The Future of Body-Focused Repetitive Behavior Treatment:

A Serious Game Intervention

Olivia Archer
School of Communications
Elon University
Elon, North Carolina, USA
oarcher@elon.edu

ABSTRACT behaviors that seem to stick around. Addiction is not defined by

People with body-focused repetitive behaviors (BFRBs) are
traditionally treated with cognitive behavioral therapy (CBT), but
patients often face relapse and irreversible effects. This literature
review suggests serious games as a more innovative and effective
treatment approach. Instead of sole reliance on in-person therapy,
which concerns issues like affordability, availability, and access,
people should turn to the future of treatment – serious games.
Serious games integrate digital gaming technology to address a
specific set of learning objectives of behavioral goals. Serious
gaming offers a more engaged and hands-on approach to alleviate
the symptoms of body-focused repetitive behaviors. Additionally,
they capitalize on the preexisting, positive relationship the world
already maintains with games. By viewing serious games as a
CBT variant and incorporating particular designs, personalization
models, and research, games present the opportunity to potentially
eradicate a seemingly incurable disorder.
KEYWORDS
BFRBs, intervention, serious games, CBT
ACM Reference format:
Olivia. Archer. 2022. The Future of Body-Focused Repetitive Behavior
Treatment: A Serious Game Intervention (Unpublished literature review).
Elon University, Elon, NC, USA.
1  INTRODUCTION
Addiction is pill popping. Syringes. Another drink. One more bet.
The last time. They swear. But addiction is more than substances.
Addiction is the all-consuming, self-destructive, and debilitating
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the medium, but by the action and consequence. While people
think of addiction as relating to substances, it also presents
through other mediums. A prevalent example is body-focused
repetitive behaviors (BFRBs). BFRBs refer to recurrent, motoric
acts involving any excessive self-grooming behavior (Grant et al.,
2022). This includes actions of picking, pulling, and biting
involving one’s hair, skin, nails, cheeks, or lips that cause physical
damage to the body. While these behaviors are common habits,
their pathological manifestations are rare and have been met with
multiple unsuccessful attempts to stop or decrease the habit.
(Houghton et al., 2019). BFRBs bring feelings of shame and
embarrassment and are notoriously difficult to treat (Stewart &
Lipner., 2020).
While cognitive behavioral therapy (CBT) is seen as the most
helpful and common treatment option, BFRBs remain under-
researched and in need of long-term solutions since they seldom
go into full remission (Stock et al., 2020). Serious games are
nonconventional, but a promising solution to this disorder. With
over 3.24 billion gamers logging 3 billion hours of weekly games,
experts acknowledge games’ camaraderie, sense of community,
and ability to engage people (Kowal et al., 2021). While games
were initially developed for entertainment purposes, game-based
interventions prove effective in addressing barriers relating to
access and engagement in healthcare. Even though serious games
are a relatively new area of interest, they have the power to
change behavior through more innovative and persuasive tactics.
The development and increased use of technology seem to be at
the forefront of digital intervention. Therefore, this literature
review examines how interactive gaming could provide people
with BFRBs with the most beneficial and effective treatment
option.

© 2022 Copyright held by the owner/author(s). In the first section of the paper, I review the neurobiology of
BFRBs. To holistically understand manifestations of BFRBs, it is

