed); **Significance at P<0.01 (two-tailed). STAIC – State-Trait Anxiety Inventory for Children; SD – Standard deviation

On comparing life events, five life events stood out [Table 2], out of 50 from LESIC.[17] Among these life events, change in parent's financial status was found to be positively correlated with three BFRBs – hair pulling (P = 0.001), nail biting (P = 0.031), and skin picking (P = 0.036). We also found that the study group scored significantly higher on life event severity score (P = 0.01) and life event stress score (P = 0.01).

Table 2

Comparison of a set of life events (L) between school-going children and adolescents with body-focused repetitive behaviors and without body-focused repetitive behaviors (n=42)

Life events	Cases (n=21), n (%)	Controls (n=21), n (%)	χ2 (df=1)	P
L2 (beginning another school year)	8 (23.8)	1 (2.8)	6.929	0.020*
L6 (change in parent’s financial status)	7 (16.7)	1 (2.4)	5.559	0.045*
L8 (acquisition of TV by family/going for a picnic or excursion)	10 (23.8)	2 (4.8)	7.467	0.015*
L11 (not being sent to school against child’s wish)	5 (11.8)	0 (0)	5.676	0.048*
L25 (birth of a brother or sister)	8 (19.0)	1 (2.4)	6.929	0.020*

*Significance at P<0.05 (two-tailed)

DISCUSSION

In our study, 16 out of 21 students (76.2%) with BFRBs were female. This finding is consistent with previous studies.[125] The percentage of individuals affected with BFRBs varies across studies owing to different criteria used to assess BFRBs. Two times a week[2] criteria reported 63.6% nail biting, and five times a day[5] criteria (used by us) showed a lesser presence at 52.4%.[15] Moreover, our study is on the child population, which makes the comparison even more difficult.[1]

We found the study group scoring significantly higher on STAIC (trait, state, and total) than controls [Table 1]. There is evidence for failure in regulation of unpleasant emotions – anxiety, boredom, tension, frustration in the causation of BFRBs.[6] Similarly, failure or deficits in managing these unpleasant emotions is linked to state anxiety (anxiety disorders) and trait anxiety.[3] Hence, poor management of unpleasant emotions can lead to both BFRBs and state-trait anxiety, while an affected individual tries to modulate associated negative affect.[136] Hence, it seems that our study group has significantly higher levels of anxiety, and BFRBs help deal-related negative affect.

The literature stresses the role of life events in anxiety disorders and OCRDs, reporting excess of undesirable life events before the onset of the illness.[910] A higher score on life event severity and life event stress in the study group is a significant finding of our study. Adverse life events triggering OCRD in the form of BFRBs seem to be the presentation in our study group. Furthermore, recent studies conducted on children[13] and adolescents[14] reported an association between stressful life events, anxiety, and NSSIs (including BFRBs). BFRBs are also on a spectrum of self-harm behavior.[12] Taking these findings into perspective, the presence of adverse life events precipitating anxiety followed by repetitive behaviors – BFRBs – seems to be the presentation in the population we studied.

Our study identified five life events that were perceived as more adverse than other life events by the children with BFRBs [Table 2]. One recent study conducted on children[13] in China using a 27-item scale to assess life events found an association of both minor NSSIs (BFRBs) and moderate-severe NSSIs with the following adverse life events – (1) interpersonal problems and (2) adaptation to loss and health. The adverse life events we found BFRBs associated with also deal with similar life circumstances. We also found a positive correlation between one of the life events – change in parent's financial status – and hair pulling, nail biting, and skin picking. There is a complex relationship between loss, health, financial status, and interpersonal problems, affecting one another. There is also growing evidence citing anxiogenic parenting practices (overinvolvement, conflict, accommodation, etc.) in the causation of BFRBs.[11] Adverse life events evoke anxiogenic behavior in the families that may contribute to the occurrence of BFRBs in children.

Bias with a self-report questionnaire (MHQ[15]) cannot be ruled out in our study. One could argue that the use of GHQ could have contributed to reduction in the additional 12 subjects of whom life events and anxiety could be assessed. However, we intended to assess BFRBs only in the nonclinical population. As a result, none of the students having BFRBs were ever diagnosed with OCD, Tourette's syndrome, autism, Asperger's syndrome, or a developmental disability, as reported by the guardians. To the authors' knowledge, no studies have been carried out in the Indian population, so studies involving a larger population of school-going children are required to substantiate the findings of our research.

In summary, we think that BFRBs in children are multifactorial. State-trait anxiety and adverse life events have a significant association with BFRBs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.