Anxiety and body-focused repetitive behaviors: A systematic review and meta-analysis of comorbidity rates and symptom associations

Body-focused repetitive behavior (BFRB) disorders, including hair pulling disorder (trichotillomania [TTM]) and skin picking disorder (SPD), frequently co-occur with anxiety disorders, but reported comorbidity rates vary widely. Additionally, research on the relationship between anxiety and BFRB symptoms has yielded inconsistent findings. This meta-analysis and systematic review examined (1) the prevalence of comorbid anxiety disorders in individuals with BFRB disorders and (2) correlations between anxiety and BFRB symptom measures. The study protocol was pre-registered on PROSPERO. A systematic search of PsycInfo, PubMed, and Web of Science identified 119 studies (N=15,902) reporting anxiety prevalence rates in BFRB disorders and/or correlations between anxiety and BFRBs. Random-effects meta-analyses were conducted, including subgroup analyses for TTM and SPD, and meta-regression to examine potential moderators. Results indicated that comorbid anxiety disorders, including generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), social anxiety, panic disorder, and specific phobia, were relatively common in BFRBs. Current prevalence rates were 19.2% for GAD, 12.8% for OCD, 10.6% for social anxiety, and 27.5% for 'any anxiety disorder.' Lifetime prevalence rates were 22.4% for GAD, 13.8% for OCD, 11.0% for social anxiety, and 35.9% for 'any anxiety disorder.' Pooled correlations between anxiety and BFRB severity were low to moderate (all BFRBs r=.29; TTM r=.27; SPD r=.34). Anxiety symptoms showed stronger correlations with focused BFRB measures (r=.42) than automatic (r=.15). These findings highlight a nuanced relationship between anxiety and BFRBs. While comorbid anxiety disorders are frequently observed in BFRB populations, anxiety severity is only modestly associated with BFRB severity. Implications for future research and clinical practice are discussed.