Podcast: When Does Nail Biting or Skin Picking Become a Medical Condition?

Guest Bio

Luisa Zettinig is a public health executive and businesswoman, whose career has spanned multiple countries and sectors. She currently lives in Zurich, Switzerland, where she works at the children’s hospital and as the strategy director at Nudge. Her passion lies in the application of technology to improving healthcare provision and the treatment of mental health conditions.Nudge is a UK-based company on a mission to raise awareness of body-focused repetitive behaviors (BFRBs). Their product, the Nudge Band, was born out of the founding team’s shared wish to develop an affordable, evidence-based solution for people affected by BFRBs, such as compulsive skin picking, hair pulling and nail biting. The Nudge Band is a wrist-worn smart device that uses sophisticated technology to alert the wearer whenever their hand moves towards their face. Learn more and order your band at: www.nudgeband.co.uk

Inside Mental Health Podcast Host

Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without.

To book Gabe for your next event or learn more about him, please visit gabehoward.com.

Episode Transcript

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Mental Health: A Psych Central Podcast where experts share experiences and the latest thinking on mental health and psychology. Here’s your host, Gabe Howard.

Gabe Howard: Calling into our show today, we have Luisa Zettinig. Ms. Zettinig is a health care manager and businesswoman whose career has spanned multiple countries and sectors. Her passion lies in the application of technology to improving health care provision and the treatment of mental health conditions. Ms. Zettinig, welcome to the show.

Luisa Zettinig: Hey, Gabe. Thank you for having me. I’m really excited to be here today.

Gabe Howard: We are excited that you are here as well. And today we’re going to be discussing body focused repetitive behaviors or BFRB’s. And I discovered that I have a BFRB. I always knew that I had trichotillomania. The show did not diagnose me. I just didn’t realize that trichotillomania, or hair pulling, was a part of the body focused repetitive behavior category because, for whatever reason, I had just never heard the term before. So before we get too far into the episode, can you tell our listeners what body focused repetitive behaviors or BFRB’s are?

Luisa Zettinig: Yes, sure. It’s incredible how many people aren’t aware that they actually have a BFRB. So it’s funny you say that because my story is also similar. So BFRB’s are bodily focused repetitive behaviors and they appear in hair pulling or skin picking. So people who suffer from BFRB’s sometimes aren’t really aware that they’re doing it. You start pulling your hair or picking your skin when you’re stressed. It’s often related also to anxiety or depression and comes with other mental health issues.

Gabe Howard: I learned that I had trichotillomania because my family would constantly say, Stop pulling your hair, stop pulling your hair. Stop pulling at your hair. Stop touching your hair. I just, I didn’t even know that I was doing it.

Luisa Zettinig: Yeah, exactly. But also for people who suffer from BFRB’s badly, it’s really debilitating because you might pull out your eyebrows completely or completely lose your hair or have really bad skin issues. So it reaches a point for a lot of people that you seek professional help. Of course, the aspect of your friends and family constantly pointing out that you’re pulling your hair or picking your skin also is something that’s not really very helpful. And that’s why you kind of have that sort of negative feedback. And that’s also a reason why people go and seek help or find more information about the condition.

Gabe Howard: My family very much saw it not as a medical condition, but as just a bad habit. How is it different? How can somebody tell if they just have a quirk, a bad habit, or if they’ve moved into, you know, having a medical condition, you know, body focused repetitive behavior?

Luisa Zettinig: You know, learning about BFRB’s for me personally has been really liberating as well, because I also thought it’s just a bad habit and it’s just something that you have to try harder and you can change. I don’t want to directly compare it to depression, but it’s like telling somebody to be happy or relax. There’s that element of lack of control. So, you know, it’s not just about changing your, you can’t just switch off the behavior. So it’s not just an annoying habit that you can just sort of get yourself to stop by strong willpower. It’s more deep rooted because you’re doing it unconsciously or it’s something that happens unconsciously and it’s really hard to control and requires a lot of help and attention to really learn how to change your behavior. Seeking help is super important. And I think it’s really important that you inform yourself and that you can look at websites and find out more about BFRB’s because diagnosis is often far along down the path. The first step is to sort of talk about it and what what annoys you or how you’re affected and how BFRB’s affect your everyday life.

Gabe Howard: One of the things that I’ve noticed in the mental health field is that people believe they have to be positive that they have a medical condition before they’ll seek care. So they have to be positive that they have depression or positive that they have bipolar disorder. And I know there’s a lot of people who might not be positive that they have a body focused repetitive behavior. They’re just not sure. Can you talk to those folks? And I don’t want to say give them permission, but give them encouragement to seek help, seek treatment and find out for sure where they lie on that spectrum versus them sitting at home and thinking to themselves, well, I’m not sure I have an issue, so I won’t go to the doctor yet.

