Swati Thesis 27.3.18

BODY FOCUSSED REPETITIVE BEHAVIOURS IN SCHOOL GOING
CHILDREN AND ADOLESCENTS AND ITS RELATIONSHIP WITH STATE-

TRAIT ANXIETY AND LIFE EVENTS
By
Dr. Swati Sailly
Under the guidance of

Dr. Sanjay Kumar Munda, D.P.M, M.D.,
Assistant Professor of Psychiatry
And Co-guidance of
Dr. Roshan V. Khanande, M.D.,
Assistant Professor of Psychiatry
CENTRAL INSTITUTE OF PSYCHIATRY

KANKE, RANCHI-834006
DISSERTATION
SUBMITTED TO RANCHI UNIVERSITY
IN PARTIAL FULFILLMENT OF
DIPLOMA IN PSYCHOLOGICAL MEDICINE (DPM)
(Session- 2016-2018)
DECLARATION
I hereby declare that the present study entitled "BODY FOCUSSED REPETITIVE BEHAVIOURS
IN SCHOOL GOING CHILDREN AND ADOLESCENTS AND ITS RELATIONSHIP WITH STATE-TRAIT
ANXIETY AND LIFE EVENTS" has been conducted by me at Central Institute of Psychiatry,
Ranchi, under the guidance and supervision of Dr S.K.Munda, Asst. Professor , Central
Institute Of Psychiatry and co-guidance of Dr. Roshan V. Khanande, Asst. professor of
psychiatry, Central Institute Of Psychiatry, Ranchi.
This dissertation is submitted to Ranchi University in partial fulfillment of the requirements

of Diploma in Psychological Medicine.
I further declare that this is an original study and no part of it has been published or
submitted to any university previously.
(Dr. Swati Sailly)
Ranchi
Dated:
Government of India
CENTRAL INSTITUTE OF PSYCHIATRY

KANKE, RANCHI - 834006, JHARKHAND
CERTIFICATE
This is to certify that Dr. Swati Sailly is a bonafide student of Central Institute of Psychiatry,
Ranchi, pursuing the course of Diploma In Psychological Medicine in Ranchi University for
the academic session 2016-2018. She has carried out this study entitled “BODY FOCUSSED
REPETITIVE BEHAVIOURS IN SCHOOL GOING CHILDREN AND ADOLESCENTS AND ITS
RELATIONSHIP WITH STATE-TRAIT ANXIETY AND LIFE EVENTS” at the institute under my
personal supervision. It has not formed the basis for award of any other degree or diploma
to the candidate. This work is a record of the candidate’s personal efforts. This dissertation
is hereby approved for submission to Ranchi University as partial fulfillment of the
requirements for the Diploma in Psychological Medicine.
(Dr. Roshan V. Khanande) (Dr S.K.Munda)

Asst. Professor of Psychiatry Asst. Professor of Psychiatry
Central Institute of Psychiatry Central Institute of Psychiatry
Ranchi, Jharkhand Ranchi, Jharkhand
Place:
Dated:
ACKNOWLEDGEMENT
I would like to extend my sincere gratitude to my esteemed guide and worthy supervisor Dr
S.K.Munda, Asst. Professor of Psychiatry, Central Institute of Psychiatry, for his logistic and
exemplary guidance in giving this study its present form. He inspired me and allowed me to
carry out this work in this institution.
I also express my gratitude to Dr. Roshan V. Khanande, M.D., Asst. Professor Psychiatry,
Central Institute of Psychiatry, who guided and encouraged me through all the steps of my
work on this topic. His valuable time, suggestions and the support at every step helped me
to make this work possible.
I would like to dedicate this research to my father Dr. Mithilesh Prasad who is my inspiration
and reason for everything I am, my mother Mrs. Renu Prasad and brother Shivanshu
Shubham who have forever made sacrifices for me and whose selfless love and support
lasted with me during this work.
I am overwhelmingly grateful to my friends Dr Abhinav Srivastava and Dr. Anweshan Ghosh .
I would like to express my thanks to my seniors especially Dr Shweta and Dr. Rajiv and my
juniors.
I would also like to express my sincere thanks to Dr. Nirmalya and Mr. Justin for helping me
in my dissertation
I am thankful to school authorities of Cambrian Public School, Kanke Road and all
participants of this study, without whom this study would not have been completed.
(Dr. Swati Sailly)

CONTENTS
INTRODUCTION.................................................................................................. 1
REVIEW OF LITERATURE ..................................................................................... 4
METHODOLOGY ............................................................................................... 23
RESULTS ........................................................................................................... 29
DISCUSSION ..................................................................................................... 39
SUMMARY AND CONCLUSION ......................................................................... 45
LIMITATIONS AND FUTURE DIRECTIONS .......................................................... 47
REFERENCES..................................................................................................... 48
APPENDICES ..................................................................................................... 55
INTRODUCTION
Body-focussed repetitive behaviours (BFRBs) refer to a group of problematic, destructive

and apparently non-functional behaviours directed towards one’s own body (Hensen,
1990).These includes collection of motoric acts like skin picking (dermatillomania), hair
pulling (trichotillomania) and nail biting (onychophagia) and more like lip chewing that are
difficult to suppress and which result in physical and psychological difficulties (Woods et
al,2001). Such behaviours act as a coping mechanism for a person during stressful
conditions. These behaviours for some individuals are simply referred to as nervous habits
(Hansen et al, 1990). However, these nervous habits become problematic when it cause
significant distress and when they interfere with the person’s everyday functioning. When
these BFRBs cross this line, then they are classified as a ‘disorder’ and is presently classified
under obsessive-compulsive and related disorder (OCRD) in the DSM-5 (APA, 2013) and
have been proposed under the same rubric in ICD-11 draft. ICD -10 classifies it as other
specified behavioural and emotional disorders with onset usually occurring in childhood and
adolescence. The typical onset and severity peak for BFRBs appears to be during childhood
and adolescence (Woods & Houghton, 2016).They are among the most poorly understood,
misdiagnosed, and under treated groups of disorders. The key factor underlying BFRBs is
difficulty resisting the urge or impulse to perform a certain behaviour and performing which
causes a degree of relief. The behaviour continues because the BFRB results in a more
pleasant state therefore, it is negatively reinforced. Prevalence estimates indicates that such
behaviours are quite common among students. Nail biting of two times or more per week
was reported among 63.6% students in United States of America (Hansen et al, 1990).
Another study from USA, using the stringent criteria of five times or more per week stated
21.8% students engaged in mouth, lips or cheeks chewing and 10.1% engaged in habitual
nail biting (Woods et al, 1996). In one of the survey in college students found that 13.7% of
the sample endorsed in the study have at least one repetitive behaviour that occurred more
than five times per day for at least 4 weeks and produced some type of psychological or
physical disruption of functioning (Teng et al, 2002). Based on questionnaire screenings, a
BODY FOCUSSED REPETITIVE BEHAVIOURS IN SCHOOL GOING CHILDREN AND ADOLESCENTS AND ITS
RELATIONSHIP WITH STATE-TRAIT ANXIETY AND LIFE EVENTS 1
lifetime repetitive behaviour rate of 3.5% was found in college students of Germany (Bohne
et al, 2002).
Hair pulling and skin picking are most prevalent of these conditions, and the most likely to
be accompanied by the distress and impairment (Keuthen et al, 2010). Other bodily targets
of repetitive behaviour such as hair manipulation, nail biting and chewing gums, lips and
cheek can be classified under the residual category of other BFRBs if they meet other
essential diagnostic requirements .The essential features of trichotillomania and excoriation
disorder are repetitive and persistent pulling of hair or picking of skin resulting in hair loss or
skin lesions, respectively. Severe or clinical Nail Biting involves biting past the nail bed and
cuticles, drawing blood and resulting in chronic scarring, or in red, sore, infected fingers
(Wells et al,1998).
Current conceptualization of BFRBs places them on the obsessive-compulsive spectrum

(APA, 2013); however, use of BFRBs as a means to alleviate or relieve negative emotional
states suggest associations with anxiety are also likely (Woods & Houghton, 2014). Body-
Focused Repetitive Behaviour Disorders are distinct from other OCRD in that they are rarely
preceded by cognitive phenomenon such as intrusive thoughts, obsessions, or
preoccupations, but instead may be preceded by sensory experiences (Grant et al, 2014).
However, their inclusion in the OCRD grouping is based on evidence of their relatedness to
OCD in terms of phenomenology, patterns of familial aggregation, and aetiologic
mechanisms. At the phenomenological level Body-Focused Repetitive Behaviour Disorders
are often accompanied by urges, and once performed relieve anxiety. At the neurobiological
level there is evidence of fronto-striatal circuitry dysfunction as is observed in other OCRD
(Chamberlain et al, 2008). Body-Focused Repetitive Behaviour Disorders frequently co-occur
with OCD (Lochner et al, 2005). Body-focused repetitive behaviours appear to be related to
other clinical symptoms. For example, adulthood excoriation disorder has been associated
with greater impulsiveness and with increased obsessive-compulsive, depressive, and
anxiety symptom severity (Hayes et al, 2009). A high prevalence of comorbid obsessive-
compulsive disorder, depression, and anxiety disorders has also been found in adults with
excoriation disorder (Leibovici et al,2014) and trichotillomania (Gupta et al, 2015) while
pathological nail biting in adults has been related to high levels of anxiety and obsessive-
compulsive symptoms (Gupta et al,2015).
A life event is a significant occurrence involving relatively abrupt change that may produce
serious and long lasting effects (Setterson et al, 1997 ). One of the studies in India by Dhuri
et al, (2014) there is mention about life event related stresses that may result in both
physical and mental health problems. Few studies have investigated the role of such events
in anxiety spectrum disorder specifically in obsessive compulsive disorder (OCD) and some
of these studies have reported a significant excess of undesirable life events prior to the
onset of the illness (Gothelf et al,2004;Khanna et al,1988;kulhara et al,1986). Emotional
stress level is usually manifested as a symptom of anxiety or depression and trait anxiety is a
general tendency to respond fearfully to a variety of aversive stimuli (Spielberger, 1985).
BFRBs are common in the general public and have been studied. As per the current
literature available, there is significant overlap between BFRBs and anxiety. Few studies
mentioned above talk about increased prevalence of BFRBs among patients with Anxiety
disorders. Moreover, significant life events have been studied and found important in
relation to giving rise to stress and underlying distress. Indian studies have also reported
more preceding undesirable life events in patients with Anxiety disorder than in controls
(Khanna et al, 1988). Till date there is limited study of BFRB’s in children and adolescents
population. BFRBs and its relationship with anxiety and stress are well known and if state
trait anxiety that define different aspects of anxiety in a subject and life events that
determines stressfulness could be a reason behind BFRB’s it would be worth studying the
relationship between BFRBs, state-trait anxiety and significant life events. To our best
knowledge no studies have been one in India on relationship between BFRB’s, state trait
anxiety and life events , so present study plans to investigate the same.
REVIEW OF LITERATURE
 BODY FOCUSSED REPETITIVE BEHAVIOURS: AN OVERVIEW

