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FREQUENCY OF BODY-FOCUSED REPETITIVE BEHAVIOURS IN MEDICAL STUDENTS OF PESHAWAR.

Byline: Shifa A. Khan, Mahd Aftab Khan, Mahnoor Khan, Mifrah Rauf Sethi and Muhammad Irfan

ABSTRACT

Objective: To find out the frequency of body-focused repetitive behaviours (BFRBs) in medical students of Peshawar.

Methodology: This cross-sectional study included students from different medical colleges of Peshawar. Habit questionnaire was used to check the common habits; it consists of 11 questions with a simple 'Yes' or 'No' responses and noting the feelings before, during and after committing the behaviour. The Cronbach's alpha reliability of Habit questionnaire in our study was 0.88. SPSS v.20 was used to analyze the data and a p value of <0.05 was considered significant for results when tests of significance were applied.

Results: The mean age of the sample (n=549) was 20.7 +-1.5 years with majority were male students (n=285, 51.9%) and from private sector (n=432, 78.7%). The most common habit in medical students was chewing lips (n=365, 66.5%). The most common feeling associated before and during committing these habits was irritability [(n=84, 15.3%) and (n=99, 18%)] while it was calmness, after committing the habits (n=121, 22%). The gender wise comparison showed that statistically significant habit in male was punching a wall (p= 0.000) and in females, it was chewing lips (p= 0.024). Similarly students of public sector had significantly more involvement in the habits of biting nails, chewing lips, clinching/ grinding teeth, scratching/picking skin, pulling hair on head and eyebrows/ lashes and punching wall, as compared to private sector (p <0.05).

Conclusion: There was a high frequency of body-focused repetitive behaviours in medical students. Significantly more common habit in females was chewing lips while in males, it was punching the wall.

KeyWords: Body-focused repetitive behaviours, Medical students, Peshawar.

INTRODUCTION

Body-focused repetitive behaviours (BFRBs) is an umbrella name given to a group of compulsive behaviours, which may cause damage to one's appearance causing physical injury and/or significant distress. People with this problem engage in body-focused activities like nail biting, hair pulling, skin picking, cheek biting and inner lip biting1. The individuals experience ongoing and repetitive urges towards these behaviours. These groups of disorders are relatively harmless at lower frequencies. However, the increased frequency may lead to significant distress and impairment in social and occupational areas or may also cause damage/injury to the body2. Trichotillomania is believed to affect 10 million people in United States3. Nail biting generally increases from childhood to adolescence and then decreases in adulthood4. It ranges from 28 to 33% during childhood and approximately 45% of adolescents are nail biters5.

It is an unfortunate fact that BFRBs are less focused and still, research in this field recognize and manage them as distinct entities. There are many reasons to consider them as one entity because it makes it not only less of a labour to manage but also focuses on the fact that they are all directly related to damaging one's own body parts such as lips and finger nails. Trichotillomania and skin picking are categorically placed under DSM-5 as part of obsessive compulsive disorders6. Medical students due to academic stress may engage themselves in certain habits. This study was therefore conducted in order to find the frequency of body focused repetitive behaviours (BFRBs) in medical students and find out the feelings associated before, during and after committing these habits.

METHODOLOGY

This cross-sectional study included students of private and public sector medical colleges of Peshawar, Pakistan, using purposive sampling technique. These included Peshawar Medical College, Khyber Medical College, Rahman Medical College and Kabir Medical College. The study was approved by Ethical Review Committee of Peshawar Medical College and each participating institute was approached for permission, before starting data collection. All the students who participated in the study were informed about the purpose of the study and were included after their consent. All the information provided was kept confidential. Habit questionnaire was used to check the common habits7. The questionnaire consists of 11 questions with a simple 'Yes' or 'No' as possible responses and their respective frequencies in the past 2 weeks. A few more questions on moods and feelings that people may have before, during and after the habitual behaviour are also part of the questionnaire.

