Deep Dive into Body-Focused Repetitive Behaviors (BFRBs)
- Julia Bickerstaff
- Dec 9, 2025
- 7 min read
Do you bite your nails, pick your skin, pull your hair, etc.?
These behaviors are super common, but aren't talked about nearly enough due to the stigma and shame associated with them.
As a therapist specializing in BFRBs who also has lived experience with a BFRB, spreading awareness and challenging stigma is very important to me and my work. BFRBs are very common, but simultaneously very misunderstood, and many people don't even know or realize that there is a treatment for them.
I fell into that category, and it wasn't until I was 25 that I learned there's a whole specialization for these behaviors. I personally believe that knowing this information and normalizing these diagnoses can help reduce shame and encourage people to seek the help they deserve.
With that being said, let's take some time to learn and talk about BFRBs.
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What are body-focused repetitive behaviors?
Body-focused repetitive behaviors, or BFRBs, are defined by the TLC Foundation for BFRBs as:
"Any repetitive self-grooming behavior that involves biting, pulling, picking, or scraping one’s own hair, skin, lips, cheeks, or nails that can lead to physical damage to the body and have been met with multiple attempts to stop or decrease the behavior.” (1)
Common BFRBs can include, but aren't limited to:
» Trichotillomania (hair-pulling)
» Excoriation Disorder (skin-picking)
» Lip picking
» Nail biting
» Tongue chewing
The damage caused by the behavior is accidental, as its main goal is to meet a need that the body is not getting otherwise. The behavior might be done to help regulate mood, provide a sense of stimulation or rewarding experience, or correct an imperfection in appearance that creates uncomfortable sensory input. Again, not exhaustive, but provides an idea of what motivations might look like.
BFRBs fall under the OCD-related disorder umbrella due to the compulsive nature of the problem behavior (picking, pulling, chewing, etc.).
There are several negative consequences that can occur as a result of BFRBs (5):
» High levels of distress
» Social and/or occupational impairment
» Low self-esteem
» Strained relationships
» Irreversible damage to hair growth or quality
» Medical consequences (pain, infections, scarring, tissue damage, inflammation, dental damage, digit purpura, and intestinal blockages)
Causes of BFRBs
While there is no set and/or single cause for BFRBs, research shows that different factors influence their development:
Genetics (2)
» BFRBs run in families - if an immediate family member has a BFRB, chances of you inheriting one are higher
» Twin studies show a strong genetic component, even in different environments
Environment (2, 3)
» Stressors in the environment (both positive and negative) have a chance of manifesting a BFRB, especially if a person is already predisposed
» Examples of environmental stressors: moving, starting college, getting married, new job, etc.
Other factors (2)
» Temperament - high levels of anxiety or boredom, for example, can influence a BFRB
» Age of onset - typically around the time of puberty, as acne and hair growth can increase
» Gender - by adulthood, at least 75% of reported cases are women; not to say BFRBs don't occur in men, they may just be less likely to report. Hair-pulling can also worsen in females prior to their menstrual cycle, but data is not consistent for during pregnancy
» Did you know that hair pulling can occur in infancy?? The behavior typically resolves in early development
Common Myths (4)
BFRBs are OCD.
Nope, different diagnoses, although they are related through compulsive behaviors. They both have different treatments, including mediations, and BFRBs lack obsessions, which are necessary for an OCD diagnosis. There is also a level of enjoyment and satisfaction in BFRB behaviors, where compulsive behaviors done in OCD are a result of distress that the person feels compelled to do.
BFRBs are caused by trauma.
There is little research that supports the idea that BFRBs are the result of unresolved traumas. BFRBs can be triggered moreso by life events, both positive and negative. About 50% of people report a negative event occurring around the same time the BFRB starts; not everyone with trauma has a BFRB, but some people with a BFRB do have a history of trauma.
BFRBs are extremely rare.
BFRBs are very misunderstood and underdiagnosed. About 1-2 people out of 50 will experience hair-pulling in their lifetime, and about 2-5% of the population picks their skin to the point of tissue damage. Chances are these numbers are even higher, as associated shame decreases reporting.
BFRBs are considered self-harm.
While both self-harm and BFRBs cause damage to the body, the goals behind those behaviors are very different. Self-harm is typically done with the intention to reduce or drown out emotional pain, or serve as punishment. The damage is done on purpose and with intent, whereas damage in BFRBs is unintentional. BFRBs pose as self-regulating behaviors that are pleasurable and intended to meet some sensory need.
Bad parenting causes BFRBs.
Most parents are very supportive of their child with a BFRB. Genetics, environmental factors, and neurobiological influences all interact with one another and lead to BFRBs, not bad parenting.
Only women experience BFRBs.
BFRBs affect both men and women equally, but since the behaviors are moreso reported by women, it gives the illusion that men do not experience BFRBs. Men may be less likely to seek help or report the behavior, leading to likely skewed percentages.
