Hair-Pulling, Skin-Picking and Other BFRBs


– Carolyn Moriarty, LCPC



Body-Focused Repetitive Behaviors (BFRBs) describe a group of repetitive and compulsive actions directed towards one’s own body. These behaviors can result in physical damage to the body over time.

Common examples of BFRBs include hair pulling (trichotillomania), skin picking (dermatillomania/excoriation disorder), and nail biting. Individuals with BFRBs often engage in these behaviors to cope with stress, anxiety, or other emotional challenges.


BFRBs are not


Subtypes of Body-Focused Repetitive Behavior


Common examples of BFRBs include:

Trichotillomania (Hair Pulling Disorder)

  • Individuals with trichotillomania repeatedly pull out hair from their scalp, eyebrows, eyelashes, or other body areas.
  • Trichotillomania can lead to noticeable hair loss, resulting in bald patches or thinning areas.

Dermatillomania (Skin Picking/ Excoriation Disorder)

  • Individuals with this disorder repeatedly pick at their skin, leading to tissue damage, scarring, and sometimes infection.
  • Behaviors may target various body areas, such as the face, arms, hands, or other regions.

Onychophagia (Nail Biting)

  • Individuals with onychophagia habitually bite their own fingernails or toenails.
  • Behaviors may involve chewing on the entire nail, biting the cuticles, or even biting the surrounding skin.
  • Behaviors can lead to various consequences, including damaged or deformed nails, infections around the nail bed, and sore or bleeding fingertips.


Important Features of BFRBs


  • Urge and Tension: Before engaging in the BFRB, individuals often experience an increasing sense of tension or an irresistible urge. The act of picking/pulling provides temporary relief or a sense of satisfaction, followed by feelings of guilt, shame, or regret.
  • Physical Consequences: BFRBs can lead to wounds, scabs, tissue damage, infection and hair loss.
  • Attempts to Stop: Individuals with BRFBs often make repeated attempts to stop or reduce the picking/pulling behavior but may find it challenging to control. BFRBs are compulsive behaviors that individuals find challenging to control, even if they are aware of the potential consequences.
  • Impact on Daily Life: BFRBs can significantly impact daily functioning, relationships, and self-esteem. Some individuals may experience social withdrawal or distress related to their appearance.
  • Onset and Course: BFRBs may begin in adolescence or adulthood. The course of the disorder varies, with some individuals experiencing episodic episodes and others having a chronic and persistent pattern.


Causes & Contributing Factors


Just like most mental health issues, some individuals are just born with a predisposition to developing BFRBs. But even though genetics may contribute to BFRBs, there are a variety of factors involved as well. For this reason, it’s not helpful to blame BFRB on any single aspect of a person’s circumstances.

Other reasons why an individual may be more prone to developing BFRBs include:

  • age of onset
  • gender (BFRBs are more prevalent in women)
  • temperament (e.g. impulsivity, perfectionism—picking/pulling as a means of control)
  • amount of environmental stressors
  • sensory sensitivities
  • difficulties with emotional regulation (BFRBs often done in response to tension, stress, or emotional discomfort)




Treatment for BFRBs may involve a combination of therapeutic approaches, addressing both behavioral and psychological aspects. Oftentimes, BFRBs are dismissed as a “bad habit”, or a written off as a simple problem that can be dealt with on one’s own. This, coupled with shame and embarrassment, and a lack of BFRB specialists can pose significant barriers to treatment.

If someone is experiencing BFRBs, it’s recommended that they seek the guidance of a mental health professional who specializes in this concern for appropriate assessment and intervention. Educating individuals about the nature of BFRBs, their triggers, and the cycle of urges and behaviors is an important component of treatment.


Here’s are potential treatment approaches for BFRBs:

Habit Reversal Therapy (HRT)

Here are the key components of Habit Reversal Training:

  • Awareness Training: The first step in HRT is increasing awareness of the habit. Individuals learn to recognize specific situations, emotions, or other triggers that precede the habitual behavior.
  • Competing Response: Once awareness is established, individuals are taught to develop a “competing response”—a behavior that is physically incompatible with the habit and can be performed instead of the undesired behavior (i.e. the habit is hair-pulling, a competing response might be clenching fists, holding a mug, painting nails, etc.)
  • Function Analysis: Understanding the function or purpose of the repetitive behavior is crucial. In this step, a treatment professional will help the individual identify whether the behavior serves as a means of coping with stress, boredom, or other emotional states. This helps in tailoring the intervention.
  • Development of Motivation: Individuals work on developing their motivation to change the behavior. This involves exploring the personal reasons and benefits of making the change.
  • Generalization: The goal is to generalize the new response to a variety of situations. The individual practices the competing response in various contexts to strengthen its effectiveness.
  • Social Support: Involving family or close friends in the process can enhance the effectiveness of HRT. Supportive relationships can provide encouragement, reinforcement, and understanding.


Habit Reversal Training is often used in combination with other therapeutic approaches, such as:

Cognitive-Behavioral Therapy (CBT)

CBT is a widely used and evidence-based therapeutic approach for BFRBs. It is based on the premise that distorted or negative thought patterns contribute to emotional distress and maladaptive behaviors. CBT aims to identify and modify these patterns, fostering healthier cognitive processes and promoting positive behavioral changes.

Mindfulness and Acceptance-Based Therapies

Techniques such as mindfulness meditation and acceptance and commitment therapy (ACT) can help individuals become more aware of their thoughts and emotions, and learn to accept them without judgment. Mindfulness can be particularly effective in reducing the urge to engage in BFRBs.



Seeking Mental Health Support

Understanding the underlying mechanisms of BFRBs can empower individuals to better manage their condition. If you are struggling, it may be helpful to seek support from a mental health professional who can provide guidance and strategies for coping with BFRBs in a way that avoids blame or shame. Consider scheduling an appointment with Chicago Counseling CenterOur therapists can develop an appropriate treatment plan tailored to your specific needs. Meet our team to learn more!



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