important to understand the biological components surrounding
the behavior. I also discuss overlapping disorders that provide
insight into potential treatment options. In the following section, I
review the roles of emotion and distraction in treatments for
repetitive behavior. This offers insight into features treatment
plans should employ to produce practical treatment plans. In the
final section, I will introduce and propose serious gaming
strategies as the most effective and integral part of treating
BFRBs.
2.1 Neurobiology of BFRBS and Similar Disorders
The most effective way to curate a treatment plan for any disorder
is to understand underlying biological deficits. While the etiology
of BFRBs is difficult to specify, research suggests a range of
corresponding biological dysfunction associated with the disorder.
Understanding these biological complexities is necessary to study
and design effective treatment options focused on the proper area
of concern. The neural components of this disorder suggest better-
adapted and suited courses of treatment. Potential problematic
areas include issues with reward processing, excessive sensory
sensitivity and difficulty regulating sensory inputs, and resulting
impulsivity.
Reward processing is the first area examined. The noticeable
picking and pulling of BFRBs can be described as addictive and
pleasurable, like the feelings associated with a substance abuse
problem. BFRBs are linked to disordered reward processing. To
analyze the emergence and responsiveness of BFRBs, Grant et al.,
(2022) completed extensive neuroimaging. Examination of the
reward circuitry activation of patients with BFRBs indicates
evidence for dysregulated reward circuitry. Biologically, these
issues are shown by hyperactivation of the bilateral inferior
frontal gyrus in people with BFRBs when expecting rewards or
punishments (Grant et al., 2022). Since reward-seeking and
avoidance play integral roles in human behavior, dysfunctional
reward processing can form maladaptive behaviors. These
maladaptive behaviors emerge as BFRBs.
Another area of growing evidence links BFRBs to excessive
sensory sensitivity and difficulty regulating sensory inputs
(Houghton et al., 2019). Neurobiological evidence also suggests
deficits in feed-forward inhibition. The pulling and picking
associated with BFRBs once considered facets of poor behavioral
inhibition suggest additional non-motor-related causes. Pulling
and picking are maintained through sensory reinforcement which
alleviates stress by producing short-term rewarding feelings.
Therefore, people typically note somatic urges to engage in
picking/pulling. Despite unexplored sensory mechanisms involved
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in BFRBs, individuals self-report abnormal sensitivity to sensory
input. People report a higher frequency of interoceptive
sensations, higher levels of sensory intolerance, and increased
perceptual sensitivity (Houghton et al., 2019). Research
surrounding repetitive behavior supports a relationship between
perceptual anomalies and these behaviors.
Another popular theory suggests a connection between BFRBs
and impulsivity impairment. While research does not indicate
worse motor inhibition in individuals with BFRBs, findings
indicate individuals with BFRBs may exhibit issues in particular
domains of impulsivity, like delayed discounting, instead of
holistically (Murphy & Flessner, 2017). These wide-ranging
indicators of potential varying neurobiological issues thwart
treatment development. The lack of clear pathophysiological
targets and conflicting studies make it difficult for experts to
develop targeted treatment plans (Murphy & Flessner, 2017).
Consequently, there are no first-line curative medications
available for patients with these disorders (Skurya et al., 2020).
Selective serotonin reuptake inhibitors (SSRIs), however, are
commonly used with mixed results.
The most traditional and successful course of treatment is
cognitive behavioral therapy. A form of CBT is known as Habit
Reversal Therapy (HRT) (Skurya et al., 2020). HRT shows
promise in the reduction of repetitive behaviors. The objective of
this method is to allow the patient to pinpoint the triggers (i.e.,
certain activities, body postures, or tactile features) and problem-
solve ways to eliminate or modify stimulating triggers.
Regardless, patients require more developed and long-lasting
solutions. Interestingly however, HRT experienced success
through the augmentation of additional therapy methods (Skurya
et al., 2020). Therefore, the integration of other intervention
practices, like gaming, in combination with CBT, acts as a novel
and more productive treatment plan.
Other considerable factors when making treatment plans for a
lesser known disorder involves examining similar disorders and
their respective regimens. Since the field of BFRBs and
corresponding treatment options are largely unexplored and do not
maintain high efficacy rates, similar disorders offer deeper insight
and findings. The similarity of Tourette's, BFRBs, and OCD lie in
the semi-voluntary actions, similar trigger profiles, and the relief
stemming from the sensation, and the sensory stimulation itself
(O’Connor et al., 2018). Prevalence rates of comorbid OCD and
 The Future of Body-Focused Repetitive Behavior Treatment