o Prevalence of body focussed repetitive behaviour
o Body Focussed Repetitive Behaviours : Major Types
o Phenomenological similarities and covariation
o Conceptualization and place in current diagnostic system
 VARIOUS MODELS EXPLAINING BFRB’S
o Behavioural and Cognitive-behavioural models-
o Emotion regulation model
o Stimulus action model
o Frustration action model
 BODY-FOCUSSED REPETITIVE BEHAVIOURS AND ITS RELATION TO ANXIETY
o Relationship of Body-Focussed Repetitive Behaviour Disorders to OCD
o Phenomenology and symptomology
o Major types of BFRB’s and its relation to anxiety
 LIFE EVENTS, STRESS AND ANXIETY
o Life events
o State-trait anxiety
BODY FOCUSSED REPETITIVE BEHAVIOURS: AN OVERVIEW
Body-focussed repetitive behaviour (BFRB) is a general term for a group of related disorders
that includes hair pulling, skin picking, and nail biting. These behaviours are not habits or
tics; rather, they are complex disorders that cause people to repeatedly touch their hair and
body in ways that result in physical damage (Woods et al, 2001). These behaviours may be
performed when the individual is stressed or excited, or bored or inactive. Hours may be
spent in these activities, taking individuals away from family or work activities. Depression,
shame, and isolation can also result in these behaviours. This term was first suggested in a
study by (Bohne et al, 2002) to place repetitive behaviours including nail biting, skin picking,
skin biting, skin scratching, and chewing on the mouth or lips, hair pulling causing functional
impairment under one group.
A growing body of research has focused on the assessment and treatment of repetitive
behaviours such as skin picking, scratching, or biting (Woods et al,2001;Wilhelm et al,1999);
nail biting (Adesso et al, 2001 ;Woods et al,1999); and chewing on the inside of the mouth
or lips (Jones et al ,1997). Preliminary research suggests these behaviours are common and
range in severity from relatively infrequent and benign to quite frequent and damaging
(Hansen et al, 1990; Woods & Miltenberger, 1996). To date, research in this area has
identified and treated these behaviours as separate entities. However, there are many
reasons to consider classifying these behaviours under one category. First, all of these
behaviors are directed toward one’s own body and often focus on removing parts of the
body such as the fingernail or skin. Second, although all appear to be relatively common and
usually benign, frequent occurrence can result in a variety of negative physical and social
outcomes (Woods et al, 2001). For instance, nail biting may result in skin infections,
scarring, nail loss, and associated dental problems (Leonard et al, 1991), and skin picking or
scratching may result in infections, sores, tissue damage and permanent scars (Bohne et
al,2002;Keuthen et al, 2000). Also, a number of studies have shown that nail biting and skin
picking can lower people’s self evaluation and cause excessive concern over others’
evaluation of them (Hansen et al, 1990; Joubert, 1993; Wilhelm et al, 1999).
Prevalence of Body Focussed Repetitive Behaviour-
Currently, research on these behaviors has been relatively scarce, even at the level of
obtaining basic prevalence estimates. In one of the few studies to address the issue of
BFRBs Hansen et al, (1990) categorized college students as having a repetitive behavior
(habit) if the student reported engaging in a behavior two or more times per week. Using
this relatively lenient criterion, Hansen et al. found that nail biting occurred in 63.6% of the
sample. A subsequent study by Woods et al, (1996) used more stringent criteria for
identifying repetitive behaviors in college students. Stating that the repetitive behavior had
to occur at least five times per day to be classified as a habit, Woods et al, (1996) found that
21.8% of the sample engaged in habitual chewing on mouth, lips, or cheeks and 10.1%
engaged in habitual nail biting. In the case of BFRBs, another area of functioning that may
be significantly affected involves physical functioning. As discussed earlier, BFRBs may
produce a variety of physical sequelae. Thus, to accurately ascertain the extent to which
BFRBs are an actual diagnosable problem, not only must data be collected on how
frequently these behaviors occur in an individual but also and more importantly the extent
to which these behaviors produce some type of impairment must be considered.
Unfortunately, studies did not incorporate this variable into their operational definitions
when determining the prevalence of BFRBs, (Hansen et al, 1990; Woods et al, 1996).
Keuthen et al, (2000) sampled 105 U.S. college students and found that 3.8% engaged in
skin picking that produced physical injury and significant distress for the individual. Likewise,
Bohne et al, (2002) found that 4.6% of 133 German college students engaged in self-
injurious skin picking, which produced significant distress for the individual. Although these
sample sizes were small, it is clear from the data that at least one type of BFRB (skin picking)
has a relatively high prevalence rate. Unfortunately, little data exist on the prevalence of
other BFRBs that incorporate the key diagnostic feature of social, occupational, or physical
impairment. One more survey of college students by Teng et al, (2002) found that 13.7% of
the sample endorsed in at least one repetitive behavior that occurred more than five times
per day for at least 4 weeks and produced some type of psychological or physical disruption
of functioning
Above mentioned prevalence estimates indicates that such behaviors are quite common
among students. Hair pulling and skin picking are most prevalent of these conditions, and
the most likely to be accompanied by the distress and impairment (Keuthen et al, 2010).
Other bodily targets of repetitive behavior such as hair manipulation, nail biting and
chewing gums, lips and cheek can be classified under the residual category of other BFRBs if
they meet other essential diagnostic requirements. The essential features of
trichotillomania and excoriation disorder are repetitive and persistent pulling of hair or
picking of skin resulting in hair loss or skin lesions, respectively. Severe or clinical Nail Biting
involves biting past the nail bed and cuticles, drawing blood and resulting in chronic scarring
or in red, sore, infected fingers (Wells et al,1998).
Recent study conducted by Siddiqui et al, (2012) the prevalence of BFRBs among medical
students of Karachi was found to be 46 (22%). For those positive for BFRBs, gender
distribution was females 29 (13.9%) and males 17 (8.1%). The average age of participants
was 21.5 ranging from 18–27. Among these students, 19 (9.0%) were engaged in
dermatillomania, 28 (13.3%) in trichotillomania and 13(6.2%) in onychophagia. To meet
criteria for BFRBs, students reported engaging in an activity more than five times a day for
at least 4 weeks or more. Many of the students being engaged in an activity also reported
that that activity resulted in noticeable hair loss, interfered with day to day activity, caused
injury, permanent scar or damage or made them seek medical attention.
Body Focussed Repetitive Behaviours: Major Types
Trichotillomania
In ICD-10, trichotillomania is classified in the section on disorders of adult personality and

behaviour, as one of the habit and impulse disorders. It is described as ‘‘A disorder
characterized by noticeable hair-loss due to a recurrent failure to resist impulses to pull out
hairs. The hair pulling is usually preceded by mounting tension and is followed by a sense of
relief or gratification. This diagnosis should not be made if there is a pre-existing
inflammation of the skin, or if the hair pulling is in response to a delusion or a hallucination.
Excludes: stereotyped movement disorder with hair-plucking.’’
Christenson et al, (1991) explored the prevalence of trichotillomania in 2579 college

students and reported that 0.6% of participants (n = 15)met the DSM diagnostic criteria for
current or lifetime trichotillomania; however, when the criteria of tension prior to pulling
and gratification or relief from tension after pulling were removed, 1.5% of males (n = 17)
and 3.4% of females (n = 47) met the diagnostic criteria. A 1994 survey of 288 college
students by Stanley et al ,(1994) found that 15.3% reported HP; a more recent study of 830
adults also reported that 0.6% of the sample met the full criteria for trichotillomania,
although 6.51% of the sample acknowledged HP unrelated to grooming (Duke et al,2009).
Discrepancies in the data on trichotillomania prevalence can be attributed to small sample
sizes and to differences in diagnostic criteria between studies. It seems prudent to conclude
that the prevalence rate of trichotillomania as described by the DSM criteria is
approximately 0.6%, but that a considerably greater proportion of the population reports
subclinical HP. Many studies have reported a higher incidence of trichotillomania in females,
but this finding may reflect a treatment-seeking bias or the social acceptability of hair loss in
men (Christenson & Mansueto, 1999). Trichotillomania often develops in early adolescence
(Cohen et al,1995). Some research has supported a bimodal distribution of onset, with a
peak at the beginning of puberty and an earlier peak between ages two and six years;
however, HP in young children tends to remit spontaneously, whereas adolescent HP tends
to persist if left untreated (Wilhelm & Margraf, 1993). Trichotillomania is considered to be a
chronic disorder that fluctuates over time (Flessner et al, 2009) and varies from individual to
individual (Keuthen et al, 1998).
Skin-picking
Pathological skin-picking (SP) refers to repetitive picking of skin or scabs, causing tissue
damage and distress or impairment, in the absence of a dermatological condition (Grant et
al, 2009; Keuthen et al, 2010; Stein et al., 2010). Common sites for picking include easily
accessible areas such as the face, upper body, cuticles, and extremities. Skin picking has
been included as independent diagnosis in DSM-5, listed as Excoriation Disorder (Skin-
Picking Disorder) in the category of Obsessive–Compulsive Spectrum Disorders (APA, 2013).
Skin Picking prevalence rates of 1.4% to 5.4% have been reported in various populations,
including community samples, college students, dermatology clinic patients, and a large US
population sample (Bohne et al, 2002; Hayes et al, 2009; Keuthen et al, 2010; Keuthen et al,
2000). However, reports of the prevalence of skin Pulling must be interpreted with caution
due to the absence of established diagnostic criteria. SP appears to have a trimodal age of
onset, with SP appearing before age 10, during adolescence or early adulthood (15–21
years), or between ages 30 and 45 years; onset in childhood and adolescence appears to be
most common (Odlaug & Grant, 2012). Skin picking appears to be more common among
females (Teng et al, 2002), although this finding may reflect a treatment-seeking bias.
Nail-biting
Nail-biting (NB) refers to an insertion of the fingers into the mouth, with contact between
the nails and teeth. Many individuals occasionally use the teeth to replace nail clippers in
grooming, however, severe or clinical Nail biting involves biting past the nail bed and
cuticles, drawing blood and resulting in chronic scarring, or in red, sore, and infected fingers
(Penzel, 1995; Wells et al, 1998). Nail Biting is widely accepted as a simple habit when it
does not have negative or distressing consequences, but falls into the category of BFRBs
when it leads to social problems or to significant tissue or nail damage (Snyder & Friman,
2012).The data about the prevalence of Nail Biting are inconsistent. (Snyder & Friman, 2012)
reviewed the literature on Nail biting and concluded that the prevalence increases in four-
to six-year-olds and peaks during puberty, with a reported prevalence rate varying between
25% and 60%. Between late adolescence and age 35 years, prevalence rates range from 10%
to 30%, falling below 10% after age 35. In a survey of 286 college students about “repeated
actions that appear to serve no useful purpose but that you continue to engage in anyway”.
Phenomenological similarities and covariation-
There is considerable overlap in phenomenology between Hair pulling , Skin picking, and
Nail Biting. All three behaviours can be triggered by tactile or visual cues (e.g., a kinky hair, a
scab, or a hangnail) and certain postures (e.g., leaning on a table with head or face in hand).
All three behaviours are performed primarily when individuals are alone or are not engaged
interpersonally, and when the hands are idle (Wilhelm et al, 1999). Episodes of BFRB may
occur daily or fluctuate over the course of weeks and months, with periods of limited BFRB,
followed by relapse. Individuals may perform the behaviour unconsciously or may follow a
ritual of tactile stimulation where in picked or pulled pieces of hair, skin, and nail are
manipulated (e.g., rolled between the fingers, stroked across the lips) or swallowed (Arnold
et al, 1998; Snorrason et al, 2012) Individuals with HP often seek certain types of hairs to
pull, and those with Skin Picking often focus on certain types of skin imperfections. In both
groups, the sight or feel of the preferred type of hair or imperfection triggers BFRB episodes
(Arnold et al, 1998; Odlaug & Grant, 2008).
Conceptualization and place in current diagnostic system-
BFRBs were variably conceptualized as obsessive–compulsive Spectrum disorders (Bienvenu

