Body-Focused Repetitive Behaviors (BFRBs)
Body-Focused Repetitive Behaviors (BFRBs) are behaviors people repeatedly perform involving their hair, skin, lips, cheeks, or nails. These behaviors, like skin picking, hair pulling, nail biting, or cheek chewing, can cause physical damage and emotional distress. What makes them particularly challenging is that even when someone wants to stop, it can feel nearly impossible to do so (American Psychiatric Association, 2013). In the DSM-5, BFRBs are categorized as OCD-related disorders, but they are not the same as obsessive-compulsive disorder (OCD). With OCD, clients experience uncomfortable urges or anxiety and perform a compulsion to relieve that discomfort, which provides only temporary relief and strengthens the cycle. With BFRBs, people experience urges to engage in the behavior and feel immediate gratification from it, more akin to behavioral addictions such as compulsive shopping or eating. Many people occasionally bite their nails or pick their skin, but BFRBs go beyond occasional habits. They occur frequently enough to cause harm, distress, or interference with daily life (Grant et al., 2017). Common forms include trichotillomania (hair pulling), excoriation disorder (skin picking), nail biting, cheek or lip chewing, and nail picking.
Why Do BFRBs Happen?
Researchers believe BFRBs develop from a mix of biological, emotional, and environmental factors. There appears to be a genetic component; BFRBs tend to run in families, suggesting that brain chemistry and regulation of neurotransmitters like serotonin and dopamine may play a role (Monzani et al., 2014). Emotional regulation is also key. Many people notice that they pick or pull when they’re stressed, bored, anxious, ashamed, or even overstimulated by
positive emotions. The behavior often provides a brief sense of calm or satisfaction, functioning as a way to soothe or regulate internal feelings (Roberts et al., 2013).
Automatic and Unconscious Behaviors
Over time, the brain learns to associate the behavior with relief, and it can become automatic, occurring with little awareness, often in specific settings such as while studying, driving, or watching TV (Flessner et al., 2008). Many people find that their BFRB happens unconsciously, without them realizing it until after it’s occurred. Because of this, becoming more mindful and aware of thoughts, sensations, and urges is a vital part of treatment. Mindfulness helps people notice the early signs of an urge and create a pause between feeling the impulse and acting on it.
BFRBs Are a Cycle
BFRBs tend to follow a repeating pattern or cycle. A person experiences an urge to engage in the behavior and feels immediate gratification. This sense of gratification reinforces the behavior, making it more likely to happen again when a similar urge appears. In other words, continuing to engage in the BFRB strengthens the cycle. But once someone starts, it can feel almost impossible to stop, and after they have stopped, they may experience a sense of overwhelming regret, guilt, shame, or distress. Eventually, another urge comes along, and unless the person has tools to interrupt the cycle, they engage in the behavior. Clients often feel hopeless and powerless to change their behavior.
How Common Are BFRBs?
BFRBs are more common than many people realize. They are often underdiagnosed or hidden due to shame. Still, studies estimate that clinically significant hair pulling or skin picking affects about 2–5% of the population (APA, 2013), while chronic nail biting may affect up to 30% of people
(Roberts et al., 2013). Both men and women experience BFRBs, though women are more likely to seek help or receive a diagnosis (Grant & Chamberlain, 2016).
Evidence-Based Treatments
The good news is that effective, evidence-based treatments are available. Cognitive Behavioral Therapy (CBT) is a leading approach, helping people recognize the triggers and thought patterns that maintain the behavior (Grant & Chamberlain, 2016). A key component, Habit Reversal Training (HRT), teaches awareness of the urges and how to substitute them with a competing response in the form of an intentional, safe movement that interrupts the cycle (Azrin & Nunn, 1973). The Comprehensive Behavioral (ComB) model expands on this by identifying the sensory, emotional, cognitive, and environmental factors driving the behavior and creating personalized strategies for each (Mansueto et al., 1997). Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) are often used alongside these behavioral methods. ACT helps individuals develop a new relationship with their urges, allowing them to be present without acting on them, while DBT builds emotional regulation and distress tolerance skills (Twohig & Woods, 2001). Together, these therapies empower people to respond differently to triggers and begin to unlearn the habitual cycle.
