Body-Focused Repetitive Behaviors

Understanding Body-Focused Repetitive Behaviors

Body-focused repetitive behaviors, or BFRBs, include repeated skin picking, hair pulling and nail biting that can be difficult to stop. Some happen without much awareness. Others involve a strong urge or a search for a particular sensation, such as a rough patch of skin. The behavior can cause damage and interfere with everyday life.^[1]

Skin-picking disorder and hair-pulling disorder have specific diagnostic criteria. Clinicians consider repeated attempts to stop, the physical effects and significant distress or disruption. An occasional grooming habit does not, by itself, establish either diagnosis.^[2][3]

What Skin Picking and Hair Pulling Can Look Like

A person may pull hair while watching television and notice only when they see the hairs. Someone else may deliberately search for a strand that feels different. These illustrate automatic and focused pulling. The same person can experience both.^[8]

Skin picking can also happen with little awareness or with close attention to the skin. The short-term sensation may be satisfying or relieve tension even when the person dislikes the wounds afterward.^[2]

The names below describe different patterns. They are starting points for a conversation, not a way to diagnose yourself:

Excoriation disorder is the clinical name for skin-picking disorder. You may also see dermatillomania. Trichotillomania means hair-pulling disorder. Learning a long name is less important than being able to explain what happens to you.^[1]

For picking-specific wound care, treatment options and appointment questions, explore skin-picking disorder treatment and support.

For hair-loss concerns, age-specific care and treatment questions, explore hair-pulling disorder treatment and support.

When to Ask for an Assessment

Consider seeking help when picking or pulling causes injuries, distress, repeated unsuccessful efforts to stop, or interference with work, school or relationships. There is no requirement to spend an hour a day doing it before these disorders can be considered.^[2][3]

A clinician looks beyond the visible damage. For skin picking, they consider whether a skin condition, substance effects or another mental health condition better explains it. For example, picking caused by stimulant effects needs a different assessment from excoriation disorder.^[2]

Hair loss also has several possible explanations. A clinician may examine the affected area and investigate medical causes. For hair-pulling disorder, the pattern must not be better explained by a medical condition or another mental health disorder.^[3]

Get Physical Symptoms Checked Too

Arrange medical care for skin wounds that are not healing within a few days, serious skin damage or signs of infection. A clinician can also assess acne or eczema that may be contributing to picking. You do not have to solve the behavior before seeking skin care.^[6]

Tell a healthcare professional if you chew or swallow pulled hair. Swallowed hair can collect in the digestive tract and cause a blockage or other serious complications. This is an important part of the assessment, even if it feels embarrassing to mention.^[8]

How Treatment for BFRBs Works

Behavioral treatment focuses on what happens around picking or pulling and on practicing a different response. Habit reversal training is a treatment approach that builds awareness of the behavior and teaches an action that cannot happen at the same time as picking or pulling.^[4]

For example, a therapist might help someone notice their hand moving toward their hair, then practice an agreed response with their hands. The plan should fit the person and the situation. Stimulus control means changing parts of the setting that make the behavior easier to start.^[4]

Matching the Plan to Your Pattern

Comprehensive behavioral treatment, often shortened to ComB, considers sensations, thoughts, feelings, movements and surroundings. A texture-seeking pattern may need a different strategy from one linked to boredom or a particular place. This helps explain why advice that works for someone else may not fit you.^[9]

In their explanation for the International OCD Foundation, Charles Mansueto, PhD, and Ruth Golomb, LCPC, describe adjusting treatment based on the person’s feedback about what is useful. The practical lesson is to tell your therapist when a strategy is awkward, ineffective or difficult to use in daily life.^[9]

Medication and Supplements

Medication is sometimes considered alongside behavioral treatment. Ask what benefit is expected for your particular symptoms, what side effects to watch for and when the plan will be reviewed. Evidence for adults does not automatically apply to children.^[3]

Do not start a supplement for picking because an online post calls it natural. In Harvard Health Publishing, psychiatrist Lisa Zakhary, MD, PhD, advises discussing supplements with a doctor first because interactions and other safety considerations matter.^[7]

Recognizing Progress

Review the pattern with your therapist over time. A useful plan includes maintaining gains and responding when picking or pulling returns. A recurrence is information to discuss and use to adjust the plan.^[9]

Possible questions include: “Am I noticing earlier?” “Which situations remain difficult?” and “Is this strategy realistic at school or work?” These are conversation prompts, not a score or a test of willpower.

How to Describe Picking or Pulling at an Appointment

Writing a few notes beforehand can make an appointment easier. Mayo Clinic recommends bringing information about symptoms, possible triggers, treatments tried and medicines or supplements used.^[5]

Writing for UT Southwestern, psychologist Kipp Pietrantonio, PhD, suggests: “Tell us how much time you spend, the damage you’ve noticed, and what you do before, during, and after sessions.”^[10]

If you are unsure what to say, bring these questions:

• Could a skin or hair condition be contributing?
• Does this pattern need a mental health assessment?
• Which treatment approach would you recommend, and why?
• What should I do about the physical damage?
• How will we decide whether treatment is helping?

Helping Someone Without Shame

For someone with hair-pulling disorder, encouragement from loved ones and help getting treatment can be valuable. Ask whether they want you involved in appointments rather than assuming you should take charge.^[5]

A supportive opening might be: “I can see this is bothering you. Would you like help finding someone who understands it?” If reminders are wanted, agree on what they should sound like and where they are welcome. Avoid making every conversation about the person’s skin or hair.

For a child or teenager, ask prospective clinicians about their experience with that age group and how they involve caregivers. For an adult, offer practical help such as comparing appointments or writing down questions while leaving room for their preferences.

Support for families facing mental health concerns includes help with conversations, appointments and relatives’ own needs.

Finding a BFRB Therapist Near You or Online

Look for someone who can explain how they treat skin picking, hair pulling or the specific behavior you want help with. Zakhary emphasizes working with a therapist trained in skin-picking treatment. An anxiety or OCD listing alone does not tell you whether that clinician has this experience.^[7]

The International OCD Foundation’s provider directory offers in-person and teletherapy searches. Provider descriptions are largely self-reported. Confirm BFRB experience, availability and suitability directly rather than treating a listing as a guarantee.^[11]

When contacting a local practice or an online provider, ask:

• Relevant experience. “How do you treat my particular behavior, and do you work with people my age?”
• Practical treatment. “Do you use habit reversal training or ComB, and what would we practice?”
• Physical care. “How would we coordinate with my doctor or dermatologist?”
• Online access. “Can you provide care where I will be located during sessions?”
• Cost and availability. “What are your fees, insurance arrangements and current wait times?”
• Fit. “How will we review progress and change the plan if it is not helping?”

If the first person you contact does not treat BFRBs, ask for a referral to someone who does. Understanding other mental health concerns can help you explain what else you want support with.

In the U.S., call or text 988 for suicidal thoughts or emotional distress. You can also contact 988 about someone else. For an immediate medical emergency or danger, call 911.^[12]