et al., 2000) and impulse control disorders (APA, 2000). The designation of obsessive–
compulsive spectrum disorders was not implausible. Repetitive motor symptoms in BFRBs
share features with the repetitive compulsive rituals observed in individuals with obsessive–
compulsive disorder (OCD); further, like individuals with OCD, individuals who suffer from
Hair Pulling, Skin picking, or Nail biting perceive the behaviour as difficult to resist, despite
aversive consequences (Bohne et al, 2005). However, differences between BFRBs and OCD
have been reported in terms of phenomenological experiences and situational triggers for
the behaviour. For example, obsessive thoughts are a prominent feature of OCD, but are
less commonly associated with trichotillomania (Keuthen et al., 1998). Individuals with
BFRBs report that episodes of body-focused behaviour are likely to occur during sedentary
activity (O'Connor et al, 2003) or in the presence of specific emotions (Duke et al , 2010). In
contrast individuals with OCD report that their repetitive or ritualistic behaviour is often
precipitated by ‘danger cues’ such as dirt or germs (Keuthen et al., 1998); the cues may or
may not be accompanied by negative emotion. BFRBs were conceptualized as impulse
control disorders because individuals with these problems report diminished control over
the behaviour and an urge or craving prior to engaging in the behaviour. Some individuals
also report pleasure during BFRB (Schreiber et al., 2011).
Notably, recent changes to the DSM 5 have identified two BFRBs (i.e., hair pulling and skin
picking disorders [HPD and SPD, respectively]) as distinct psychological disorders, both
clustered within the category of obsessive compulsive and related disorders (OCRDs)
(APA,2013). Functional similarities are present across the various repetitive behaviors so,
the creation of a separate diagnostic category is a logical step considering the apparent
functional and topographical similarities between and the negative outcomes produced by
these repetitive behaviors. Likewise, the use of a separate label has provided a diagnostic
home for repetitive behaviors that cause problems for the individual. Creation of a separate
category has seeked attention of researchers to proceed in a more integrated and
presumably rapid fashion.
VARIOUS MODELS EXPLAINING BFRB’S:
Behavioural and Cognitive-behavioural models-
Behavioural models for BFRBs explain how seemingly self-defeating and self-punishing
behaviour is maintained by learning, practice, and repetition. Cognitive-behavioural models
add that maladaptive behaviours are often triggered by distorted or unhelpful thoughts; the
thoughts are generated in certain situations, and subsequently trigger negative emotions
and or maladaptive behaviour. Behavioural and Cognitive-behavioural models for
psychopathology further assume that maladaptive behaviour is maintained by positive or
negative reinforcement.
The Cognitive-behavioural model (Mansueto et al,1997) was developed by Mansueto and
colleagues to explain Trichotillomania. The Cognitive-behavioural model is an inclusive
model that proposes that the urge to engage in BFRB is triggered by internal and external
cognitive, affective, and environmental cues; facilitated or inhibited by the internal or
external environment; and positively and negatively reinforced via positive emotion and
relief from negative emotion. This model focuses on negative reinforcement of BFRB
through relief from painful or unpleasant affect. Individuals with trichotillomania, skin
picking, and nail biting report that the urge to pick, pull, or bite occurs more frequently
under certain conditions, and that various external or internal cues trigger the urge
(Diefenbach et al,2002;Duke et al,2010; Mansueto et al,1997; Williams et al, 2006). External
triggers for episodes of BFRB include implements (e.g., hairbrush, tweezers) and settings
(e.g., the bedroom). Internal triggers may be sensory, motor, cognitive, or affective. Sensory
triggers include physical sensations such as the feeling of a coarse hair between the fingers,
the texture of a hard scab, or the rough edge of a hangnail. Motor triggers refer to
behaviours like driving or talking on the telephone. Cognitive and meta-cognitive triggers
are thoughts or beliefs that provoke the urge to pull, bite, or pick (e.g., “Why are my
eyebrows so bushy?” and “I'll never be able to stop biting my nails, so why try” (Mansueto
et al,1997). Affective triggers include such states as frustration, depression, boredom,
anxiety, or tension. These emotions may be generated by an external event or by cognitions
such as those described above. The emotions may directly trigger an episode of BFRB;
alternatively, the urge to engage in the behaviour may be triggered by an external or
environmental cue, and the effort to control the urge (i.e., to not pick, bite, or pull) may
provoke further difficult emotions, creating a vicious cycle of emotions and BFRB.
Facilitators and inhibitors are objects, places, people, thoughts, and emotions that
respectively encourage or discourage an episode of BFRB. For example, the presence of a
mirror can facilitate Hair Pulling and Skin Picking, where as the presence of another person
may inhibit the behaviour. A thought (e.g., “No one's watching; I can pull all I want”) can be
a cognitive facilitator, whereas an emotion such as shame about physical appearance can
inhibit an episode of BFRB.
Once an individual engages in an episode of BFRB, positive and negative reinforcement

increase the likelihood of continued pulling, biting or picking. Pleasure or relief immediately
afterward provides sensory positive reinforcement, and satisfaction and the feeling of
achievement gained from the removal of a certain type of hair (e.g., kinky, split, wrong
color), skin (e.g., rough or scabbed), or nail (e.g., broken, rough, too long) provides affective
and cognitive reinforcement. The pleasure or satisfaction that follows a pulled hair, or a
picked scab or nail may also create relief from negative emotions; relief is a powerful
negative reinforcer, and BFRBs may be consistently used to keep negative emotions at bay
(Mansueto et al, 1997).Episodes of BFRB are often idiosyncratic and follow an observable
sequence. For example, one case study described a female trichotillomania patient who
pulled out her hair when she was waiting or felt like she was wasting time. She was able to
identify frustration and impatience as the dominant emotions present during HP and to
identify trigger thoughts such as “I'm not fast enough” and “I'm not performing well.” These
thoughts increased her tension level and provoked hair pulling (Pélissier & O'Connor, 2004).
Emotion regulation model-
Emotional regulation(ER) model refers to the ways in which individuals identify (i.e., attend
to, label, evaluate) and respond to (i.e., express, try to modify) emotional experiences
(Diefenbach et al, 2008). Emotional regulation can be further understood as the process
through which individuals influence the presence and timing of certain emotions, and how
emotion is experienced and expressed (Gross, 1998). Some conceptualizations of emotional
regulation emphasize the ability to decrease and control negative emotions and reduce
arousal, whereas others suggest that emotional regulation is defined by the ability to
experience, differentiate between, and respond spontaneously to the full range of
emotional experiences (Gratz & Roemer, 2004). The latter definitions imply that awareness
and understanding of emotions in turn improves ability to monitor, experience, accept, and
modify both positive and negative affect (Gratz & Roemer, 2004). The distinction between
emotional regulation as emotional control/suppression and emotional regulation as
awareness and understanding is critical because some literature suggests that efforts to
control emotional experience and efforts to avoid, or reject uncomfortable emotions may
underlie psychological symptoms. Adaptive emotional regulation may therefore require
acceptance of both pleasant and unpleasant emotional responses (Hayes,1996; Linehan,
1993).
Finally, some research suggests that emotional regulation can only be understood within the
context and demands of a given situation. Adaptive emotional regulation therefore requires
context-dependent flexibility, and strategic modulation of arousal in order to maintain goal-
directed activity and inhibit impulsive behaviour when negative emotions develop (Gratz &
Roemer, 2004). Modulation implies altering the intensity or duration of arousal, rather than
changing or eliminating the emotion that is experienced. The emotional regulation model
for BFRBs focuses on negative reinforcement: the function of BFRBs is presumed to be
alleviation or relief from negative emotions, and the relief reinforces and perpetuates the
behaviour. This model combines the role of uncomfortable emotional experiences in
triggering an episode of BFRB, the role of the body-focused behaviour in modulating
emotional arousal, and the role of relief from negative emotional arousal in maintaining and
reinforcing the behaviour. Adapted from research on emotional regulation in
trichotiilomania, the emotional regulation model for BFRBs proposes that individuals with
BFRBs have difficulty controlling certain emotions and engage in body-focused behaviour to
avoid, decrease, or attenuate aversive affect; BFRB’s persist despite negative consequences
because they are negatively reinforced by distraction or escape from undesired emotions or
difficult events .However, the emotional regulation model further suggests that individuals
with BFRBs are characterized by a general deficit in emotional regulation that promotes the
adoption of maladaptive coping methods (Snorrason et al, 2010). Episodes of BFRB result
from a drive to stop experiencing a given affective state, and a lack of alternative methods
for coping with the state (Shusterman et al, 2009). Deficits in ER may stem from many
factors, including problems with impulse control, and difficulty identifying, understanding,
or accepting emotions (Gratz & Roemer, 2004). (Snorrason et al ,2010) further hypothesized
that individuals with skin picking may experience greater emotion reactivity, that is, they
tend to frequently experience intense and persistent emotions (Nock et al, 2008).
Applied to all problematic body-focused behaviours, Snorrason and colleagues' model

implies that, in individuals with BFRBs, chronically high levels of emotional arousal are
coupled with a fundamental deficit in emotional regulation, prompting the adoption of
maladaptive ER strategies such as hair pulling, skin picking, and nail biting. It is unclear
whether the anxiety, tension, or other negative affect that can precede episodes of BFRB
are produced by external stressors, or whether increase in tension is produced by efforts to
avoid engaging in BFRB.
Stimulus regulation model-
The ER model fails to explain the initial development of the use of BFRBs as a means of
regulation. Penzel (2002) proposed a stimulus regulation (SR) model based on his clinical
work with individuals with trichotiilomania. The stimulus regulation is based on Penzel's
observations in his clinical practice that individuals with trichotiilomania pull out hair both
when they are over stimulated (due to stress or to positive or negative excitement) and
under stimulated (due to inactivity or boredom), Penzel hypothesized that individuals with
BFRBs experience malfunctions in nervous system mechanisms that balance internal levels
of stress.
According to the stimulus regulation model, BFRBs represent an effort to externally regulate
an internal state of sensory imbalance. Although individuals with BFRBs are exposed to the
same levels of environmental stimulation as are individuals without BFRBs, the former
group's nervous systems have a different threshold for physiological stimulation (Penzel,
2002). The model proposes that individuals with BFRBs experience pleasure from behaviour
that others experience as painful. In individuals who are under stimulated, the intensity of
the physiological sensation of pulling, picking, or biting provides relief; in individuals who
are over stimulated, the sensations provide distraction from the source of overstimulation.
The stimulation regulation model adds to the emotion regulation model by explaining why
individuals resort to this particular behaviour to regulate levels of stimulation.
According to Penzel (2002), BFRBs develop because: (a) hair, skin, and nails are plentiful and
are within reach at all times; (b) the areas on the body where hair pulling (and to a lesser
extent, skin picking and nail biting) occur are rich sites of nerve endings, providing good
sources of stimulation; (c) hair, skin, and nails are very interesting and stimulating to touch;
(d) genetic predispositions to BFRBs may be present in the brain as part of an old grooming
program and BFRBs can therefore be performed nearly automatically and without much
attention; (e) BFRBs can be extremely rewarding and pleasurable; and (f) BFRBs can be
performed both alone and in the company of others.
Frustrated action model-
O'Connor and colleagues (O'Connor et al., 2001; Pelissier & O'Connor, 2004) reported that
some individuals with BFRBs demonstrate a form of organisational perfectionism
characterized by unwillingness to relax and difficulty with appropriate pacing of tasks.
Individuals with this maladaptive style of planning aim to be productive at all times, often
setting unrealistic standards and trying to do too much at once. They are consequently
susceptible to frustration, impatience, and dissatisfaction when standards are not met, and
to boredom when productivity is impossible. According to the frustrated action (FA) model
for BFRBs, body-focused habits function to release the tension generated by these emotions
(O'Connor, 2002). BFRBs are subsequently negatively reinforced by a decrease in negative
affect and positively reinforced by the feeling of ‘taking action’ (i.e., engaging in BFRBs) after
the initial desired action was thwarted.
The frustration action model has also received some independent research support. Studies
that used questionnaire measures to measure emotional state during BFRBs have found
that individuals engage in hair pulling, skin picking , and nail biting when they are bored,
frustrated, or inactive (Bohne et al, 2002; Diefenbach et al, 2002; Duke et al, 2010). (Teng et
al, 2004) reported that students with skin picking, nail biting, mouth chewing, skin-biting,
and skin-scratching demonstrated significantly more BFRBs in conditions designed to induce
boredom than in a control condition. Similarly, (Williams & Rose, 2006) manipulated
emotion in undergraduates students reporting NB, and concluded that NB occurred
primarily in states of boredom or frustration.
BFRB’s AND IT’S RELATION TO ANXIETY
Traditionally, behaviours such as skin picking, nail biting, and chewing on the mouth have
been called nervous habits (Hansen et al, 1990), suggesting that such behaviours occur as a
function of anxiety. Indeed, research supports this hypothesis as in research with nail-biting
populations shows a correlation between the presence of nail biting and measures of
individual anxiety (Klatte & Deardorff, 1981) and research on skin picking suggests a similar
relationship (Arnold et al, 1998). In addition to a potential anxiety function, researchers
have begun to show that the behaviour may be a function of environmental restriction.
Woods et al, (2001) found that for some children who bit their nails, the behaviour was a
direct result of being in a restricted environment (e.g., alone with nothing to do or alone
and watching television). Likewise, ethological research demonstrates that nonhuman
animals will engage in skin picking or gouging when in restricted environments (Harlow &
Harlow, 1962). It has been demonstrated that individuals who pull out hair and pick skin
have elevated rates of comorbid psychiatric disorders (57% for trichotillomania; 55% for skin
picking; Flessner, 2012), often anxiety and depression. Such findings suggest that stress is
generated by external causes and subsequently maladaptively regulated through BFRBs.
This possibility is reinforced by Teng and colleagues' report that individuals with BFRBs
demonstrate greater trait anxiety (Teng et al, 2004). However, it seems likely that, in some
individuals, efforts to avoid engaging in an episode of BFRB may create further emotional
arousal, compounding the problem and creating a cycle of elevated tension or emotional
arousal, difficulty regulating emotion, and BFRBs.
Relationship of Body-Focused Repetitive Behaviour Disorders to OCD-
Interestingly, research identifies a considerable co-morbidity between OCD and body-

