Ask almost anyone about GLP-1 medications right now, and you’ll get a lively conversation—not just about weight, but about everything else these drugs seem to potentially impact. One of the more surprising conversations in therapist circles involves a set of behaviors most of us don’t connect to metabolism at all: body-focused repetitive behaviors, or BFRBs.
BFRBs include hair pulling, skin picking, nail biting, and related behaviors like cheek biting, lip biting, and cuticle picking. What these behaviors tend to share is a certain tenacity. They often persist despite distress and repeated, earnest attempts to stop.
Potential Impact of GLP-1 Receptor Agonists on BFRBs
What makes GLP-1 receptor agonists, namely semaglutide, tirzepatide, and others, so interesting is that their effects appear to extend well beyond appetite. GLP-1 receptors are found throughout the brain, including in regions tied to reward and impulse control. And, there is emerging evidence that these medications may quiet what we consider to be the brain’s “craving” circuitry: the urge-driven, automatic pull that shows up not only in overeating, but in drinking, smoking, and, as case reports suggest, might also be in BFRBs as well.
While we don’t yet have sufficient, controlled research on GLP-1s and BFRBs, we have case reports from both patients and clinicians suggesting there may be a relationship, and these reports have been consistent enough to warrant attention. Patients have reported that these medications, prescribed for weight management, have stopped or sharply reduced their hair pulling, skin picking, or nail biting. Others describe the urge itself as having “quieted.” Perhaps the “food noise” often associated with these medications may also be “BFRB noise.” This is notable, given how resistant these behaviors can be to change.
It is possible these medications are modulating the same reward and urge pathways that underlie BFRBs, essentially turning down the signal strength of the behavior loop. Whether that’s a direct neurochemical effect, an indirect one through reduced overall impulsivity/compulsivity, or something we have yet to identify, we don’t yet know. But it’s a question worth exploring.
It is important to consider this in the context of BFRB heterogeneity: Even if this holds true, it may describe the experience of only a subset of people living with a BFRB. If GLP-1s offer some people relief from urges they’ve wrestled with for years, this is significant. It may even be a clue, pointing us toward better, more integrative approaches to treatment.
Role of Behavioral Therapy in BFRB Treatment
Of course, although this is an exciting avenue to explore, it’s also important to remember that behavioral therapy remains the standard of care for BFRBs, and it does something medication cannot do: It addresses the function the behavior serves, the reason it shows up there in the first place, and helps to more adaptively meet that need. Ultimately, treating the whole person with a broad view and integrative approach to treatment is essential to improving outcomes.
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