Body-Focused Repetitive Behaviors
(BFRBs)
Hair Pulling, Skin Picking, and Related Conditions Explained
Natalie Noel, LMHC | Anxiety & OCD Treatment Specialists | Tampa, FL
Read More About Our Specialties
You have tried to stop. Maybe hundreds of times. You tell yourself today will be different. And then almost without realizing it you are doing it again. Pulling. Picking. Biting. And the shame that follows can feel defeating.
If this sounds familiar, you are not alone. Body-focused repetitive behaviors or BFRBs affect millions of people. They are real, recognized conditions. And they are treatable.
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At Anxiety & OCD Treatment Specialists, we work with children, teens, and adults who struggle with BFRBs. For BFRBs, we offer in-person sessions in Tampa, Florida, and virtual sessions across Florida.
Quick Answer: What Is a BFRB?
A body-focused repetitive behavior (BFRB) is a compulsive, repetitive action directed at the body like pulling hair, picking skin, biting nails, or chewing cheeks. BFRBs are not habits or bad choices. They are recognized mental health conditions that fall under the Obsessive-Compulsive and Related Disorders category in the DSM-5. They are treatable with the right specialized therapy.
Types of Body-Focused Repetitive Behaviors
BFRBs come in several forms. The two most well-known are trichotillomania and excoriation disorder but there are others. Here is an overview:
| BFRB | What It Involves | Common Locations |
|---|---|---|
| Trichotillomania | Compulsive hair pulling | Scalp, eyebrows, eyelashes, beard, pubic area |
| Excoriation Disorder | Compulsive skin picking | Face, arms, hands, legs, back, scalp |
| Onychophagia | Compulsive nail biting | Fingernails, toenails, surrounding skin |
| Dermatophagia | Compulsive skin biting or chewing | Inside of cheeks, lips, fingers, knuckles |
| Rhinotillexomania | Compulsive nose picking | Nose often with picking at surrounding skin |
| Morsicatio Buccarum | Compulsive cheek biting | Inner cheeks, lips, gum tissue |
All of these behaviors share a common pattern: they are repetitive, they are hard to control, they often happen automatically, and they cause distress or interfere with daily life, relationships, or physical health.
Trichotillomania (Hair Pulling Disorder)
Trichotillomania often called “trich” is the compulsive urge to pull out hair from the scalp, eyebrows, eyelashes, or other parts of the body. It is more common than most people realize, affecting about 1 to 2 percent of the population.
Hair pulling is not about vanity or a desire to hurt oneself. Most people with trichotillomania describe a building tension before pulling and a sense of relief immediately afterward similar to how a pressure valve works. The relief is temporary. The cycle continues.
- Noticeable thinning or bald patches on the scalp, eyebrows, or eyelashes
- Pulling hair while reading, watching TV, falling asleep, or during stress
- Pulling that happens automatically without fully realizing it
- Examining, playing with, or mouthing pulled hairs after removal
- Trying repeatedly to stop or cut back and not being able to
- Wearing hats, scarves, or makeup to hide hair loss
- Avoiding social situations, swimming, or intimacy because of appearance
- Swallowing pulled hair or follicles
Trichotillomania is not a choice, a phase, or something a person can just stop if they try hard enough. It is a recognized disorder that requires specialized treatment not willpower.
Excoriation Disorder (Skin Picking Disorder)
Excoriation disorder also called skin picking disorder or dermatillomania involves compulsive picking at the skin. This can include picking at pimples, scabs, bumps, or even healthy skin. It is not about hygiene or grooming. It is a compulsion that many people feel powerless to stop.
Like trichotillomania, skin picking often provides a brief sense of relief or satisfaction followed by shame, distress, and sometimes physical damage to the skin. Wounds, scarring, and infection are common consequences of severe excoriation disorder.
Signs of Excoriation Disorder
- Spending significant time picking at skin sometimes hours per day
- Picking at perceived imperfections, scabs, or perfectly healthy skin
- Picking that happens automatically while scrolling, watching TV, or during stress
- Skin sores, scarring, or infections caused by picking
- Wearing concealing clothing or makeup to hide picked areas
- Feeling unable to stop even when the picking causes pain or bleeding
- Distress, shame, or embarrassment about the behavior
BFRBs Are Not Self-Harm
BFRBs are sometimes confused with self-harm, but they are different conditions.
Self-harm is typically driven by a desire to feel pain or to punish oneself.
BFRBs are driven by an urge to regulate tension or sensory discomfort not to cause pain.
The distinction matters because the treatment approaches are different.
If you are unsure which applies to you or someone you love, a proper assessment
with a trained specialist is the best first step.
Why Do BFRBs Happen?
BFRBs do not have one single cause. Research points to a mix of factors:
- Genetics. BFRBs tend to run in families. If a parent or sibling has a BFRB or OCD, you are more likely to develop one too.
- Brain chemistry. BFRBs are linked to differences in how the brain processes urges, rewards, and emotional regulation.
- Stress and anxiety. Many people find that their BFRB worsens during stressful periods. The behavior becomes a way of managing uncomfortable emotions even if only briefly.
- Sensory needs. Some people with BFRBs describe a strong sensory component seeking a specific texture, feeling, or sensation. This is sometimes called a "just right" feeling.
- Automaticity. Many BFRB episodes happen without conscious awareness. The person is absorbed in another activity and does not realize they are pulling or picking until it is already happening.
Understanding your personal triggers whether emotional, sensory, situational, or automatic is a key part of treatment. It is different for every person.
Who Is Affected by BFRBs?