focused repetitive behaviours (BFRBs) such as Trichotillomania (hair pulling disorder; HPD),
excoriation (skin picking disorder; SPD), nail biting, cheek biting, and teeth grinding.
Collectively, literature examining BFRBs demonstrates significant impact among these
behaviours as well, including psychosocial and physical impairment . Though OCD may be
studied to a greater extent within the broader research community, these more recent
findings suggest significant (though clearly not complete) overlap among OCD and BFRBs
and highlight the similar psychosocial impact attributed to both clusters of behaviour
(Lochner et al, 2005).Confirmation of presence or lack of relationships between OCD and
BFRBs) may have critical implications for several areas including the conceptualization and
perhaps most notably—treatment of OCD and BFRBs. For example, considering the high
rates of co-morbidity among these behaviours, understanding such relationships may
naturally lend itself towards development of more trans-diagnostic interventions or,
alternatively, point to the need for discrete interventions (Lochner et al., 2005).
Phenomenology and Symptomatology
Recent research has identified some consistent similarities with respect to the
phenomenology of OCD and BFRBs. In particular, BFRBs and OCD are both characterized by
repetitive behaviours conceptualized to provide a form of relief or pleasurable sensation
(e.g., anxiety relief, emotional regulation, etc.). Though several BFRBs (e.g., teeth grinding
and nail biting) have yet to be acknowledged within the DSM 5, similarities in
phenomenology have provided partial justification for the grouping of Hair pulling disorder
and Skin picking disorder within the broader OCRD cluster (APA, 2013). Somewhat relatedly,
recent literature has also identified relationships among OCD and BFRBs in regards to
symptomatology (e.g., aggression symptoms within OCD related to skin picking) . For
example, Weingarden & Renshaw,(2015) reviewed 100 studies assessing the role of shame
within OCRDs. Within this context, general shame was referred to as self-conscious
emotions, by which individuals judge themselves negatively. Such emotions have been
shown to be related to negative outcomes, including social withdrawal and depression.
Weingarden and Renshaw’s review demonstrated general shame among all OCRDs, with
particular symptom-based shame specific to OCD (i.e., shame regarding content of
obsessions and/or compulsions) and BFRBs (i.e., body shame and shame related to pulling
and picking). These authors posited that such results suggest the need for further research
examining shame within the context of OCRDs and highlight the potentially important
clinical implications for work of this nature (e.g., interventions highlighting the necessity for
providing psychoeducation and non judgment, addressing shame as a treatment goal, etc.).
To be sure, however, not all research or researchers agree that OCD and BFRBs are
inextricably linked. Interestingly, despite some of the similarities noted above, some
researchers hypothesize that OCD and BFRBs—though related on a trivial level—have little
to no relation in regards to symptom function or motivation. In particular, Abramowitz &
Jacoby,(2015)posit that while compulsive behaviours are cued by irrational and anxiety
provoking thoughts, skin picking and hair pulling are cued by negative emotions (e.g.,
tension, depression, anger, boredom, etc.) with considerable implications for BFRBs as
emotion regulatory behaviours.
Beyond the neurocognitive literature, familial studies similarly highlight potential

relationships between OCD and BFRBs. Keuthen et al, (2000) study demonstrate rates of
OCD significantly higher among hair pulling disorder probands with and without OCD,
suggesting an etiological relationship between the two disorders. What is more, based upon
their findings, the authors hypothesize a familial subtype of hair pulling disorder specifically
related to OCD. Interestingly, corroborating findings discussed previously when compared to
hair pullers without OCD, hair pullers with OCD demonstrated greater self-reports of anxiety
and depressive symptomatology. With this latter finding notwithstanding, further support
for a familial relationship among OCD and BFRBs has noted increased risk for BFRBS (i.e.,
Hair Pulling Disorder [4 %], skin picking [17 %], and nail biting [15 %]) among relatives of
individuals with OCD (Stein et al, 2016).
Major types of BFRB’s and its relation to Anxiety-
A number of studies have endeavoured to establish the rates of various psychological

symptoms and disorders in individuals with BFRBs, and the relationship between BFRB
severity and psychological symptom severity. Studies in this area explored the relationships
in HairPulling, Skin Picking, and Nail Biting in both clinical and non-clinical samples.
Hair-Pulling
Diefenbach et al, (2002) reported that 55% of their sample of 44 individuals with
trichotillomania had a co-existent mood or anxiety disorder; the most common diagnoses
were generalized anxiety disorder (GAD), social phobia, and specific phobia.(Christenson et
al ,1991) reported that 82% of a sample of 60 adult hair pullers (50 of whom met the DSM-III
criteria for trichotillomania met the diagnostic criteria for another past or current DSM Axis I
disorder. Thirty-four percent of respondents in a large Internet survey of individuals
reporting symptoms consistent with a trichotillomania diagnosis also reported having
sought help for a comorbid psychological problem, primarily mood and anxiety disorders
(Woods DW et al, 2006). In a study of Hair Pulling phenomenology in a community sample,
(Duke et al ,2009) compared depression and anxiety symptoms in 54 self-reported hair-
pullers with symptoms in 776 individuals who did not report Hair Pulling, and found that the
Hair pulling group had significantly greater symptoms of anxiety or depression
Skin-Picking
Where Skin Picking is concerned, similar findings have been reported. Arnold et al,(1998)
found that each of their 34 participants with pathological skin picking met DSM criteria for
at least one current or lifetime comorbid psychiatric disorder, primarily mood and anxiety
disorders, a minority of participants reported SP in the context of OCD (6%) or body
dysmorphic disorder (BDD) . Hayes et al, (2009) found significant correlations between Skin
Picking severity and depressive, impulsive, anxious, and obsessive–compulsive symptom
severity in 222 skin-pickers in a non-clinical community sample Snorrason et al ,(2010) also
did observe a relationship between skin picking symptoms and severity of depression or
anxiety symptoms.
Nail-Biting
It is commonly assumed that Nail Biting is related to anxiety or is a sign of emotional

tension, but this assumption has been the subject of insufficient research (Wells et al, 1998).
Joubert, (1993) measured nail biting and other habits including hair pulling, skin picking,
nose-picking, and teeth-grinding in 139 men and women, and reported that individuals with
NB tended to have elevated scores on measures of manifest anxiety and Obsessive
Compulsive symptoms. Klatte & Deardorff, (1981) measured anxiety in 10 individuals with
symptomatology and 10 controls, and found that individuals with symptomatology reported
greater anxiety. Joubert, (1993) reported no relationship between symptomatology and
level of happiness (i.e., NB was not associated with unhappiness), but Hansen et al, (1990)
reported a relationship between Nail Biting and negative appraisals of health and
appearance. The research on NB is confounded by the difficulty of distinguishing non-
distressing symptomatology from problematic and distressing Nail Biting. Much of the
literature may focus on mild symptomatology that does not cause distress, creating a
limited understanding of the relationship between symptomatology and psychological
symptoms or psychopathology.
Multiple BFRBs
Several studies focused on the relationships between psychological symptoms and more
than one different BFRB. (Hajcak et al,2006) investigated the prevalence of Hair Pulling and
Skin Picking in a large college sample, and the relationship between the frequency of pulling
or picking and anxiety or other negative emotions. The authors found that skin-pickers and
hair-pullers had significantly higher scores on measures of affective distress than did
controls. More specifically, individuals with Trichotillomania reported elevated anxiety,
stress reactivity, and Obsessive Compulsive symptoms, whereas individuals with skin picking
reported more pathological worry. (Lochner et al,2002) reported that 51.8% of a sample of
68 individuals with Trichotillomania had a current or lifetime comorbid diagnosis; the most
common diagnoses were major depressive disorder, OCD, and GAD. The authors further
reported that 47.6% of a sample of 21 patients with pathological Trichotillomania had a
comorbid diagnosis; the most common diagnoses were major depression and dysthymia.
Finally, (Teng et al, 2004) explored BFRBs in undergraduate students and found that
students with problematic body-focused behaviours were more anxious and more
depressed than were controls. Further, participants reported that their negative affective
states were directly related to self-reported impairment from BFRB.
LIFE EVENTS, STRESS AND ANXIETY
Life events
A life event is a significant occurrence involving a relatively abrupt change that may produce
serious and long lasting effects (Setterson et al,1997).Research has demonstrated that life
event related stresses may result in both physical and mental health problems (Cohen
,1980). Some studies have reported a significant excess of undesirable life events and
distress prior to the onset of the anxiety spectrum (Gothelf et al ,2004;Khanna et al,1988
;kulhara et al,1986).
Lazarus ,(1976) suggested that stress occurs when demands placed on an individual exceed
his or her resources."Stress" is the organism's response to stressful conditions or stressors,
consisting of a pattern of physiological and psychological reactions, both immediate and
delayed. "Onset of illness" is defined by the appearance of clinical symptoms of disease.
"Predisposing factors" are longstanding behaviour patterns, childhood experiences, and
durable personal and social characteristics that may alter the susceptibility of the individual
to illness. "Precipitating factors," in contrast, influence the timing of illness onset; the term
refers for the most part to more or less transient changes in current conditions or
characteristics, and it is such changes that constitute our present subject of inquiry. It is the
chronic diseases rather than the acute, infectious ones that are usually thought to be
particularly influenced by the experience of stress. Following sequence of conditions should
be considered: social stressors, mediating factors, stress, and onset of illness. In this context
the term "social stressors" refers to personal life changes, such as bereavement, marriage,
or loss of job, which alter the individual's social setting. A more specific definition is
proposed by Holmes & Rahe (2007), who define as stressors as any set of circumstances the
advent of which signifies or requires change in the individual's ongoing life pattern.
According to this conception, exposure to social stressors does not cause disease but may
alter the individual's susceptibility at a particular period of time and thereby serve as a
precipitating factor. "Mediating factors" are those characteristics of the stressful event, of
the individual, and of his social support system that influence his perception of or sensitivity
to stressors. In general, consideration of mediating variables contributes to an
understanding of differential sensitivities to social stressors. Gersten et al ,(1974), however,
regard undesirability rather than simply total amount of change as the better definition of
stressor. On the basis of community survey data about nearly 700 children, they concluded
that the number of undesirable life events or a balanced scale (sum of undesirable events
minus sum of desirable events) is a better predictor of behavioral impairment than is the
total number of changes.
State and trait anxiety
State and trait anxiety theory states that the person (trait anxiety) and the situation are
important determining levels of state anxiety. The facet of trait anxiety and stressful
situation must be congruent in order to evoke increase in state anxiety (Spielberger,1983).
Speilberger,(1983) defined trait anxiety as an individual’s predisposition to respond, and
state anxiety as a transitory emotion characterised by physiological arousal and consciously
perceived feelings of apprehension, dread, and tension.
Endler et al,(1991) conceptualised state and trait anxiety as multidimensional and discussed
the relationship between state and trait anxiety and importance of situation. The facets of
trait anxiety are a specification of the circumstances. An individual who is high on a specific
facet of trait anxiety, when in a stressful situation that is congruent to the facet of trait
anxiety ,the individual’s level of state anxiety will increase. There will be no increase in state
anxiety if that individual is not in a stressful condition (Endler et al, 1997).
Multidimensional model of state-trait anxiety
METHODOLOGY
 AIM
 OBJECTIVES
 NULL HYPOTHESIS
 MATERIALS AND METHODS
o Venue
o Study Design
o Sampling technique
o Sample size
 INCLUSION CRITERIA
 EXCLUSION CRITERIA
 TOOLS
 DESCRIPTION OF TOOLS
 PROCEDURE
 STATISTICAL ANALYSIS
AIM
To study the BFRB’s in school going children and adolescents and to see its relationship with
state trait anxiety and life events.
OBJECTIVES
 To assess the presence of BFRBs in school going children and adolescent.