BFRBs among adults range from 16-35% (Hodges, 2019). This
substantial statistic indicates the potential for shared treatment
options between these disorders.
OCD has been the subject of elemental intervention for over 20
years (Murphy et al., 2016). Moderate cases of OCD are typically
combatted through exposure and response prevention (ERP)
(Hong et al., 2018). While this process is effective, the process is
drawn out and costly. To provide a more manageable and
available option, Hong et al. 2018 explored serious games. A pilot
mobile serious game, RAW HAND, integrated ERP principles,
and notably improved OCD symptoms. After weeks of playing the
game, OCD subjects patients had notably improved symptoms as
well as decreased depressive and anxiety symptoms. This is one
example of the untapped potential games offer people with similar
neural functions or pathologies to OCD.
Since remission of BFRBs is uncommon, a more focused and
deliberate course of action based on neurobiology is vital for the
efficacy of treatment plans. Research on reward processing
demonstrates how the desirability and addictiveness of pulling
from dysregulated reward circuitry form maladaptive behaviors.
Excessive sensory sensitivity and difficulty regulating sensory
inputs suggest deficits in feed-forward inhibition create unhealthy
relationships between BFRBs and the short, but immediate feeling
of positive reinforcement. Other evidence suggests a correlation
between BFRBs and impulsivity impairment. However, despite
gaining a fundamental understanding of neurobiological
dysfunction and comparing similar disorders like OCD, they are
only one step towards abating symptoms of BFRBs. Beyond
neurobiology and shared pathologies, emotions play a crucial role
in influencing and affecting behavior.
2.2 Emotional Regulation Strategies
Emotions play an integral role in understanding BFRBs and their
impacts and response to treatment. Emotion regulation is another
commonly used model to understand and explain BFRBs.
According to the model, BFRBs are characterized by global
deficits in emotion regulation (Snorrason et al., 2010). This theory
asserts that BFRBs act as a coping mechanism to relieve negative
feelings. Instead of the behavior acting as reinforcement, it is the
sense of relief from the behavior that perpetuated the behavior. A
stimulus model offers an understanding of the disorder as a
soothing mechanism and means of regulation (Snorrason et al.,
2010). An individual may experience peaking and crashing waves
of emotion and seek a feeling of regularity and homeostasis.
Regulation of emotion is an extremely important and adaptive
process within social environments. The two main attempts at
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controlling emotions include attentional control, known as a
distraction, or cognitive change, known as reappraisal (Kanske et
al., 2011). Kanske et al. demonstrated effectiveness in both
regulation strategies in downregulating emotional responses to
both positive and negative stimuli. Notably, each regulation
strategy was distinct and involved different psychological
mechanisms and ties to a varying pattern of connectivity (Kanske
et al., 2011). While distraction relies on people shifting focus
away from an emotional stimulus, reappraisal maintains focus on
the emotional stimulus, while changing the meaning in relevance
to the stimuli.
Another study measured the different forms of emotion regulation
through electrocortical responses to emotional and neutral images
over different phases (Thiruchselvam et al., 2011). Again,
distraction encouraged an attention shift away from particularly
emotionally volatile aspects of stimuli. Reappraisal aimed to re-
evaluate given emotional events and their EEG. The study
suggested distraction reduced emotional intensity and diminished
activation in pain-related regions of the brain. Distraction proved
to be a first-line defense against the emotional stimulus
(Thiruchselvam et al., 2011). However, the study also indicated
that pushing off engagement with the stimuli through distraction
causes greater emotional responses upon exposure to the stimulus.
When understanding the implication of these studies, patients with
BFRBs need a direct form of therapy against their viewpoints on
BFRBs. For example, a study examined the prediction of
automatic and focused skin picking (SPD) based on trait disgust
(Schielne et al., 2018). SPD is another BFRB that impacts people
mentally, physically, and emotionally. Results indicated SPD
subtypes could each be predicted by different personality traits.
Focused picking aligned with disgust proneness and behavioral
self-disgust. This feeling of disgust makes people experience
contempt towards particular stimuli and encourages avoidance,
clearing, grooming, and distancing. Behavioral self-disgust is
when individuals consider their behavior repulsive (Schielne et
al., 2018). These feelings of disgust are misguided and need to be
addressed directly through reappraisal. Other similarly echoed
ideas about the importance of reappraisal note a positive first step
in treatment is removing the stigma of embarrassment surrounding
BFRBs (Steward and Lipner, 2020).
Patients potentially respond differently to the treatment of their
BFRBs due to their individualized application of emotional

