Understanding Body-Focused Repetitive Behaviors (BFRBs)

Body-Focused Repetitive Behaviors (BFRBs) are a group of complex, often misunderstood behaviors that involve repeatedly damaging one’s own hair, skin, or nails. Common examples include trichotillomania (hair pulling), excoriation disorder (skin picking), chronic nail biting (onychophagia), and cheek or lip biting. Although these behaviors may appear to be habits, BFRBs are better understood as mental health conditions that exist at the intersection of compulsivity, emotional regulation, and sensory processing.

What Are Body-Focused Repetitive Behaviors?

BFRBs are characterized by recurrent behaviors that result in physical damage and significant distress or impairment in daily functioning. Individuals may spend hours each day engaging in these behaviors, often experiencing shame, secrecy, and frustration when attempts to stop are unsuccessful. Importantly, BFRBs are not self-harm behaviors in the traditional sense; they are not motivated by a desire to cause pain or injury, but rather by urges that can feel automatic or difficult to resist (Grant et al., 2012).

Common Types of BFRBs

• Trichotillomania (hair pulling)
• Excoriation (skin picking) disorder
• Chronic nail biting (onychophagia)
• Cheek and lip biting

Are BFRBs a Mental Health Disorder?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) classifies trichotillomania and excoriation disorder under “Obsessive-Compulsive and Related Disorders ,” reflecting their shared features with obsessive-compulsive disorder (OCD), while also acknowledging important differences (American Psychiatric Association [APA], 2022).

Why Do BFRBs Occur?

There is no single cause of BFRBs. Current research suggests a multifactorial origin involving genetic vulnerability, neurobiological differences, and environmental influences. Neuroimaging studies have identified differences in brain regions associated with habit formation, impulse control, and emotional regulation (Stein et al., 2010).

On a psychological level, BFRBs often function as a coping mechanism. Some individuals pull, pick, or bite in response to stress, anxiety, boredom, or frustration, while others report engaging in BFRBs during periods of concentration or dissociation. Many people describe a sense of relief, gratification, or sensory satisfaction during or after the behavior, even when it is followed by guilt or distress.

The Impact of BFRBs on Mental Health and Daily Life

BFRBs can have profound emotional, social, and physical consequences. Visible hair loss, skin lesions, or nail damage may lead individuals to avoid social situations, intimacy, or professional opportunities. Shame and fear of judgment often prevent people from seeking help, reinforcing isolation and worsening symptoms (TLC Foundation for Body-Focused Repetitive Behaviors, 2023).

Comorbid conditions are common and may include anxiety disorders, depression, OCD, attention-deficit/hyperactivity disorder (ADHD), and trauma-related disorders. These co-occurring conditions can complicate diagnosis and treatment if BFRBs are not identified and addressed directly.

Evidence-Based Treatment for BFRBs

Effective treatments for BFRBs are available, and recovery is possible. The gold-standard psychological treatment is Habit Reversal Training (HRT), often delivered as part of a broader cognitive-behavioral therapy (CBT) framework. HRT focuses on increasing awareness of the behavior, identifying triggers, and developing competing responses that reduce the likelihood of engaging in the BFRB (Azrin & Nunn, 1973).

Acceptance and Commitment Therapy (ACT) has also shown promise, particularly in helping individuals relate differently to urges and uncomfortable internal experiences rather than attempting to suppress them. In some cases, medication—such as selective serotonin reuptake inhibitors (SSRIs) or N-acetylcysteine (NAC)—may be used as an adjunct to therapy, although medication alone is generally insufficient (Grant et al., 2016).

Reducing Stigma and Increasing Awareness

One of the greatest barriers to care for individuals with BFRBs is stigma. These behaviors are frequently minimized, misunderstood, or mischaracterized as “bad habits” or a lack of willpower. Increasing public and professional awareness is essential for early identification, compassionate care, and improved outcomes.

Mental health professionals play a critical role in normalizing conversations about BFRBs and providing evidence-based treatment. Likewise, community education and advocacy efforts can help individuals recognize that they are not alone—and that help is available.

Conclusion

Body-Focused Repetitive Behaviors are complex, treatable mental health conditions that deserve greater understanding and clinical attention. With appropriate support, evidence-based intervention, and a reduction in stigma, individuals with BFRBs can develop healthier coping strategies and experience meaningful improvements in quality of life.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11(4), 619–628.

Grant, J. E., Odlaug, B. L., & Kim, S. W. (2012). A clinical comparison of pathologic skin picking and trichotillomania. Journal of Psychiatric Research, 46(4), 486–492.

Grant, J. E., Chamberlain, S. R., Redden, S. A., et al. (2016). N-acetylcysteine in the treatment of excoriation disorder. JAMA Psychiatry, 73(5), 490–496.

Stein, D. J., Grant, J. E., Franklin, M. E., et al. (2010). Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder. American Journal of Psychiatry, 167(8), 879–885.

TLC Foundation for Body-Focused Repetitive Behaviors. (2023). What are BFRBs?