 To assess and compare state-trait anxiety between school going children and
adolescents with BFRB’s and without BFRB’s
 To assess and compare life events between school going children and adolescents
with BFRB’s and without BFRBs
NULL HYPOTHESIS
 There would be absence of body focused repetitive behaviour among school going
population.
 There would be no significant difference in state-trait anxiety between school
children and adolescents having BFRBs and those not having BFRB’s.
 There would be no significant difference in life events of children and adolescents
having BFRB’s and those not having BFRBs.
MATERIALS AND METHODS
Venue:
School in Ranchi (from class 5 to class 10) - Cambrian public school, Kanke Road, Ranchi.
Study Design:
School based cross sectional study conducted over a period of one year from June 2017 to
March 2018.
Sampling:
Random sampling
Sample:
All the students belonging to class 5th to 10th whose guardians gave consent to participate in
study.
Inclusion criteria:
1. Students less than 18 years of age and either sex.

2. Students belonging to grade 5th to 10th standard.
3. Guardian giving written informed consent.
Exclusion criterion:-
1. 1.Major neurological or medical illness (including head injury and epilepsy)

2. Substance dependence, except nicotine or caffeine use.
3. Family history of any psychiatric illness.
4. H/o either any psychiatric illness in children or who scored more than cut off mark
on GHQ-12
5. Children whose consent of participation is not given by the guardian.
Tools and their descriptions-
A research specific consent form –bilingual in both English and Hindi.
Life event scale for Indian children,(LESIC)- Malhotra ,1993
British life event inventory was adopted for use on Indian population by Indian psychiatrist
Savita Malhotra from PGI, Chandigarh ,India as life event scale to measure stress in children
in 1993. The process of adaptation involved evaluation of the scale by experienced
professionals in the terms of relevance of items and appropriate stress score keeping in
mind the Indian socio-cultural context. It is a set of 50 questions that are relevant to
children and adolescent designed to assess positive and negative life event effect on Indian
child. It is a measure of stress applicable to Indian population. Set of questions are asked to
parents of children and scoring is done. Each event was assigned a stress score between 0-
100 indicating stressfulness of the event. Test-retest reliability after 3 months (.89) and
interrater reliability (.99) were very high.
STAIC(state- trait anxiety inventory for children ) –Speilberger et al, 1983
The State-Trait Anxiety Inventory for Children (STAIC) was initially developed as a research
tool for the study of anxiety in elementary school children. It is comprised of separate, self-
report scales for measuring two distinct anxiety concepts: state anxiety (S-Anxiety) and trait
anxiety (T-Anxiety). While especially constructed to measure anxiety in6 to 14-year old
children, the STAIC may also be used with younger children with average or above reading
ability and with older children who are below average in ability. The STAIC S-Anxiety scale
consists of 20 statements that ask children how they feel at a particular moment in time.
The STAIC T-Anxiety scale also consists of20 item statements, but subjects respond to these
items by indicating how they generally feel. The S-Anxiety scale is designed to measure
transitory anxiety states, that is, subjective, consciously perceived feelings of apprehension,
tension, and worry that vary in intensity and fluctuate over time. The T-Anxiety scale
measures relatively stable individual differences in anxiety proneness, that is, differences
between children in the tendency to experience anxiety states. High T-Anxiety children are
more prone to respond to situations perceived as threatening with elevations in S-Anxiety
intensity than low T-Anxiety children.
In essence, each STAIC item is a 3-point rating scale for which values of 1, 2, or 3 are
assigned for each of the three alternative choices. Thus, scores on both the STAIC S-Anxiety
and T-Anxiety subscales can range from a minimum of 20 to a maximum score of 60. The
alpha reliability of the STAIC S-Anxiety scale, was .82 for males and .87 for females. For the
T-Anxiety scale, the alpha coefficients were .78 for males and .81 for females. The internal
consistency of the STAIC scales is reasonably good and the test-retest reliability (stability) of
the T-Anxiety scale is moderate. The test-retest correlations for the STAIC S-Anxiety scale
are quite low, as would be expected for a measure designed to be sensitive to the influence
of situational factors. In measuring the concurrent validity, the STAIC T-Anxiety scale
correlated .75 with the Children's Manifest Anxiety Scale (CMAS) and .63 with the General
Anxiety Scale for Children (GASC).
Modified habit questionnaire- Teng et al, 2002
Habit is a brief of five items self–report questionnaire that provides a standardized

assessment of the frequency and duration of BFRBs. The Habit Questionnaire is self report
and set of 20 questions and has been found to possess moderate test–retest reliability of
.69 of diagnosis of BFRB. It includes 4 sections and each section have 5 sub-questions that
has to be answered in ‘yes’ or ‘no’.
General health questionnaire- 12– Goldberg, 1970
Measure of current mental health of the subject. The scale asks whether the respondent has
experienced a particular symptom or behaviour recently. There are 12 items and each item
is rated on four-point scale and gives a total score of 36 or 12 based on the selected scoring
methods. The most common scoring methods are bi-modal (0-0-1-1) and Likert scoring
styles (0-1-2-3). Scores ranges from 0-12 or 0-36 depending upon the scoring system. High
score indicates more serious psychological problems. A score of 4 or more has been used as
a suitable cut off point for caseness.
Procedure:
The study was conducted in the Cambrian Public school, after seeking permission from
school authority. Consent forms were distributed to guardians of 978 students from class 5th
-10th and written consent was taken from the guardians after explaining the method and
purpose of study.
Relevant socio-demographic details were collected from the 109 students whose guardians
gave consent to participate in the study. To rule out conditions that commonly co-occur
with BFRBs, participants were asked to indicate if they had ever been diagnosed with
Obsessive– compulsive disorder, Tourette’s syndrome, Autism, Asperger’s syndrome or a
developmental disability in the given sheet itself.
After collecting the socio-demographic details, Modified habit questionnaire, which a self -
administered questionnaire, were distributed among students.
33 students reported ‘yes‘ on modified habit questionnaire. They were rated on ‘GHQ-12’ to
measure current mental health. Students were assessed as per the bi-modal scoring system
and those scoring cut-off score of 4 or more than 4 were excluded from the study.
The 21 students were left after excluding those with GHQ score of 4 or more than 4. These
students were assigned to Case group and same number of age ,sex and educational
matched students with a GHQ score of less than 4 were taken as controls from students
reporting ‘no’ on modified habit questionnaire and were assigned to Control group.
In the next step, students of both Case and Control group were given state trait anxiety
inventory for children and life event scale used for Indian children population and assessed
accordingly.
STATISTICAL ANALYSIS
The results obtained was analysed by using the computer software program, Statistical
Package for Social Sciences-version 24.0 (SPSS-24.0) for Windows®, with different
parametric and nonparametric measures being used, wherever applicable in following
steps:
Step-I: Description of sample characteristics with descriptive statistics- percentage, mean

and standard deviation.
Step-II: Group differences for sample characteristics were examined with independent t-test
and chi-square test wherever applicable. For non-parametric distribution Mann-Whitney U
test was applied.
Step-IV: STAIC and life event scores were compared across various subtypes of BFRBs using
independent sample t-test.
In this study, a level of significance (α) of < 0.05 (two tailed) were taken to consider a result
statistically significant.
RESULTS
 SAMPLE CHARACTERISTICS
o SOCIODEMOGRAPHIC VARIABLES
o CLINICAL VARIABLES
 PRESENCE OF BODY FOCUSSED REPETITIVE BEHAVIOURS IN SCHOOL GOING
CHILDREN AND ADOLESCENTS
 COMPARISON OF STATE TRAIT ANXIETY AND LIFE EVENT BETWEEN CHILDREN AND
ADOLESCENTS WITH BFRB’s AND WITHOUT BFRB’s.
 COMPARISON OF BFRB’S WITH STATE TRAIT ANXIETY AND LIFE EVENTS
Table-1: Comparison of Socio-demographic characteristics (categorical) between the case

and control (N=42)
Case Control
χ2
Variables n = 21 n = 21 p
(df =1)
n(%) n(%)
Sex Male 5 (23.8) 7 (33.3) 0.467 0.734
Female 16 (76.2) 14 (66.7)
Hindu 15 (71.4) 17 (81.0) 4.411 0.220
Muslim 5 (23.8) 2 (9.5)

Religion
Christian 1 (4.8) 0 (0)
Others 0 (0) 2 (9.5)
Rural 5 (23.8) 5 (23.8) 0.000 1.000

Domicile
Urban 16 (76.2) 16 (76.2)
Nuclear 12 (57.1) 14 (66.7) 0.404 0.525

Family type
Joint 9 (42.9) 7 (33.3)
Siblings Present 18 (85.7) 21 (100) 3.231 0.072
Absent 3 (14.3) 0 (0)
Parent occupation One parent employed 21 (100) 20 (95.2) 1.024 0.311
Both parents employed 0 (0) 1 (4.8)
Table-1: shows comparison of the socio demographic variables (categorical) between the
case and control groups. Greater proportion of the respondents in study are females in both
case and control groups. Participants in greater proportion are from urban background.
They mostly belong to nuclear families and have siblings. Most have only one parent
employed and most of the participants belong to hindu religion. The data showed no
significant difference in sex , religion ,domicile, siblings parent occupation and family type
between case and control groups.
Table-2: Comparison of Socio-demographic characteristics (continuous) between the case

and control groups (N=42)
Variables Case Control t p

n = 21 n = 21 (df = 40)
Mean ±SD Mean ±SD
Age (In years) 12.8±1.209 12.4±1.167 0.909 0.369
Mother education (in number of years) 11.76±3.239 13.33±2.955 0.642 0.108
Father education (in number of years) 14.81±3.281 15.14±3.038 0.342 0.734
Education of Participants 8.57 ±1.599 8.81± 1.167 -0.551 0.585