BFRBs can start at any age but they most often begin in childhood or adolescence. Trichotillomania typically starts between ages 10 and 13. Excoriation disorder often begins in early teen years, sometimes triggered by puberty-related skin changes.
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BFRBs affect people of all genders, backgrounds, and ages. They are often kept secret for years sometimes decades because of shame. Many people have never told their doctor, let alone a therapist.
BFRBs also frequently co-occur with other conditions, including:
A thorough assessment helps identify what else might be contributing and ensures your treatment plan addresses the whole picture.
How Are BFRBs Treated?
Habit Reversal Training (HRT)
HRT is the most researched and widely recommended treatment for BFRBs. It has three main components:
- Awareness training. Learning to notice exactly when, where, and how the BFRB happens including the automatic episodes you may not even realize are occurring.
- Competing response. Practicing a different physical behavior that is incompatible with the BFRB. For example, when the urge to pull arises, clenching a fist or squeezing a fidget tool instead.
- Social support. Involving a trusted person who can offer gentle, agreed-upon support when they notice the behavior occurring.
The Comprehensive Behavioral Treatment Model (ComB)
ComB is a newer and more individualized approach to BFRB treatment. Instead of one standard protocol, it assesses your specific triggers across five areas sensory, cognitive, affective (emotional), motor, and environmental and builds a treatment plan targeting exactly what drives your behavior.
ComB is considered the current gold standard for BFRB treatment and is especially useful when HRT alone has not been enough.
Cognitive Behavioral Therapy (CBT)
CBT addresses the thoughts and beliefs that fuel BFRBs like shame, perfectionism, or the belief that the urge is too powerful to resist. It helps people develop a more realistic and compassionate relationship with their behavior and their recovery.
A Note on Medication
Unlike OCD, there is no single FDA-approved medication specifically for BFRBs. However, some medications including SSRIs and N-acetylcysteine (NAC) have shown promise in research studies and may be helpful for some people, particularly when anxiety or OCD is also present.
We are therapists, not psychiatrists, and do not prescribe medication. If medication may be appropriate for you, we will refer you to a trusted psychiatrist and coordinate your care. Behavioral therapy remains the most effective and well-supported treatment for BFRBs and it is where we focus.
What to Expect When You Work With Us
Many people with BFRBs have tried to stop on their own and felt like failures when they could not. We want you to know that BFRBs are not a willpower problem. They respond to the right treatment, delivered by a trained specialist.
- Free consultation. A 10-minute call to learn about what you are experiencing and answer your questions with zero judgment.
- Full assessment. We assess your specific BFRB, your triggers, your history, and any co-occurring conditions.
- A personalized treatment plan. HRT, ComB, or a combination of both built specifically around your behavior and your life.
- Practical skills between sessions. Recovery happens in daily life, not just during appointments. We give you tools to use in real time.
- We work with all ages. We treat children, teens, and adults. For children and teens, parents are an active part of the process.
Treatment length varies depending on the severity of the BFRB and how long it has been present.
In-Person and Virtual Sessions
In-person
730 S Sterling Ave, Suite 306, Tampa, FL 33609
Virtual
Available throughout Florida
Virtual sessions work very well for BFRBs. In fact, being in your home environment where BFRBs most often occur can make it easier to practice skills in context and identify triggers in real time.
Frequently Asked Questions
Can I really stop a BFRB? I have tried so many times.
Most people with BFRBs have tried to stop on their own and most have not succeeded with willpower alone. That is not a personal failure. BFRBs are neurologically driven behaviors that require a specific behavioral approach, not determination. With the right treatment, most people see significant and lasting reduction in their BFRB.
Are BFRBs a form of OCD?
BFRBs and OCD are in the same family of conditions in the DSM-5 called Obsessive-Compulsive and Related Disorders. They share some features, like repetitive behavior and difficulty stopping. But they are not the same thing. OCD is driven by obsessions and fear of harm. BFRBs are driven more by urges, tension relief, and sensory needs. Some people have both. A proper assessment helps identify what is driving your behavior.
Is it normal to not even notice I am doing it?
Yes this is one of the most common features of BFRBs. Many episodes are “automatic” happening while you are focused on something else, like reading, driving, or watching TV. Awareness training (a core part of HRT) specifically targets this. You cannot change what you cannot notice. Learning to catch the behavior earlier or the urge before the behavior is a big part of treatment.
My child picks their skin or pulls their hair. What should I do?
First, try not to react with alarm or criticism. Negative attention can increase shame and shame often makes BFRBs worse. A calm, supportive response is best. Then consult a specialist who works with children and BFRBs. Early treatment tends to lead to better outcomes. We work with children and involve parents directly in the treatment process.
Is this something I will have to manage forever?
Potentially, but management doesn’t have to be daunting. Many people with BFRBs achieve full remission meaning the behavior stops and the urges are minimal. Others learn to manage urges so effectively that the BFRB no longer interferes with their life.
What is the difference between trichotillomania and excoriation disorder?
Trichotillomania involves pulling hair from the scalp, eyebrows, eyelashes, or body. Excoriation disorder involves picking at skin including pimples, scabs, or healthy skin. Both fall under the BFRB umbrella. Both are treated with similar approaches, though the specific techniques are tailored to each condition. Some people have both at the same time.
You Have Tried to Stop on Your Own. Now Let Us Help.
BFRBs thrive in secrecy and shame. The longer they go untreated, the more entrenched they become. But with the right specialist and the right treatment, real change is possible no matter how long you have been struggling.
Our team at Anxiety & OCD Treatment Specialists is trained specifically in BFRBs. We are not going to judge you, and we are not going to tell you to just stop. We are going to help you understand why it is happening and build a real plan to change it.