The Cronbach's alpha reliability of Habit questionnaire in our study was 0.88. The results were analyzed using SPSS v.20. Analysis of the basic variables was carried out using descriptive statistics for finding frequencies and percentages of BFRBs. Chi-square test was used to find out the differences based on gender and public and private sector institutions. The results were considered significant at p <0.05 level.

Table 1: Frequencies of demographic variables (n=549)

S. No.###Variables###Frequency(%)

1###Gender###Male###285(51.9%)

###Female###264(48.1%)

2###Institutes###Private###432(78.7%)

###Public###117(21.3%)

3###Year of Schooling###Pre-clinical(1stand 2nd Year)###458(83.5%)

###Clinical(3rd, 4th and Final Year)###91(16.5%)

###Biting Nails###264(48.1%)

###Chewing Lips###365(66.5%)

###Biting Cheeks###160(29.1%)

###Grinding/ Clinching Teeth###238(43.4%)

###Scratching/Picking Skin###185(33.7%)

4###Behaviours###Pulling Hair on Head###159(29.0%)

###Pulling hairs on Eye Brows/Lashes###133(24.2%)

###Deliberately Self-Cutting###66(12.0%)

###Punching Wall or Other Object###249(45.4%)

###Hitting Self###142(25.9%)

###Burning Self###88(16.0%)

Table 2: Details of Habit questionnaire showing body focused repetitive behaviour in last 2 weeks (n=549)

###Frequency in Last Two Weeks

S. No.###Behaviour###Not at all###Once###2-4 times###More than

###(%)###(%)###(%)###4 times(%)

1###Biting Nails(n=264)###58(22.0)###72(27.2)###68(25.8)###66(25.0)

2###Chewing Lips(n=365)###44(12.1)###61(16.7)###147(40.3)###113(30.9)

3###Biting Cheeks(n=160)###39(24.3)###50(31.3)###44(27.5)###27(16.9)

4###Grinding/ Clinching Teeth(n=238)###56(23.5)###68(28.6)###80(33.6)###34(14.3)

5###Scratching/picking Skin(n=185)###51(27.6)###58(31.3)###51(27.5)###25(13.6)

6###Pulling Hair on Head(n=159)###45(28.3)###35(22.0)###49(30.8)###30(18.9)

7###Pulling hairs on Eye brows/Lashes(n=133)###35(26.3)###38(28.6)###44(33.1)###16(12.0)

8###Deliberately Self-cutting(n=66)###16(24.3)###27(40.9)###20(30.3)###3(4.5)

9###Punching Wall or Other Object(n=249)###70(28.1)###79(31.7)###64(25.7)###36(14.5)

10###Hitting Self(n=142)###46(32.4)###50(35.2)###31(21.8)###15(10.6)

11###Burning Self(n=88)###22(25.0)###31(35.2)###22(25.0)###13(14.8)

Table 3: Comparison of Habit questionnaire on gender and students of public and private sector institutions (n=549)

S.###Behaviour###Gender###Private / Public Institutes

No.###Male(%)###Female(%)###p value###Private Sector(%)###Public Sector(%)###p value

###n=285###n=264###n=432###n=117

1###Biting Nails(n=264)###139(48.8)###125(47.3)###.739###198(45.8)###66(56.4)###.042*

2###Chewing Lips(n=365)###177(62.1)###188(71.2)###.024*###266(61.6)###99(84.6)###.000*

3###Biting Cheeks(n=160)###86(30.2)###74(28.0)###.581###119(27.5)###41(35.0)###.113

4###Grinding/ Clinching Teeth(n=238)###127(44.6)###111(42.0)###.552###169(39.1)###69(59.0)###.000*

5###Scratching/picking Skin(n=185)###97(34.0)###88(33.3)###.862###135(31.2)###50(42.7)###.020

6###Pulling Hair on Head(n=159)###90(31.6)###69(26.1)###.160###116(26.9)###43(36.8)###.036