The Role of Self-Compassion
Self-compassion is another powerful part of recovery. When people learn to treat themselves with the same understanding they would offer a friend, it becomes easier to move through setbacks without shame. Research by Kristin Neff (2003) and Neff and Germer (2013) shows that
practicing self-compassion improves emotional regulation and accelerates recovery, helping people often get better faster. Therapy that includes self-compassion training helps clients notice their thoughts, feelings, sensations, and urges without judgment. They can remind themselves that they are not alone, as many others share this struggle, and then say something kind or supportive to themselves. This shift toward being ‘on their own side’ reduces self-criticism, builds resilience, and supports long-term healing.
Finding Hope and Healing
Body-Focused Repetitive Behaviors are not signs of weakness or lack of willpower; they are complex, brain-based conditions that respond to understanding and compassionate, evidence-based care. With the proper treatment and support, people can and do recover. Therapies such as CBT, ComB, ACT, DBT, and self-compassion practices offer concrete tools for change. Over time, with patience and practice, individuals can reduce urges, rebuild confidence, and reconnect with life in meaningful ways. There is every reason to feel hopeful because healing is absolutely possible.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
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. https://doi.org/10.1016/0005-7967(73)90119-8
Flessner, C. A., Woods, D. W., Franklin, M. E., Keuthen, N. J., & Piacentini, J. (2008). Cross-sectional study of women with trichotillomania: Phenomenology, functional impairment, and treatment utilization. Journal of Anxiety Disorders, 22(4), 806–815. https://doi.org/10.1016/j.janxdis.2007.08.001
Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania and skin-picking disorder: An update. Psychiatric Clinics of North America, 39(2), 369–381. https://doi.org/10.1016/j.psc.2016.01.009
Grant, J. E., Odlaug, B. L., & Chamberlain, S. R. (2017). Clinical characteristics and treatment response in body-focused repetitive behavior disorders. Journal of Psychiatric Research, 91, 52–60. https://doi.org/10.1016/j.jpsychires.2017.02.013
Mansueto, C. S., Golomb, R. G., Thomas, A. M., & Stemberger, R. M. T. (1997). A comprehensive model for behavioral treatment of trichotillomania. Cognitive and Behavioral Practice, 4(1), 23–44. https://doi.org/10.1016/S1077-7229(97)80028-7
Miltenberger, R. G., et al. (2021). Emerging technology for body-focused repetitive behaviors: A review of wearable devices. Behaviour Research and Therapy, 139, 103834. https://doi.org/10.1016/j.brat.2021.103834
Monzani, B., Rijsdijk, F., Anson, M., & Mataix-Cols, D. (2014). A twin study of body-focused repetitive behaviors. Comprehensive
Psychiatry, 55(5), 1333–1339. https://doi.org/10.1016/j.comppsych.2014.03.004
Neff, K. D. (2003). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and Identity, 2(2), 85–101. https://doi.org/10.1080/15298860309032
Neff, K. D., & Germer, C. K. (2013). A pilot study and randomized controlled trial of the mindful self-compassion program. Journal of Clinical Psychology, 69(1), 28–44. https://doi.org/10.1002/jclp.21923
Roberts, S., O’Connor, K., & Bélanger, C. (2013). Emotion regulation and other psychological models for body-focused repetitive behaviors. Clinical Psychology Review, 33(6), 745–762. https://doi.org/10.1016/j.cpr.2013.05.004
Twohig, M. P., & Woods, D. W. (2001). The use of acceptance and commitment therapy in the treatment of trichotillomania. Cognitive and Behavioral Practice, 8(3), 25–33. https://doi.org/10.1016/S1077-7229(01)80039-6