Anxiety is the only emotion to cause BFRBs.
While anxiety can be influential in BFRB behavior, more factors influence the behaviors. Other emotions, beliefs, sensations, places, thoughts, and triggers also play a role in BFRB behavior.
Treatment (6)
Cognitive behavioral therapy (CBT) is the gold-standard approach for treating BFRBs. Underneath that CBT umbrella, we have our two main modalities to specifically treat BFRBs:
Habit Reversal Training (HRT)
HRT was the initial treatment for BFRBs developed in the 70s and viewed BFRBs as "nervous habits" in response to stress. HRT proposed that the behaviors became automatic and outside one's conscious awareness after extensive repetition. HRT consists of three main parts:
Awareness training: designed to bring the problem behavior into conscious awareness, which better provides opportunities to implement interventions to stop it.
Competing response training: the hallmark of HRT; teaches clients to engage in behaviors that are incompatible with the problem behavior when they experience an urge; for example, you can't pick/pull when your fists are balled up or when you sit on your hands! The idea is that you engage in the incompatible behavior when you feel the urge to pick/pull, and wait it out as the urge passes. Over time, you habituate to the feeling (get used to it) and you see first hand that you don't have to act on the urge to make it go away.
Social support: includes getting family members and loved ones involved with treatment by providing support/reminders when in a triggering situation or when they notice the problem behavior, and positive feedback when noticing competing responses in action.
HRT was very promising when first developed, but effectiveness and durability decreased over time. Research has shown that HRT is more effective in providing short-term improvement rather than long-term results, which is where the ComB Model comes in.
Comprehensive Behavioral Model (ComB)
Creating in 1997, the Comprehensive Behavioral Model (ComB) was created based on the idea that people engage in BFRBs to meet one or more need that is not currently being met. The ComB Model was created to provide more individualized care and include areas that were not addressed in HRT. There are three stages in the ComB Model:
Building Awareness: similar to HRT, the first stage of the ComB Model focuses on increasing one's awareness of the problem behavior by identifying triggers that kickstart and maintain the behavior. This step is important, as it helps uncover information that may have been overlooked otherwise. When behaviors become more predictable, they are easier to manage. The first stage of the ComB Model is to become aware of these triggers through tracking them. There are five domains that trigger and maintain BFRBs, and are usually the result of an unmet need in that area. These domains are known as SCAMP (Sensory, Cognition, Affective, Motoric, Place).
Planning and Preparation: in this stage, you review the SCAMP tracking forms and choose interventions that address your specific triggers and needs. This is where treatment becomes more individualized compared to HRT: instead of having everyone engage in competing responses, you take the time to choose what skills may be most helpful for you based on your own personal triggers, needs, and preferences.
Putting the Plan Into Action: the third and final stage is to take the chosen interventions and create an action plan, which outlines your chosen interventions and how you will utilize them. You start incorporating interventions into your daily routine in order to begin minimizing the problem behavior. From here, you'll assess your progress each week and make modifications to your action plan as needed until you reach your goal.
Adjunctive Treatments (6)
Although HRT and the ComB Model were created specifically for BFRBs, other types of therapy have been effective in strengthening gains and further minimizing the problem behaviors.
Acceptance and Commitment Therapy (ACT)
ACT therapy is all about being non-judgmental of our internal experience, and letting thoughts and feelings come and go as they please, because that is what makes us human. We don't have to label our internal experience as good or bad, and we can coexist with these uncomfortable sensations.
In the realm of BFRBs, ACT can be helpful in fostering non-judgmental acceptance of urges to pick/pull without acting on them or trying to make them go away. ACT clarifies your values and helps align your behaviors with said values in order to live a full life. Through mindfulness, you work to remove the significance previously attached to the internal experience (such as urges), and better understand that just because you experience something does not mean we have to react to it.
Dialectical Behavioral Therapy (DBT)
There are four main pillars (treatment areas) in DBT: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. However, in the context of BFRBs, all pillars but interpersonal effectiveness are addressed.
Similar to ACT, mindfulness helps a person become more aware of their BFRB experience and accept it for how it is without acting on it. This leads into emotion regulation and distress tolerance, both used to help individuals better mange their emotions and tolerate discomfort without making the situation worse.
Resources
You can learn more about BFRBs and their treatment, as well as search for specialized clinicians, at:
The TLC Foundation for Body-Focused Repetitive Behaviors (TLC)
International OCD Foundation (IOCDF)
OCD: https://iocdf.org/
Anxiety & Depression Association of America (ADAA)
BFRB Changemakers
Picking Me Foundation
Stop Pulling
Habit Aware
If this post resonated with you, feel free to reach out at any time. You are not alone; there is help available and hope that things will get better. I'm rooting for you!
Have a wonderful week!
Julia
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Amazing post, Julia!