(In number of years)
Table 2 shows the comparison of socio demographic variables (continuous) between the
case and control groups. The case group consists of 21 participants with mean age of
12.8±1.209 years while the control group had 21 participants with mean age of 12.4±1.167
years. Education of mother in case group was 11.76±3.239 years and 13.33±2.955 years in
control group. Education of father in case group was 14.81±3.281 years and 15.14±3.038
years in control group. No significant difference was found in age, birth order, mother
education, father education, and education of participants in between two groups.
Table-3:Number and Percentage of students with Body focussed repetitive behaviour
Behaviour Frequency (N=109)

n(%)
Hair pulling 4 (3.6)
Nail biting 11 (10.1)
Chew mouth, lips and cheeks 17 (15.6)
Skin picking 2 (1.8)
Total 21 (19.3)
Table-3: shows the frequency of body focussed repetitive behaviour in the study population.
Table -4: Characteristics of Body Focussed Repetitive Behaviours in children and

adolescents (n=21)
HAIR NAIL CHEWING SKIN
VARIABLES
PULLING BITING MOUTH PICKING
n(n%) Yes 4 (19) 11(52.4) 17(81) 2(9.5)
No 17(81) 10(47.6) 4(19) 19(90)
FREQUENCY <5 times/day 2(9.5) 6(28.6) 11(52.4) 1(4.8)
>5times/day 2(9.5) 5(23.8) 6(28.6) 1(4.8)
DURATION 2-4 weeks 4(19) 6(28.6) 9(52.9) 1(4.8)
4 weeks to 12 months 0 2(9.5) 4(23.5) 0
>12 months 0 3(27.3) 4(23.5) 1(4.8)
PROBLEMS Noticeable hair loss 1(4.8) 0 8(38.1) 1(4.8)
Interfere day to day activity 2(9.5) 8(38.15) 7(33.3) 1(4.8)
Behaviour causes injury 1(4.8) 2(9.5) 2(9.5) 0
Cause permanent scar or damage 0 0 0 0
Seek medical attention 0 0 0 0
Medical professional suggested you to 0 1(4.8) 0 0
stop it
Behaviour under the influence of alcohol 0 0 0 0
or drugs
ATTEMPTS Yes 3(14.8) 8(38.1) 12(57.1) 2(100)
TO REDUCE
No 1(4.8) 3(14.3) 5(23.8) 0
BEHAVIOUR
Table-4: shows that Hair pulling is present in 4 out of 21 participants i.e 19% of total
participants in case group. Out of 4 having hair pulling, 2 of them have for less than 5 times
per day duration and 2 of them have for more than 5 times a day duration. Behaviour is
present for duration of less than 4 weeks. Table also shows that out of 4 participants in
which hair pulling is present 1 of them have noticeable hair loss as a problem and in two of
them presence of hair pulling interferes with day to day activities and in 1 of them hair
pulling cause injury in some or other way. Out of 4, 3 of them attempt to stop hair pulling
while one of them does not give any attempt to stop the behaviour.
Nail biting is present in 11 out of 21 participants i.e 52.4% of total participants in case group.
Out of 11 having nail biting, 6 of them have for less than 5 times per day duration and 5 of
them have for more than 5 times a day duration. Behaviour is present for less than 4 weeks
duration in 6 students, 2 of them are having this behaviour for 4weeks to 12 months
duration and 3 students are having this behaviour for more than 12 months. Table also
shows that out of 11 participants in which nail biting is present in 8 of them it interferes
with day to day activities and in 2 of them nail biting cause injury and 1 them was advised by
a medical professional to stop nail biting. 8 of them make attempt to stop nail biting while 3
of them does not give any attempt to stop the behaviour.
Lip chewing is present in 17 out of 21 participants i.e 17 of total participants in case group.
Out of 17 having lip chewing, 11 of them have for less than 5 times per day duration and 6
of them have for more than 5 times a day duration. Behaviour is present for less than 4
weeks duration in 9 students, 4 of them are having this behaviour for 4weeks to 12 months
duration and 4 students are having this behaviour for more than 12 months. Table also
shows that out of 17 participants in which lip chewing is present in 8 of them it interferes
with day to day activities and in 7 of them lip chewing cause injury and in 2of them causes
permanent scar or damage.12 of them make attempt to stop lip chewing while 5 of them
does not make any attempt to stop the behaviour.
Skin picking is present in 2 out of 21 participants’ i.e 2 of total participants in case group.
Out of 2 having skin picking, 1 of them has for less than 5 times per day duration and 1 of
them has for more than 5 times a day duration. Behaviour is present for less than 4 weeks
duration in 1 student and 1 student is having this behaviour for more than 12 months. Table
also shows that out of 2 participants in which skin picking is present in 1 of them it
interferes with day to day. Both of them make attempt to stop skin picking.
Table-5: Comparison of STAIC scores between children and adolescents with and without
Body Focussed Repetitive Behaviour (N=42)
Variables Case Control t p

(n=21) (n=21) (df=40)
Mean ±SD Mean ±SD
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*
Legend: STAIC – State-trait anxiety in children
* Significance at p<0.05 (2-tailed)
** Significance at p<0.01 (2-tailed)
Table-5: shows the comparison of STAIC scores between students with and without body
focussed repetitive behaviour. The difference in STAIC state scores in children with body
focussed repetitive behaviours (32.19±5.759) and children without body focussed repetitive
behaviours (26.67±5.782) was found to be significant (t=3.102, p=0.004). The difference in
STAIC trait scores in children with body focussed repetitive behaviours (35.48±9.136) and
children without body focussed repetitive behaviours (28.62±8.034) was found to be
significant (t=2.583, p=0.014). The difference in STAIC total scores in children with body
focussed repetitive behaviours (66.05±15.522) and children without body focussed
repetitive behaviours (55.10±13.722) was also found to be significant (t=2.423, p=0.020).
Table-6: Comparison of Life event scores between children and adolescents with and
without Body Focussed Repetitive Behaviour (N=42)
Variables Case Control Mann- Z p

Whitney
(n=21) (n=21)
U
Mean ±SD Mean Mean ±SD Mean
rank rank
Life event 11.33±6.843 29.79 2.52±2.522 13.21 46.5 -4.394 0.001**

severity score
Life event 293.43±192.589 29.17 72.48±71.932 13.83 59.5 -4.057 0.001**

stress score
** Significance at p<0.01 (2-tailed)
Table-6: shows the comparison of Life event scores between students with and without
body focussed repetitive behaviour. The difference in Life event severity scores in children
with body focussed repetitive behaviours with mean 11.33±6.843 (Mean rank 29.79) and
children without body focussed repetitive behaviours with mean 2.52±2.522 (mean rank
13.21) was found to be significant (M-W U=46.5, p=0.001). The difference in Life event
stress scores in children with body focussed repetitive behaviours with mean
293.43±192.589 (mean rank 29.17) and children without body focussed repetitive
behaviours with mean 72.48±71.932 (mean rank 13.83) was also found to be significant (M-
W U=59.5, p=0.001).
Table-7a: Comparison between scores for state-trait anxiety in students with and without
hair pulling (N=21)
Variable Hair Pulling t P

(df=19)
Yes (n=4) No (n=17)
Mean ±SD Mean ±SD
STAIC total score 78.5±18.27 63.1±13.81 1.895 0.073
STAIC state score 34.5±7.59 31.6±5.38 0.887 0.386
STAIC trait score 44.0±12.1 33.4±7.37 2.282 0.034*
Table-7b: Comparison between scores for life events in students with and without hair
pulling (N=21)
Variables Hair Pulling Mann- Z P

Whitney
Yes (n=4) No (n=17) U
Mean ±SD (Mean Mean ±SD (Mean

Rank) Rank)
Life event 13.7±6.40 13.50 10.7±7.01 10.41 24.0 -0.899 0.369

severity score
Life event 365.7±199.99 13.25 276.4±192.99 10.47 25.0 -0.807 0.420

stress score
* Significance at p<0.05 (2-tailed)
Table-7a&b: shows the comparison between hair pulling with state-trait anxiety and life
events in students with and without hair pulling. STAIC trait scores showed a significant
difference (t=2.282, p=0.034) between children with and without hair pulling behaviours.
There was no other significant difference found in other scores between the students with
and without hair pulling.
Nail biting (N=21)
Variable Nail Biting t P

(df=19)
Yes (n=11) No (n=10)
Mean ±SD Mean ±SD
STAIC trait score 38.2±8.46 32.5±9.34 1.463 0.160
Table-8b: Comparison between scores for life events in students with and without Nail
biting (N=21)
Variables Nail Biting Mann- Z P

Whitney
Yes (n=11) No (n=10) U

Rank) Rank)
Life event 14.45±6.96 13.73 7.90±5.02 8.00 25.0 -2.121 0.034*

severity score
Life event 360.0±197.61 12.95 220.2±166.31 8.85 33.5 -1.515 0.130

stress score
*Significance at p<0.05 (2-tailed)
Table-8a&b: shows the comparison between Nail biting with state-trait anxiety and life
events in students with and without nail biting. Life event severity scores showed a
significant difference (M-W U=25.0, p=0.034) between children with and without nail biting.
There was no other significant difference found in other scores between those with and
without nail biting.
mouth, lips or cheeks chewing (N=21)
Variable Chew mouth, lips or cheeks t P

(df=19)
Yes (n=17) No (n=4)
Mean ±SD Mean ±SD
Table-9b: Comparison between scores for life events in students with and without mouth,
lips or cheeks chewing (N=21)
Variables Chew mouth, lips or cheeks Mann- Z P

Whitney
Yes (n=17) No (n=4) U

Rank) Rank)
Life event 10.2±5.99 10.18 16.0±9.20 14.50 20.00 -1.259 0.208

severity score
Life event 260.7±168.91 10.12 432.5±251.50 14.75 19.00 -1.344 0.179

stress score
Table 9a&b shows the comparison between mouth, lips or cheeks chewing with state-trait
anxiety and life events in student with and without mouth, lips or cheek chewing . No
significant difference was found between the two groups.
Table-10a: Comparison between scores for state-trait anxiety in students with and
without skin picking (N=21)
Variable Skin picking t P

(df=19)
Yes (n=2) No (n=19)
Mean ±SD Mean ±SD
Table-10b: Comparison between scores for life events in students with and without skin
picking (N=21)
Variables Skin picking Mann- Z P

Whitney
Yes (n=2) No (n=19) U

Rank) Rank)
Life event 14.5±10.61 13.75 11.0±6.68 10.71 13.50 -.662 .508

severity score
Life event 343.0±294.16 12.50 288.2±190.01 10.84 16.00 -.360 .719

stress score
Table-10a&b: shows the comparison between skin picking with state-trait anxiety and life
events in students with and without skin picking. No significant difference was found
between the two groups.
DISCUSSION
 DISCUSSION OF METHODOLOGY
o Study design
o Assessment of tools
 DISCUSSION OF RESULTS
o Socio-demographic and clinical characteristics
o Characteristics of body focussed repetitive behaviours in the case group
o Comparison of state-trait anxiety between children and adolescents with
BFRB’s and without BFRB’s
o Comparison of life event scores between children and adolescent with BFRB’s
and without BFRB’s
o Comparison of BFRB’s with state trait anxiety and life events.
The present study aimed at assessing the presence of Body focussed repetitive behaviours
in school going children and adolescents and to compare the state–trait anxiety and
undesirable life events among participants with and without BFRB’s. The study also looked
for any presence of BFRB’s in subjects with anxiety states, significant life events and
underlying stress .
DISCUSSION OF METHODOLOGY:
Study Design
It was a school based study with participants belonging to class 5th to class 10th. Random
sampling was done. It was a cross sectional study. After taking permission from School
authority of Cambrian Public School, Kanke road, consent forms were distributed to
guardians of 978 students belonging to class 5th to 10th. Guardians of 109 students gave
consent to participate in the study. Conditions that commonly co-occur with BFRBs and past
and family history of any psychiatric illness were ruled out in the given sheet itself. After
collecting the socio-demographic details, Modified habit questionnaire were distributed
among students, on which 33 students reported ‘yes‘. They were rated on ‘GHQ-12’ to
measure current mental health. 21 students were left after excluding those with GHQ score
of 4 or more than 4. These students were assigned to Case group and same number of age,
sex and educational matched students with a GHQ score of less than 4 were taken as
controls from students reporting ‘no’ on modified habit questionnaire and were assigned to
Control group. In the next step, students of both Case and Control group were given state
trait anxiety inventory for children and life event scale used for Indian children population
and assessed accordingly.
Most of the studies in past have been carried out in adults (Woods et al, 1996) or young
adults (Siddiqui et al, 2015). For example, past study conducted by Siddiqui et al, (2012) in
three large medical colleges of Karachi comprising of 3000 students was to see the
prevalence of BFRBs in college going young adults. We have carried out our study in school
going population to assess the presence of BFRBs in this demographic and also, since the
literature from Indian subcontinent on BFRBs in children and adolescents are limited, we
chose to take study sample of school going children and adolescent belonging to class 5th to
10th. School was chosen as a venue for our study as it provides a better representation of
children and adolescents from different socioeconomic classes and cultures
Assessment of tools
Consent forms were distributed in bilingual format consisting of Hindi and English language.
Relevant socio-demographic details were taken on data sheet and guardians were also
instructed to mention any family history and past history of psychiatric illness in their
children on the same socio-demographic sheet. Students with significant past history or
family history were excluded from our study. In our study ‘Modified habit questionnaire’
was used to assess which of the students were positive for BFRB’s and further to find out
details of the BFRB’s. To check the current mental health of students they were given
General Health questionnaire and cut off score was 4. Subsequently students who were
eligible for further study process were assessed on State -Trait anxiety inventory for children
and life events scale for Indian children. State trait anxiety is a self report questionnaire
whereas life event scale was to be filled by guardians indicating how stressful the
mentioned events were to their child.
Past study by Siddiqui et al, (2012) did not use any screening tool for measuring current
mental status of their participants but we in our study used GHQ-12 as screening tool to rule
out any ongoing serious psychological morbid process in our study population. We opted for
STAIC to measure anxiety scores as it is a self report questionnaire with lucid and easy
language. Similarly, life event scale by Savita Malhotra was opted as it is designed keeping in
mind the Indian scenario. Moreover no studies have been done in past using these scales to
find out any relationship between BFRB’s, state-trait anxiety and life events.
DISCUSSION OF RESULTS:
Discussion of Socio-demographic
In our study socio-demographic variables showed no significance difference between case

