The Connection Between Body-Focused Repetitive Behaviors and ADHD

I am a cognitive behavioral therapist specializing in OCD, anxiety disorders, BDD, and body-focused repetitive behaviors (BFRBs). I am also trained and certified to treat ADHD.

One study published in the Journal of the American Academy of Child and Adolescent Psychiatry found that 39.9% of patients with trichotillomania also had ADHD, compared to 19.9% of the control group (Trivedi et al., 2023). Another study published in Psychiatry Research found that 23.5% of individuals with excoriation disorder also had ADHD (Grant & Chamberlain, 2020).

What are Body-Focused Repetitive Behaviors (BFRBs)?

BFRBs are a mental health disorder characterized by compulsive behaviors such as:

Hair pulling (trichotillomania)

Skin picking (excoriation disorder)

Nail biting

Cheek biting

Unlike simple habits, BFRBs are classified as clinical disorders because they can significantly impair a person’s life—socially, academically, or occupationally. Only trichotillomania and excoriation disorder have their own standalone diagnostic classifications. Other BFRBs are classified under “Other Specific Obsessive-Compulsive and Related Disorders.” In other words, BFRBs are not OCD.

BFRBs are self-soothing behaviors that provide immediate gratification. Thus, stopping the behavior is not easy and often requires professional treatment.

Treating BFRBs

The treatment for BFRBs follows evidence-based protocols that include:

Cognitive Therapy – Clients learn to identify unhelpful, distorted thoughts that lead to pulling or picking and restructure them to be more rational and reasonable.

Habit Reversal Training (HRT) – A behavioral intervention for BFRBs involving several components, including building awareness of one's urges to pick or pull, identifying situations, places, and activities that trigger the behavior and developing a competing response one can use in place of the BFRB.

The Comprehensive Behavioral (ComB) Approach – This approach begins with a structured, in-depth assessment to identify the unique pattern of sensory (sensations), cognitive (thoughts), affective (feelings), motor (movements), and place (environmental) factors or domains that trigger or maintain the BFRB.

Mindfulness Training - Increases awareness of thoughts, feelings, sensations, and urges that lead to skin picking or hair pulling. Clients learn to tolerate uncomfortable urges by “riding the wave of discomfort” without engaging in the BFRB.

Acceptance and Commitment Therapy (ACT) - A treatment approach using mindfulness tools to manage uncomfortable urges along with a focus on taking action on activities one finds meaningful or important without giving in to the urge to pick or pull.

What is ADHD?

ADHD (attention deficit hyperactivity disorder) is a neurodevelopmental condition that affects how the brain develops and functions.

There are three subtypes of ADHD:

Inattentive – Difficulty focusing, following through on tasks, and organizing activities.

Hyperactive-Impulsive – Excessive movement, restlessness, and impulsivity.

Combined Type – A combination of inattentive and hyperactive-impulsive symptoms.

Impact on Executive Functioning

ADHD affects executive functioning, which is the set of mental skills that help with planning, organizing, managing time, and regulating emotions. Peg Dawson, an expert in ADHD, categorizes these executive functioning skills into 11 areas:

Response Inhibition – The ability to think before acting and resist impulsive behavior.

Working Memory – Holding and manipulating information temporarily to complete tasks or solve problems.

Emotional Control – Regulating emotional responses in challenging situations.

Flexibility – Adapting to changes and revising plans as needed.

Sustained Attention – Maintaining focus on a task despite distractions.

Task Initiation – Beginning tasks promptly and independently.

Planning/Prioritization – Creating a structured approach to goal completion.

Organization – Keeping track of materials, ideas, and responsibilities.

Time Management – Estimating and effectively allocating time for tasks.

Goal-directed persistence – Sticking to a goal despite obstacles or distractions.

Metacognition – Monitoring and adjusting one’s own thinking and learning processes.

These challenges can make everyday activities, such as completing school or work tasks, more difficult and they can also affect relationships.

The Role of Dopamine in ADHD

ADHD brains have lower-than-average levels of dopamine, a neurotransmitter that regulates the body's pleasure and reward systems. This can lead to a constant search for stimulation. BFRBs, in this context, can be seen as self-stimulating behaviors that provide temporary relief from the symptoms of ADHD.

Overlap Between ADHD and BFRBs

For clients with ADHD, challenges such as impulsivity, difficulty sustaining attention, and emotional dysregulation may exacerbate BFRBs or make implementing treatment strategies more difficult. Addressing ADHD symptoms alongside BFRB treatments can improve outcomes for these individuals.

Case Example

One of my clients with ADHD and BFRB (skin picking) had been fired from two jobs in the past year due to forgetfulness and not meeting deadlines. In our sessions, we identified that difficulties with working memory, task initiation, and sustained attention exacerbated her compulsive skin-picking. To help with this, she:

Set a daily reminder on her phone to review the strategies we created to help her resist the urge to pick.

Posted written notes in visible locations in her apartment to reinforce these strategies.

Had various fidgets placed on her desk and around the house to use in place of picking.

Divided her work project into smaller, more manageable chunks instead of addressing the entire project at once.

Set a timer for how long she knew she could sustain her attention. When the timer sounded, she took a 10- to 15-minute break to do enjoyable activities, such as taking a short walk or playing the guitar. Getting started and completing one small part of the project made her less anxious and reduced skin picking.

The client chose to have a medication evaluation, significantly improving her ability to initiate tasks, sustain attention, and follow instructions. This, in turn, helped her retain a job and successfully follow through with her BFRB treatment plan.

Treatment for ADHD

ADHD is a treatable condition, and individuals can develop strategies to manage symptoms effectively. Common treatments include:

Cognitive Behavioral Therapy (CBT) – CBT techniques such as cognitive restructuring help clients with ADHD identify distorted thinking patterns and correct them with more rational and logical thinking. Behavioral interventions help clients develop methods to improve executive functioning challenges, such as time management strategies, creating structured routines, and external reminders, which can help improve organization and productivity.

Medication – Stimulant and non-stimulant medications can help regulate dopamine levels and improve focus, impulse control, and motivation.

Mindfulness Training – Improves attention and focus by gently bringing one’s attention back to the present when their minds wander, thus strengthening concentration and cognitive control. It also helps individuals with ADHD by increasing their awareness of thoughts, feelings, and urges, allowing them to manage distractions, impulsivity, and emotional reactions more effectively.

By practicing present-moment focus and tolerating discomfort without reacting, individuals can improve their self-control, attention, and overall daily functioning.

Final Thoughts

Understanding the connection between ADHD and BFRBs can help clinicians and individuals better manage these conditions. With targeted treatment approaches, individuals can gain tools to improve executive functioning and reduce the impact of BFRBs on their daily lives.