(PS2-99) What Do Experts Think? An International Investigation on Classification and Diagnosis of Body-focused Repetitive Behaviors

Background: It was not until the most recent DSM editions that body-focused repetitive behavior disorder (BFRBD) was given its own diagnostic label. While decades of research examined the nature of several disorders classified as BFRBDs (i.e., trichotillomania and excoriation disorder), there are still other conditions whose classifications remain unclear (e.g., nail biting, bruxism) despite being associated with urge-driven, often harmful manipulation of the body surface. Due to the lack of understanding of these behaviors, ambiguity exists regarding their classification in future DSM editions. This study aimed to identify areas of consensus among experts regarding conditions that should be included under the BFRB category, in order to inform future DSM editions.

Methods: We invited academic experts on BFRBs to partake in an online survey aimed at collecting their views on various questions surrounding these conditions, including phenomenology, classification, differential diagnoses, and potential alternative syndrome labels.

Results: The final sample included responses from 50 experts spanning 18 countries. Results show that most experts agreed that BFRBs should be classified as a subset of obsessive-compulsive and related disorders. Of the listed behaviors, trichotillomania and excoriation disorder were unanimously considered BFRBs, followed by a majority ( >60%) recommending the inclusion of dermatophagia, nail-biting, and lip-cheek biting as BFRBs as well. Mixed views were found among experts in considering awake bruxism and thumb-sucking in adults as BFRBs, while only a minority of experts agreed that night bruxism and knuckle-cracking qualified as BFRBs. Lastly, most experts expressed the need to differentiate between nonsuicidal self-injury (NSSI) and BFRBDs based on the type of motivation underlying the behavior (i.e., self-injury vs. tension release).

Conclusions: There is an expert consensus in support of the BFRB/BFRBD diagnostic entity. However, some disagreements were found regarding the classification of several behaviors, suggesting that some criteria require further refinement. In addition, there is a need to distinguish BFRBD from NSSI, as well as from stereotypic movement disorders, based on primary motivations.