7###Pulling hairs on Eye brows/Lashes(n=133)###73(25.6)###60(22.7)###.430###90(20.8)###43(36.8)###.000*

8###Deliberately Self-cutting(n=66)###38(13.3)###28(10.6)###.326###47(10.9)###19(16.2)###.114

9###Punching Wall or Other Object(n=249)###150(52.6)###99(37.5)###.000*###182(42.1)###67(57.3)###.004*

10###Hitting Self(n=142)###76(26.7)###66(25.0)###.656###106(24.5)###36(30.8)###.172

11###Burning Self(n=88)###54(18.9)###34(12.9)###.053###66(15.3)###22(18.8)###.356

RESULTS

The mean age of the sample (n=549) was 20.7 +-1.5 years with a range of 17-25 years. The majority were males (n=285, 51.9%) and from private sector medical colleges (n=432, 78.7%). Most of them were from Peshawar Medical College (n=265, 48.3%), followed by Khyber Medical College (n=117, 21.3%), Kabir Medical College (n=103, 18.8%) and Rahman Medical College (n=64, 11.7%). Majority were from second year (n=175, 31.9%) of their medical school studies, followed by students of third year (n=144, 26.2%), first year (n=139, 25.3%), fourth (n=87, 15.8%) and final year (n=4, 0.7%). The details are given in Table 1. According to the responses of Habit questionnaire, only 54 (9.8%) students were not involved in any body focused repetitive behaviour. The most common habit in medical students was chewing lips (n=365, 66.5%), followed by biting nails (n=264, 48.1%) [Table 1].

The most common feelings associated before committing the habits mentioned in the questionnaire were irritability, frustration or anger (n=84, 15.3%), followed by emptiness or boredom (n=83, 15.1%) and sadness (n=69, 12.6%). The most common feelings during committing the habits in were irritability, frustration or anger (n=99, 18.0%), followed by sadness (n=93, 16.9%) and emptiness or boredom (n=90, 16.4%). The most common feelings after committing the habits were calmness (n=121, 22.0%), relief (n=110, 20.0%) and guilt (n=92, 16.8%), respectively. The details of Habit questionnaire showing body focused repetitive behaviour in last 2 weeks is given in Table 2. The gender wise comparison showed that statistically significant habit in male was punching a wall (0.000) and in females, it was chewing lips (p=0.024). Public sector students showed more involvement in all these habits, as compared to the students of private sector medical colleges. The details and significance is given in Table 3.

DISCUSSION

This study was conducted to find out the occurrence of body-focused repetitive behaviours (BFRBs) in medical students of Peshawar. The prevalence of BFRBs was found to be much higher in our study than a previous survey conducted in Karachi, which stated it to be 22%8. Our study showed that the most common habit in medical students was chewing on lips followed by biting nails. Wood et al9 reported that 21.8% of the sample engaged in chewing on mouth, lips or cheeks and 10.1% engaged in nail biting. Nail biting (n=109; 34.6%) followed by skin picking (n=78; 24.8%) has also been shown to be at the top of the behaviours in a study conducted by Roberts et al10. Another study has shown biting nails to be the most common behaviour11. However, in another study, grinding teeth (54%) was the most common repetitive behaviour, followed by biting nails (36.5%)12.

One study has divided the habits in three groups, showed that the commonest group of habits was related to trichotillomania (13.3%) followed by dermatillomania (9%)8. The most common feelings associated before and during committing the habits was irritability, frustration, or anger while most common feelings after committing the habits was calmness, relief and guilt. A study by Sarah et al13 showed that participants in the BFRBs group reported a stronger urge to engage in BFRBs in the boredom/frustration condition than in the relaxation condition. The results of another study indicated significant decreases in boredom, anxiety and tension and significant increases in guilt relief, sadness and anger across time related to trichotillomania14. Based on gender, chewing lips (62.1%) and punching walls (52.6%) were more common in men while chewing lips (71.2%) and nail biting (47.3%) were a common trend in women.