and control with 21 participants in each group. Greater proportion of the respondents in
study were females. Participants in greater proportion are from urban background. They
mostly belonged to nuclear families and have siblings. Most have only one parent employed
and most of the participants belong to Hindu religion. The data showed no significant
difference in sex, religion, domicile, siblings parent occupation and family type between
case and control groups. The case group consists of 21 participants with mean age of
12.8±1.209 years while the control group had 21 participants with mean age of 12.4±1.167
years. Study conducted by Siddiqui et al, (2012) was in young adults medical students age
range of 18-27yrs with mean age of 21.5.
Discussion of clinical characterstics
According to our inclusion and exclusion criterion, 21 participants out of 109 students found
to have BFRB’s and were kept as case group. In case group, 16 out of 21 students (76.2%)
were female and 5 out of 21 (23.8%) were male. This greater occurrence among females
than males is a finding consistent with previous studies (Woods et al, 2001; Keuthen et al,
2000). Literature shows that stressful conditions tend to trigger BFRB's but their association
has not been substantiated. One of the recent study showed higher prevalence in females
may indicate that females are more prone to stressful conditions and thus tend to get
engaged more frequently in BFRBs than males (Siddiqui et al, 2012).This finding of female
involving more frequently in BFRB’s went consistent with our study.
Characteristics of BFRB’s
Among 21 students who came positive for BFRB’s, 4(19%) were engaged in hair pulling,
11(52.4%) were engaged in nail biting, 17(81%) were involved in chewing mouth, lips or
cheeks, 2(9.5%) were involved in skin picking. This shows that BFRBs are quite common in
school going children with one student having more than one type of BFRB’s at a time. Nail
biting of two times or more per week was reported among 63.6% students in United States
of America (Hensen et al, 1990). Another study from USA, using the stringent criteria of five
times or more per week stated 21.8% students engaged in mouth, lips or cheeks chewing
and 10.1% engaged in habitual nail biting (Woods et al, 1996). A study done in 3 large
medical colleges of Karachi with a study population of 210 showed that among these
students, 19(9.0%) were engaged in dermatillomania (skin picking and cheek ,lip or mouth
chewing), 28(13.3%) in trichotillomania (hair pulling) and 13(6.2%) in onychophagia (nail
biting) (Siddiqui et al, 2012). The frequency of various pathologies align almost with the
results of the Karachi study. Our study reveals that chewing mouth, lips or cheeks are more
common among participants than other forms of BFRB’s.
Many of the students being engaged in an activity also reported that that activity resulted in
noticeable hair loss, interfered with day to day activity, caused injury, permanent scar or
damage or made them seek medical attention. One of female participant reported that a
medical professional suggested her to stop the behaviour while nobody among the
participants of this study said that the behaviour occurred under the influence of alcohol or
other drugs. BFRBs are not uncommon among school students of Ranchi. It is therefore
imperative to identify the prevalence associated with BFRBs to design interventions to
curtail the burden. Reasons for BFRB’s being common among students can may be
explained on the various models behind generation of BFRB’s. Internal factors like
personality traits, boredom, negative emotions, frustration and external factors like
environmental cues , increased expectation from parents, negative childhood experience,
peer pressure can all contribute to negative emotional state and externally as BFRB’s.
Besides that, reasons such as socioeconomic factors leading to stress and anxiety among
different sets of students can be a reason of their engagement in BFRB’s. But since 1) no
literature is available proving any such facts therefore we can’t come up with a valid
conclusion in this regard.
Comparison of State-trait anxiety and Life events scores between students

with and without BFRB’s
The comparison of STAIC scores between students with and without body focussed
repetitive behaviour showed that the difference in STAIC state scores in children with body
focussed repetitive behaviours (32.19±5.759) and children without body focussed repetitive
behaviours (26.67±5.782) was significant (t=3.102, p=0.004). The difference in STAIC trait
scores in children with body focussed repetitive behaviours (35.48±9.136) and children
without body focussed repetitive behaviours (28.62±8.034) was also found to be significant
(t=2.583, p=0.014). The STAIC total scores in children with body focussed repetitive
behaviours (66.05±15.522) and children without body focussed repetitive behaviours
(55.10±13.722) also showed significant difference (t=2.423, p=0.020).While current
conceptualization of BFRBs places them on the obsessive-compulsive spectrum(APA,2013);
BFRBs are used as a means to alleviate or relieve negative emotional states. This suggests
that associations with anxiety are also likely (Woods & Houghton, 2014). This would explain
why STAIC scores are elevated significantly in children with BFRBs.
Dhuri et al,(2014) mentioned about life event related stresses that may result in both
physical and mental health problems. Few studies have investigated the role of such events
in anxiety spectrum disorder specifically in obsessive compulsive disorder (OCD) and some
of these studies have reported a significant excess of undesirable life events prior to the
onset of the illness (Gothel et al,2004;Khanna et al,1988;Kulhara et al,1986).In our study,
the difference in Life event severity scores in children with body focussed repetitive
behaviours and children without body focussed repetitive behaviours was found to be
significant(p=0.001). The difference in Life event stress scores in children with body
focussed repetitive behaviours and children without body focussed repetitive behaviours
was also found to be significant (p=0.001). This difference probably substantiates the role of
life event related stresses in anxiety which in turn is relieved by having BFRB’s.
Comparison of BFRB’s with state-trait anxiety and life events
STAIC trait scores showed a significant difference (t=2.282, p=0.034) between children with
and without hair pulling behaviours. The Trait Anxiety scale measures relatively stable
individual differences in anxiety proneness, that is, differences between children in the
tendency to experience anxiety states. High Trait Anxiety children are more prone to
respond to situations perceived as threatening with elevations in State Anxiety intensity
than low Trait Anxiety children. A high prevalence of comorbid obsessive-compulsive
disorder (OCD), depression, and anxiety disorders has also been found in adults with
trichotillomania (Gupta et al, 2015). Our finding further corroborates this association.
Life event severity scores showed a significant difference (p=0.034) between children with
and without nail biting. Pathological nail biting in adults has been related to high levels of
anxiety and obsessive-compulsive symptoms (Gupta et al, 2015)and few studies have
investigated the role of such events in anxiety spectrum disorder specifically in obsessive
compulsive disorder (OCD) and some of these studies have reported a significant excess of
undesirable life events prior to the onset of the illness(Gothelf et al,2004;Khanna et al,1988;
kulhara et al,1986).This is in line with the finding in our study.
Savita Malhotra, (1993) reported that life events in normal children (which is our study
population) usually were much less stressful than those in disordered children, which is
expressed by the higher life event severity scores in disordered children. In our study
students having BFRB’s were perceiving undesirable events like visit of a relative, acquisition
of television by parents, dispute between parents, arguments with siblings, school
examinations more stressful than students reporting ‘no’ to BFRB’s. This difference may be
because of heritable traits, temperament and coping mechanism and resilience which was
not explored in our study and which needs exploration in future.
SUMMARY AND CONCLUSION
 SUMMARY
 CONCLUSION
SUMMARY
This study was conducted at Cambrian Public School, Kanke Road, Ranchi with the aim of
assessing the presence of body focussed repetitive behaviour in students and to see its
relationship with state trait anxiety and life events. In the study ,21 students who fulfilled
inclusion and exclusion criteria and reported ‘Yes’ on Habit questionnaire were in put in
case and similarly there age ,sex educational match reporting ‘No’ on Habit questionnaire
were put in control. So, total 42 students participated in study with n=21 in each groups,
case and control. Participants of both the groups were assessed on state trait anxiety
inventory for children and life event scale.
The major findings of this study are:
 Body focussed repetitive behaviours are common in school going children and
adolescents.
 Children and adolescents with Body Focussed Repetitive Behaviours have elevated
state, trait and total score on STAIC as compared to children and adolescents
without Body Focussed Repetitive Behaviours.
 Children and adolescents with Body Focussed Repetitive Behaviours have elevated
life event stress and severity scores as compared to children and adolescents
without Body Focussed Repetitive Behaviours.
 On assessing the individual Body Focussed Repetitive Behaviours, children and
adolescents with hair pulling have elevated STAIC trait score as compared to children
and adolescents without hair pulling.
 On assessing the individual Body Focussed Repetitive Behaviours, children and
adolescents with nail biting have elevated life event severity score as compared to
children and adolescents without nail biting.
CONCLUSION
Body Focussed Repetitive Behaviours are common in normal population of school going
children and adolescent. Presence of BFRBs among them may be attributed to increased
levels of anxiety and various life events occurring in their life. Their behavior can have
serious physical and psychological consequences in their life.
LIMITATIONS AND FUTURE DIRECTIONS
LIMITATIONS
 As we have carried out this study among school students only, our findings could not
be generalized for the general population
 Also, we have excluded the disordered group of children and adolescent which could
have given a better estimate of prevalence of BFRB’s with greater accuracy .
 Students participating in study were lower than expected especially from higher
classes which could reflect underlying stigma related to mental health or
unawareness about the problematic behaviours.
FUTURE DIRECTIONS
 Additional research should be conducted to establish prevalence rates among

different populations including adults and elderly, and among populations with
cultural differences.
 Studies should also be conducted to find out the factors associated with BFRBs and
its various possible consequences. Doing so may elucidate important components of
treatment and methods to avoid engaging into such behaviors that are so physically
and socially disadvantageous.
 Studies should also be conducted in children and adolescent with other
comorbidities.
 The relationship or association between various factors like state-trait anxiety and
life event could be studied.
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APPENDICES
APPENDIX-1
GOVERNMENT OF INDIA
CENTRAL INSTITUTE OF PSYCHIATRY, RANCHI
CONSENT FORM
I………………………………………………….. hereby give the consent for participation of my

son/daughter/ward……………………………………………. in the study named “BODY FOCUSSED REPETITIVE
BEHAVIOURS IN SCHOOL GOING CHILDREN AND ADOLESCENT AND ITS RELATIONSHIPWITH LIFE
EVENTS AND STATE –TRAIT ANXIETY.” To be done at Central Institute of Psychiatry, Ranchi.
I hereby declare that:/है में भाग ले ने के ललए अपनी सहमलि दे िा/दे िी हूँ . मैं इसके द्वारा घोषणा करिा/करिी हूँ
लक:
I received the information on the above study and have read and/or understood the information/ मैंने
उपरोक्त अध्ययन के बारे में जानकारी प्राप्त कर ली है और उसे पढ़/समझ ललया है
I understand that this study is aimed at furthering the clinical knowledge in the field of mental
health/ यह अध्ययन मानलसक स्वास्थ्य के क्षे त्र में नैदालनक ज्ञान को आगे बढ़ाने के उद्दे श्य से है यह मैंने समझ ललया है .
I have been given the chance to discuss the study and ask questions/ मुझे इस अध्ययन पर चचाा और सवाल
पूछने का मौका लदया गया है .
I am aware that the information collected about my ward from his/ participation in this research and
sections of any of my medical notes may be looked at by responsible persons (ethics
committee/regulatory authorities)/ मैं समझ गया/गयी हूँ की इस शोध और मेरे लचलकत्सा नोटोों में एकलत्रि की गई
मेरे इस शोध में शालमल और इलाज सम्बन्धी जानकारी को लजम्मेदार व्यक्तक्तयोों (नैलिकिा सलमलि / लनयामकअलधकाररयोों)
द्वारा दे खा जा सकिा है .
I understand that my participation is voluntary/ मैं जानिा/जानिी हों लक मेरी भागीदारी स्वैक्तिक है .
I understood that I may withdraw at any time without this affecting future care of my
son/daughter/ward/ मैं समझ गया/गयी हूँ लक मैं मेरे भलवष्य की दे ख भाल को प्रभालवि लकए लबना लकसी भी समय
अपनी साझे दारी वापस ले सकिा/सकिी हूँ .
I understand that the details pertaining to identity of my son/daughter/ ward will not be disclosed,
unless in the interest of me, or of the scientific pursuits, without my permission/ मैं समझ गया/गयी हूँ लक
अपनी पहचान से सों बोंलधि लववरण मेरी अनुमलि के लबना, जब िक लक वह मेरे लहि में है , या वै ज्ञालनक गलिलवलधयोों के ललए
जरूरी होने के लबना खुलासा नही ों लकया जाएगा.
(Signature/LTI of the guardian) Name:

(Signature/LTI of the subject) Name:
Date: Place:
APPENDIX-2
SOCIODEMOGRAPHIC DATA
Date:
Sr No:
1.Name :
2.Address :
3.Age (in years):
4.Sex : 1. Male 2. Female
5.Religion: 1. Hindu 2. Muslim 3. Christian 4. Other
6.No.of years of education:
7. Family income:
(rupees/month)
8.Habitat 1. Rural 2. Urban
9.Family Type 1.Nuclear 2. Joint
10.Parents : 1.Both 2.Single

11.Parent’s education : 1.Father 2.Mother
(no.of years of education)
12.Parents occupation : 1.Only Father employed
2.Only Mother employed
3.Both employed
12.Siblings: 1.Present 2. Absent
13. Birth order:
14. Past history
Have you ever been diagnosed with OCD/ Tourette’s syndrome:
Have you ever been diagnosed Anxiety Disorder/ phobia:
Have you ever been on Psychotropic medication:
15. Family history of psychiatry illness:
APPENDIX 3
MODIFIED HABIT QUESTIONNAIRE
I. Hair pulling
Sr No
1 Hair Pulling 1. Yes 2. No
2 Frequency 1. < 5 times a day 2. > 5 times a day
3 Duration 1. 2-4 weeks 2. 4 weeks to 12 3. > 12 months
months
4 Problems 1. noticeable hair loss 2. interfere day to day 3. behavior cause injury
activity
4. cause permanent scar or 5. seek medical 6. medical professional
damage attention suggested you to stop it
7. behavior under the influence of alcohol or drugs
5 Attempts to 1. Yes 2. No
stop/reduce
behaviour
II. Nail Biting

Sr No
1 Nail Biting 1. Yes 2. No
months
activity
stop/reduce
behaviour
III. Chew Mouth, Lips or Cheeks
Sr No Mouth/Lips/Cheeks
(Indicate by tickmark)
1 Chewing 1. Yes 2. No
months
activity
stop/reduce
behaviour
IV. Skin Picking

Sr No
1 Skin Picking 1. Yes 2. No
months
activity
stop/reduce
behaviour
Teng EJ, Woods DW, Twohig MP, Marcks BA. Body-focused repetitive behavior problems: prevalence
in a nonreferred population and differences in perceived somatic activity. Behavior Modification.
2002 Jul;26(3):340-60.
APPENDIX 4
GENERAL HEALTH QUESTIONNAIRE
1.Have you recently been able to concentrate on whatever you are doing? Score
a. Better than usual b. Same as usual
c. Less than usual d. Much less than usual
2.Have you recently lost much sleep over worry?
a. Not at all b. Not more than usual
c. Rather more than usual d. Much more than usual
3.Have you recently felt you are playing a useful part in things?
a. More than usual b. Same as usual
c. Less than usual d. Not at all
4.Have you recently felt capable of making decisions about things?
c. Less than usual d. Much lss than usual
5.Have you recently felt constantly under strain?
6.Have you recently felt you could not overcome your difficulties?
7.Have you recently been able to enjoy your normal day-to-day activities?
c. Less than usual d. Much, less than usual
8.Have you recently been able to face up your problem?
9.Have you recently been feeling unhappy and depressed?
10.Have you recently been losing confidence?
11.Have you recently been thinking yourself as a worthless person?
12. Have you recently been feeling reasonable happy all things considered?
Total Score
APPENDIX 4
HOW-I-FEEL QUESTIONNAIRE
STAIC Form C-1
Name: _________________________________________ Age: _________ Date:_________
DIRECTIONS: A number of statements which boys and girls use to describe themselves are given
below. Read each statement carefully and decide how you feel right now. Then put an X in the box in
front of the word or phrase which best describes how you feel. There are no right or wrong answers.
Don’t spend too much time on any one statement. Remember, find the word or phrase which best
describes how you feel right now, at this very moment.
I feel very calm Calm not calm
I feel very upset upset not upset
I feel very pleasant pleasant not pleasant
I feel very nervous nervous not nervous
I feel very jittery jittery not jittery
I feel very rested rested not rested
I feel very scared scared not scared
I feel very relaxed relaxed not relaxed
I feel very worried worried not worried
I feel very satisfied satisfied not satisfied
I feel very frightened frightened not frightened
I feel very happy happy not happy
I feel very sure sure not sure
I feel very good good not good
I feel very troubled troubled not troubled
I feel very bothered bothered not bothered
I feel very nice nice not nice
I feel very terrified terrified not terrified
I feel very mixed-up mixed-up not mixed-up
I feel very cheerful cheerful not cheerful
HOW-I-FEEL QUESTIONNAIRE
STAIC Form C-2
Name: _________________________________________ Age: _________

Date:_________
DIRECTIONS: A number of statements which boys and girls use to describe themselves are given
below. Read each statement carefully and decide if it is hardly-ever, or sometimes, or often true for
you. Then for each statement, put an X in the box in front of the word that seems to describe you
best. There are no right or wrong answers. Don’t spend too much time on any one statement.
Remember, choose the word which seems to describe how you usually feel.
I worry about making mistakes hardly-ever sometimes often
I feel like crying hardly-ever sometimes often
I feel unhappy hardly-ever sometimes often
I have trouble making up my mind hardly-ever sometimes often
It is difficult for me to face my problems hardly-ever sometimes often
I worry too much hardly-ever sometimes often
I get upset at home hardly-ever sometimes often
I am shy hardly-ever sometimes often
I feel troubled hardly-ever sometimes often
Unimportant thoughts run through my mind and bother me hardly-ever sometimes often
I worry about school hardly-ever sometimes often
I have trouble deciding what to do hardly-ever sometimes often
I notice my heart beats fast hardly-ever sometimes often
I am secretly afraid hardly-ever sometimes often
I worry about my parents hardly-ever sometimes often
My hands get sweaty hardly-ever sometimes often
I worry about things that may happen hardly-ever sometimes often
It is hard for me to fall asleep at night hardly-ever sometimes often
I get a funny feeling in my stomach hardly-ever sometimes often
I worry about what others think of me hardly-ever sometimes often
Scoring Key for STAI for Children
Scoring Instructions for STAIC Form C-1
Fold this paper in half and line up next to the appropriate item numbers on the answer sheet.
Be sure you are on the correct side of the answer sheet (Form C-1). Total the scoring weights shown
for the marked responses.
Total Score for C-1 ____________

1 123
2 321
3 123
4 321
5 321 Scoring Instructions for
6 123 STAIC Form C-2
7 321 All Items on the A-Trait scale are scored as
8 123 follows:
9 321
10 123 1 point for “hardly ever”
11 321 2points for “sometimes”

3points for “often”
12 123
13 123
Total Score for C-2 _______________
14 123
15 321
16 321
17 123
18 321
19 321
20 123
Spielberger CD, Gorsuch RL, Lushene RE. Manual for the state-trait anxiety inventory.1983
APPENDIX 5
Malhotra S. Study of life stress in children with psychiatric disorders in India. Hong Kong Journal of
Psychiatry. 1993 Sep 1;3:28.

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BODY FOCUSSED REPETITIVE BEHAVIOURS IN SCHOOL GOING

CHILDREN AND ADOLESCENTS AND ITS RELATIONSHIP WITH STATE-

Under the guidance of

CENTRAL INSTITUTE OF PSYCHIATRY

This dissertation is submitted to Ranchi University in partial fulfillment of the requirements

(Dr. Swati Sailly)

CENTRAL INSTITUTE OF PSYCHIATRY

(Dr. Roshan V. Khanande) (Dr S.K.Munda)

I am overwhelmingly grateful to my friends Dr Abhinav Srivastava and Dr. Anweshan Ghosh .

(Dr. Swati Sailly)

REVIEW OF LITERATURE ..................................................................................... 4

SUMMARY AND CONCLUSION ......................................................................... 45

LIMITATIONS AND FUTURE DIRECTIONS .......................................................... 47

Body-focussed repetitive behaviours (BFRBs) refer to a group of problematic, destructive

Current conceptualization of BFRBs places them on the obsessive-compulsive spectrum

 BODY FOCUSSED REPETITIVE BEHAVIOURS: AN OVERVIEW

BODY FOCUSSED REPETITIVE BEHAVIOURS: AN OVERVIEW

Prevalence of Body Focussed Repetitive Behaviour-

Body Focussed Repetitive Behaviours: Major Types

In ICD-10, trichotillomania is classified in the section on disorders of adult personality and

Christenson et al, (1991) explored the prevalence of trichotillomania in 2579 college

Phenomenological similarities and covariation-

Conceptualization and place in current diagnostic system-

BFRBs were variably conceptualized as obsessive–compulsive Spectrum disorders (Bienvenu

VARIOUS MODELS EXPLAINING BFRB’S:

Behavioural and Cognitive-behavioural models-

Once an individual engages in an episode of BFRB, positive and negative reinforcement

Emotion regulation model-

Applied to all problematic body-focused behaviours, Snorrason and colleagues' model

Stimulus regulation model-

BFRB’s AND IT’S RELATION TO ANXIETY

Relationship of Body-Focused Repetitive Behaviour Disorders to OCD-

Interestingly, research identifies a considerable co-morbidity between OCD and body-

Phenomenology and Symptomatology

Beyond the neurocognitive literature, familial studies similarly highlight potential

Major types of BFRB’s and its relation to Anxiety-

A number of studies have endeavoured to establish the rates of various psychological

It is commonly assumed that Nail Biting is related to anxiety or is a sign of emotional

LIFE EVENTS, STRESS AND ANXIETY

State and trait anxiety

 To assess the presence of BFRBs in school going children and adolescent.

MATERIALS AND METHODS

1. Students less than 18 years of age and either sex.

1. 1.Major neurological or medical illness (including head injury and epilepsy)

Tools and their descriptions-

A research specific consent form –bilingual in both English and Hindi.

Life event scale for Indian children,(LESIC)- Malhotra ,1993

STAIC(state- trait anxiety inventory for children ) –Speilberger et al, 1983

Modified habit questionnaire- Teng et al, 2002

Habit is a brief of five items self–report questionnaire that provides a standardized

General health questionnaire- 12– Goldberg, 1970

Step-I: Description of sample characteristics with descriptive statistics- percentage, mean

Table-1: Comparison of Socio-demographic characteristics (categorical) between the case

Sex Male 5 (23.8) 7 (33.3) 0.467 0.734

Female 16 (76.2) 14 (66.7)

Hindu 15 (71.4) 17 (81.0) 4.411 0.220

Muslim 5 (23.8) 2 (9.5)

Others 0 (0) 2 (9.5)

Rural 5 (23.8) 5 (23.8) 0.000 1.000

Nuclear 12 (57.1) 14 (66.7) 0.404 0.525

Siblings Present 18 (85.7) 21 (100) 3.231 0.072

Parent occupation One parent employed 21 (100) 20 (95.2) 1.024 0.311

Both parents employed 0 (0) 1 (4.8)

Table-2: Comparison of Socio-demographic characteristics (continuous) between the case