Luisa Zettinig: I think going seeking out a professional and going to see a doctor or a therapist is a super important first step. It’s really important that you talk about how whatever it is is affecting your daily life and that you can have this open conversation about what’s on your mind. And I think, you know, the diagnosis is not the beginning of the process. It might be at the end of the process. So it’s really important to have that openness. And that’s what we at Nudge also are. What we care about is that it’s all about awareness. It’s really important to have sort of access to information, keep the barriers of entry low and just make it possible to have that conversation. And maybe at the end a therapist might have a diagnosis. But I think it’s about exploring what’s going on in your life and what is bothering you and how to find solutions. So it doesn’t really matter what it is. It’s more important about finding a way to make your, make your life easier.

Gabe Howard: So many people believe that if they have a body focused repetitive behavior, that seeking help, therapy, whatever is just being dramatic. Can you talk about that? Because it seems to be a pervasive belief not just among people who are suffering from BFRB’s, but among their supposed support system. Oh, you’re going to a doctor because you’re pulling at your hair? You’re just being dramatic.

Luisa Zettinig: Yeah. I think it’s really important to spread awareness. It’s really important to connect sufferers and and pointing them towards more support and just having an open community. Your problems are always real to you, so it’s not up to judgment for other people to judge if your issues are real or your problems are real or how big they are. It’s already such a big step to seek help and sort of admit to yourself or admit that you have a problem. So we really have to build that awareness that there’s nothing, absolutely nothing wrong or bad about BFRB’s.

Gabe Howard: How common are body focused repetitive behaviors?

Luisa Zettinig: It’s huge. And before I started my research and found out more about BFRB’s, I had absolutely no idea. We think that, they’re estimates that it affects about 5% of the world’s population. So in 20 people can suffer from BFRB’s without ever knowing it, without ever having heard the name.

Gabe Howard: And they are really, really impactful. I think I’ve done a disservice to our listeners by saying, Oh, I, I twirl my hair. But it’s a spectrum. For Gabe Howard personally, for, for me personally. I yank at my hair, I tug at my hair and I pull on it. But I’m fairly lucky in that if I keep my hair very short, that does keep it at bay. But for other people, they’re going after their eyebrows. Or of course, I’m just talking about hair. There’s also, you know, skin picking, scratching and things of that nature. This isn’t just some quirk that we’ve turned into a medical condition. This is debilitating for those who suffer from it.

Luisa Zettinig: Yeah, exactly. So you’re right, there’s a complete spectrum from pulling your eyebrows a little bit to actually not having any eyebrows at all or having no hair or having to shave your head because you keep pulling out your hair. The impact can be huge. Anything from sort of being having a bad session or pulling your hair that are picking at your skin so badly that your your face is bloody, you can’t go outside. You’re embarrassed to see other people, you can’t go to work. So it’s a huge it can be hugely debilitating for some people. And the feedback from customers has really brought me to tears. That people think they’re freaks because they pull out their hair or don’t have any eyebrows anymore or pull their eyelashes. So we’ve had people who actually have found out for the first time in their lives that they’re not alone.

Gabe Howard: And you can see where this would snowball. You mentioned not being able to go to work. In America, that’s not only how we get money, but it’s how we get health insurance. You mentioned not wanting to see friends or family. Well, there’s our support system. There are the people that that help us through trauma and illnesses and getting medical care. You’re sort of isolated and alone and lacking the resources to attack the problem head on.

Luisa Zettinig: I think so, absolutely. Yeah, it can happen that you reach a downward spiral, you’re stressed because you can’t find a job or you you had a bad session and you don’t want to go to work and then your job security might be affected. So, of course, all these additional stressors can kind of make things worse. With the pandemic, we’ve seen, we’ve kind of had both reactions. Some people who have been suffering from BFRB’s are kind of happy because they haven’t had that same sort of social exposure and interaction. So sort of that on one hand can reduce the levels of anxiety just because you’re not having to deal with people all the time. But for others, of course, being alone is kind of worse because then if I’m alone at home, I go to the mirror and squeeze my pimples or pick up my skin or start pulling the hair out. So we’ve seen it go both ways. So some people who where the pandemic has helped because they’ve spent more time alone and socializing hasn’t been an additional stress factor or others who have kind of found it harder because they have been home alone all the time.

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Gabe Howard: And we’re back discussing BFRB’s, Body Focused Repetitive Behaviors, with Luisa Zettinig. Can you talk about your personal story a little bit with a BFRB?

Luisa Zettinig: I, yeah, I’ve been skin picking sort of all my life. I have a mild form. But it’s just something that I’m very aware of, of when I’m stressed or don’t sleep enough. I kind of have these parts of my face around my chin that I always go at, and it annoys me and it annoys people around me. So it’s harmful and not helpful and that I want to manage for myself. And so I kind of really like the idea of developing a device that helps with that.

Gabe Howard: I love that you have a personal connection. So often, I think that products like this miss the mark. They don’t have that link. People don’t understand why it’s so important. They understand that it works. They understand the research, but it just doesn’t have that that connection. And it really sounds like you and your team have a real connection to this, this product and the benefits of seeking treatment, seeking help, and just moving forward in spite of a disorder that is not well known, not well understood, and frankly, sounds like it’s very debilitating to a large number of people.