regulation. BFRBs engineered a negative correlation between
carrying out a bad habit and receiving a positive response from
their body. Therefore, BFRBs act as de-stressing coping
mechanisms that reinforce bad behavior. These emotions are
managed through distraction and reappraisal. While each
regulation strategy demonstrates effectiveness in downregulating
emotional responses, pushing off emotion through distraction
causes greater emotional responses upon exposure to the stimulus.
This suggests patients need a straightforward way to engage with
the emotion of their BFRBs to reframe their feelings through
reappraisal.  BFRBs cannot be solved without addressing the
emotional component, which is why gaming technology
continually integrates emotion to get the best results.
2.3  Gaming as Future of Intervention Treatment
Games embody important aspects of science, psychology, and
emotion that make them the perfect vehicle to transform BFRB
treatment. The original entertainment based industry of games
make them hard to trust in a more pragmatic and useful sense.
Serious games, however, should not be viewed as a lackadaisical
or far-fetched last attempt as a treatment option. Games satisfy
players’ desire for autonomy, connectedness, and control
(Baranowski, 2008). 60% of gamers come from the 0-34 age
demographic, and 24% spend 1.44 average hours gaming on a
typical day. Video games extend across a diverse audience and
attract, maintain, and engage attention-which is a vital component
of effective behavior change (Baranowski, 2008). Therefore,
video games prove to be a promising solution because they offer
the opportunity for extensive player involvement ranging from
children to adults. This medium provides a channel to encourage
behavior change and communicates entertaining and engaging
messages. This channel also capitalizes on children’s preexisting
affinity for video games.
Effective behavior-changing games are a deliberately crafted CBT
variant (Hodges, 2019). There is a rise in technological delivery of
CBT through web-based programs compared to the traditionally-
delivered in-session CBT (Hodges, 2019). The uptick of
computers in the household initiated the development of mental
health therapy through technology (Li et al., 2014). With these
technologies came digital interventions with game components.
These developments are practical and wide-reaching ways to
overcome the access barrier in the healthcare sphere, primarily
among younger people.
The future of treatment options need progressive thinking, making
innovation invaluable capital for society. Many of the problems
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people face require innovative solutions, which account for the
rise in popularity of video game-inspired software to address
issues. These apps are based around gamification, which is the
“use of game design elements in nongame contexts” (Morford et
al., 2014). The efforts of gamification attempt to redesign daily
activities while implementing methods in game design.
Gamification has been applied in different contexts including
education, energy conservation, health, and fitness (Morford et al.,
2014). However, the most common application of gamification is
related to health and fitness (Kamal et al., 2011). Gaming offers a
hands-on, inventive, and nontraditional solution to people who
struggle with BFRBs.
Game mechanics are already interconnected into daily practices
and routines demonstrating their practicality and ease of
application. People (users) receive rewards for eating healthy
foods, using public transport, and practicing certain hygiene. By
curating games with particular game design elements, like
offering suitably motivating rewards, players become motivated to
change their behavior (Schuller et al., 2013). Digital games have
the power to motivate people to perform beneficial actions like
taking care of their bodies and minds. For example, games can be
designed to help overcome addictive behaviors like substance
abuse and promote mindfulness (Stock et al., 2020).
Changing behavior is a challenging feat, which is why a deliberate
and strategic process is necessary. Behavior is a complex,
formational process influenced by a multitude of factors, making
it resistant to change and hard to alter (Thompson et al., 2010).
Because of this complexity, behavioral scientists use multistep
processes to change the mediators instead of the behavior itself.
To properly engage players and change behavior, designers
employ entertainment and behavior change experts (Thompson et
al., 2010). These mediums work because entertainment maintains
players’ attention while exposing them to behavior change
procedures.
Video games also offer the individualization that basic therapy
lacks. Serious games motivate behavior and retain attention
surrounding more serious topics. While serious games have the
power to change behavior, persuade, and teach information,
strategies employed uniformly may not yield the same response
from each player (Orji et al., 2017). Essentially, the effective and
persuasive strategies that motivate one player could demotivate
others. Therefore, video games that stray from a broad approach
will be most successful. Therapists and experts in the medical
field do not have the time or resources to craft individualized
treatment plans, making video games a solid alternative. Games
that use a “one size fits all” approach are deemed ineffective
 The Future of Body-Focused Repetitive Behavior Treatment
because people are motivated by different persuasion strategies
(Orji et al., 2017). For games to achieve behavioral change in
users, they must integrate personalization models.
Games integrate many notable features making them worthwhile
mediums to communicate treatment. Reward mechanisms in
games provide a sense of fun by offering an intrinsic reward to
users (Wang & Sun, 2011). Reward systems make game
mechanisms more enjoyable by setting achievable goals and
rewarding them with an appropriate reward. Using games as a
positive behavior intervention can yield strong results. Positive
behavior interventions are more frequently and widely used in
schools. These interventions are not limited to age and expand
from early childhood to high school to reduce aggression and
lessen outbreaks of disruptive behavior (Yeung et al., 2016). The
most successful implementation plans identified sustainability and
implementation fidelity components. Implementation fidelity
explains the degree to which teachers stick to the programs
intended by the developers. Sustainability refers to the longer-
term implementation of a practice that allows for valuable
outcomes to be produced (Yeung et al., 2016). Serious games
already integrate these principles and therefore offer promising
results when supplemented with other necessary game design
factor and measures of CBT.
3  CONCLUSION
Given the nonstop progression of technology, serious games offer
a novel and practical way to address BFRBs. By integrating
important elements like reward mechanisms, positive behavior
interventions, personalization, and CBT, games include targeted
plans to garner better results. The future of BFRBs requires a
redirection away from conventional treatment. Experts in other
fields are experimenting with the design of wearable technology.
Wearables monitor the context, triggers, and consequences of
BFRBs and receive positive feedback (Searle et al., 2021). Other
wearables track hand position concerning the head (Son et al.,
2019). Regardless of the medium, people are proposing cutting-
edge and more technology-based ideas for treatment options.
Serious games continue to rise in popularity and pilot games
constantly test out different versions for efficacy. People with
BFRBs need a way to overcome their problems–and the
implementation of serious games is their answer.
ACKNOWLEDGMENTS
I thank Dr. Derek Lackaff for offering guidance and providing
insight throughout the research and writing process.
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