In a study by Siddiqui et al8, chew mouth, lips or cheeks was reported to be 41.8% (23/55) in males and 32.9% (51/155) in females while nail biting was stated to be 20% (11/55) in males and 23.2% (36/155) in females. A study conducted by Stephania et al15 showed that 15% females engaged in clinically significant skin picking compared to only 6.1% of males. This is in contrast to our finding where 34% males were involved in skin picking as compared to 33.3% females. There is dearth of literature comparing the presence of body focused repetitive behaviours between students of public and private sector medical colleges.

CONCLUSION

There is a high frequency of body-focused repetitive behaviours in medical students. The most common habit in both genders was chewing lips. However, it was significantly more in females while in males, punching the wall was the more significantly reported habit. Further investigations should be made on epidemiological, neurobiological and psychiatric levels to understand the causes and mechanisms of BFRBs and their relation to other compulsive disorders.

ACKNOWLEDGEMENT

The authors would like to thank Syeda Tabreek Motahir and Fareeha Javed for their help in data collection.

REFERENCES

1. Roberts S, O'Connor K, Belanger C. Emotion regulation and other psychological models for body-focused repetitive behaviors. Clin Psychol Rev 2013;33:745-62.

2. Grant JE, Stein DJ. Body-focused repetitive behaviour disorders in ICD-11. Rev Bras Psiquiatr 2014; 36:S59-64.

3. Diefenbach GJ, Reitman D, Williamson DA. Trichotillomania: A challenge to research and practice. Clin Psychol Rev 2000; 20:289-309.

4. Tanaka OM, Vitral RW, Tanaka GY, Guerrero AP, Camargo ES. Nailbiting or onychophagia: a special habit. Am J Orthod Dentofacial Orthop 2008; 134:305-8.

5. Leung AK, Robson WL. Nailbiting. Clin Pediatr (Phila) 1990; 29):690-2.

6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Arlington: Am Psychiatr Pub; 2013.

7. Resnick HS, Weaver T. Habit Questionnaire: Unpublished measure. Med University of South Carolina, Charleston; 1994.

8. Siddiqui EU, Naeem SS, Naqvi H, Ahmed B. Prevalence of body-focused repetitive behaviours in three large medical colleges of Karachi: a cross-sectional study. BMC Res Notes 2012; 5:614.

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10. Selles RR, Nelson R, Zepeda R, Dane BF, Wu MS, Novoa JC et al. Body focused repetitive behaviors among Salvadorian youth: Incidence and clinical correlates. J Obsessive-Compul Relat Disord 2015; 5:49-54.

11. Teng EJ, Woods DW, Twohig MP, Marcks BA. Body-focused repetitive behavior problems. Prevalence in a nonreferred population and differences in perceived somatic activity. Behav Modif 2002; 26:340-60.

12. Sacks MB, Flood AM, Dennis FM, Hertzberg MA, Beckham JC. Self-mutilative behaviors in male veterans with posttraumatic stress disorder. J Psychiatr Res 2008; 42:487-94.

13. Roberts S, O'Connor K, Aardema F, Belanger C. The impact of emotions on body-Focused repetitive behaviors: Evidence from a non-treatment-seeking sample. J Behav Ther Exp Psychiatry 2015; 46:189-97.

14. Diefenbach GJ, Mouton-Odum S, Stanley MA. Affective correlates of trichotillomania. Behav Res Ther 2002; 40:1305-15.

15. Hayes SL, Storch EA, Berlanga L. Skin picking behaviors: An examination of the prevalence and severity in a community sample. J Anxiety Disord 2009; 23:314-9.
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Title Annotation:Pakistan
Author:Khan, Shifa A.; Khan, Mahd Aftab; Khan, Mahnoor; Sethi, Mifrah Rauf; Irfan, Muhammad
Publication:Journal of Postgraduate Medical Institute
Article Type:Report
Geographic Code:9PAKI
Date:Sep 30, 2018
Words:2814
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