Gabe Howard: Is there a type of person who who has a BFRB? Does it only happen to young people or older people or men or women? Is there a commonality between BFRB sufferers?

Luisa Zettinig: It tends to be more women. So women in their young adulthood from teens. So between 15 to 35 is kind of the most common. But there’s a very broad spectrum. All genders are affected on all age groups.

Gabe Howard: Why do you think there’s not as much public attention or awareness on these conditions? I’ll be the first to admit there’s, there’s not enough public attention on mental health in general. But it really seems like body focused repetitive behaviors are completely ignored. And I’m saying this as somebody who works in mental health advocacy.

Luisa Zettinig: One reason might be the large spectrum. So there are a lot of BFRB sufferers who have a very mild form, but then the few people who have, have it really badly. So maybe it’s kind of everybody picks their skin a little bit or pulls out their hair. So I think it’s maybe the the broad spectrum that makes you feel or it’s normal. It’s just kind of an annoying behavior. So that might be one reason. And in general, it’s not not so well known or explored yet either. So also within the mental health practitioner community, we found therapists who actually haven’t heard about BFRB’s themselves. So it’s also within the professional community there’s still a lot of awareness that needs to be built up.

Gabe Howard: Well, I’m really glad that you’re out there raising that awareness and bringing down those barriers, because it can be extraordinarily debilitating for those who suffer. Now you have a product, Nudge. It’s a wearable. You wear it on your wrist and it it, well, gives you a nudge when you start the body focused repetitive behavior. Can you talk about the research that went into that, how it works and how people use it?

Luisa Zettinig: Of course, so Nudge is a smart wristband that vibrates when you’re about to touch your skin and your face. We did a lot of research about how face touching happens, how often people do it. Then also researching the behavior change therapy approaches and what helps people learn more about their behaviors. And we found that Nudge is sort of a gentle reminder when you’re about to touch your face. And for many of our sufferers, there’s that lack of awareness. It’s an unconscious behavior so much as this vibration, the motor that kind of sets off when you’re about to touch your face, and that kind of helps gives you a reminder that you’re about to do it and with time, help to change your behavior because you’re more aware of face touching.

Gabe Howard: And of course, that’s that’s the wearable aspect. That’s the vibration aspect. But community building and awareness raising is a big, big, big part of your mission. Can you talk about why that is?

Luisa Zettinig: From our initial feedback. Also because we had so many customers that came to us and said, Hey, this is the first time that I found out that I’m not alone. I thought I was a freak. I had no idea that there were other people out there who had the same issues. Mental health in general is, it has improved a lot, but we’re still really stigmatized. People don’t talk about it. Everybody has sort of a story in their family, but there’s still such a it’s still often such a difficult conversation to have had. So we kind of want to normalize it and we want to build awareness and make people feel okay and kind of say, hey, you’re not alone. It’s okay, you’re not a freak. Embrace your BFRB. And we want to have information out there to help people deal with it and improve their quality of life.

Gabe Howard: Can you walk us through a little bit of how you developed Nudge? What was the inspiration? What was the idea? What were the first steps? There has to be a story there.

Luisa Zettinig: Yeah. So we had this idea about Nudge, and then started with our research and learned more about BFRB’s and then we sort of got together and had our team’s personal experience with BFRB’s was a major factor, all of us. It was kind of this common denominator. We all, all of a sudden had a personal story to tell. So that was quite amazing. And we kind of had this idea of developing a smart wristband that would help stop touching your face. It was also my own experience with dermatillomania that sort of kicked off. And then I dug deeper and did more research and learned more and more about it. And then it was also we found out that our team all had a personal story to tell and then we were just super keen to do something in that space.

Gabe Howard: And where can folks find the nudge band on the web?

Luisa Zettinig: You can go to our website, TheNudgeBand.com or follow us on Instagram and visit our website and find more information about Nudge and about us. And we also have useful blog entries and links that are available, so it’s a useful resource for finding out more about BFRB’s.

Gabe Howard: And what’s the website and what is the Instagram link?

Luisa Zettinig: So our website is TheNudgeBand.com and the Instagram handle is @TheNudgeBand.

Gabe Howard: Ms. Zettinig, thank you so, so much for being here. I really appreciate you illuminating people on this this not well understood topic.

Luisa Zettinig: Yeah. Thank you so much. It’s been fantastic being able to talk about BFRB’s and Nudge and and thank you so much for having us.

Gabe Howard: You are very, very welcome. And to all of our listeners, a giant thank you. My name is Gabe Howard and I’m the author of “Mental Illness Is an Asshole and Other Observations,” as well as an award winning public speaker who’s probably available for your next event. My book is on Amazon, or you can get a signed copy with free show swag or learn more about me by heading over to gabehoward.com. Wherever you downloaded this episode, please follow or subscribe to the show. It’s absolutely free and hey, recommend the show to your family, friends and colleagues, whether it’s on social media, a text message, or good old-fashioned word of mouth. I would consider it a personal favor. I will see everybody next Thursday on Inside Mental Health.

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