Body-Focused Repetitive Behaviors (BFRBs)

What are BFRBs?

The International OCD Foundation defines 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."

Trichotillomania (Hair-Pulling Disorder)

Trichotillomania (TTM) is a body-focused repetitive behavior (BFRB) where individuals feel strong urges to pull out their hair—often from the scalp, eyelashes, or eyebrows. For many, it's not about wanting to remove hair, but feeling unable to resist the urge.

Hair-pulling can happen in two ways:

• •Automatic: without realizing it, often while watching TV, reading, or relaxing.
• •Focused: intentionally pulling to relieve tension, stress, or discomfort.

Impact of TTM

• •Physical effects: noticeable hair loss, bald spots, skin damage, and infections.
• •Emotional effects: shame, embarrassment, anxiety, and depression.
• •Daily life: people may avoid social situations, relationships, or activities due to appearance concerns.

TTM affects an estimated 1-2% of the population and often begins in childhood or adolescence. Triggers vary for each person and may include stress, boredom, or certain environments.

Treatment Approaches

While TTM is a chronic condition, many people learn to manage it effectively with specialized therapy. The two most widely used approaches are:

1.   Habit Reversal Training (HRT):

• •Builds awareness of hair-pulling patterns
• •Teaches relaxation and breathing skills
• •Uses competing responses (such as tensing a muscle) to interrupt urges

2.   Comprehensive Behavioral (ComB) Model:

Developed by Dr. Charles Mansueto and colleagues, this approach expands on HRT by addressing five key areas that influence pulling urges (known as SCAMP):

• •Sensory - urges related to touch, sight, or physical sensations
• •Cognitive - thoughts or beliefs about hair
• •Affective - emotions before or after pulling
• •Motor habits - routines or automatic movements linked to pulling
• •Place - environments, tools, or times of day that trigger pulling

By targeting individual triggers in these areas, ComB creates a personalized treatment plan. Research suggests it provides better long-term success than HRT alone.

Other therapeutic approaches may include:

• •ACT, CBT, and strategies to manage thoughts and emotions
• •Mindfulness and stress-management skills
• •Medication (such as SSRIs) in some cases

Hope and Recovery

Trichotillomania can feel isolating, but effective treatment exists. With the right therapy, individuals can reduce pulling, manage triggers, and regain confidence.

Skin-Picking Disorder (Excoriation or Dermatillomania)

Skin-Picking Disorder, also called dermatillomania, is a mental health condition where a person feels compelled to pick at their skin, often causing damage.

Skin-Picking Disorder is considered to be an Obsessive-Compulsive related disorder as it shares some similarities with Obsessive-Compulsive Disorder (OCD), but it is considered a distinct condition.

What It Looks Like

• •Repetitive picking at skin, sometimes for hours, leading to sores, scarring, or infections.
• •Triggered by stress, anxiety, boredom, or a focus on perceived skin imperfections.
• •Can feel like a way to relieve tension or act as a form of self-soothing.

Impacts

• •Physical effects: wounds, pain, infections, and scarring.
• •Emotional effects: shame, guilt, embarrassment, or social isolation.
• •Daily life: may interfere with work, school, relationships, and overall wellbeing.
• •Often co-occurs with OCD, anxiety, or depression.

Treatment

Effective treatment usually includes:

• •Cognitive Behavioral Therapy (CBT)
• •Acceptance and Commitment Therapy
• •Habit-reversal training
• •Comprehensive Behavioral (ComB) Treatment
• •Medication (such as SSRIs) when appropriate
• •Learning healthier ways to cope with stress and reduce compulsive behaviors

Additional BFRBs

• •Cheek biting
• •Hair cutting or hair eating
• •Lip biting
• •Nail biting or picking
• •Skin biting
• •Tongue chewing

Additional Resources

• •IOCDF - Trichotillomania
• •IOCDF - Skin-Picking Disorder
• •The TLC Foundation for BFRBs
• •PickingMe Foundation
• •Comprehensive Behavioral (ComB) Treatment for Skin Picking and Hair Pulling Disorders