Hair Pulling and Skin Picking: Understanding Body-Focused Repetitive Behaviors

It's the middle of the workday, and you realize you've been picking at your nails through an entire two-hour meeting. Or you're a parent noticing, for the third time this week, that your child's eyelashes look sparse. If this sounds like you or someone you love, here's the good news: there's a name for it (body-focused repetitive behaviors), there's a growing body of research on it, and therapy offers helpful options to treat it.

Here's what body-focused repetitive behaviors are, how they differ from OCD, the most common types, and a well-studied treatment model for reducing the urges.

What Are Body-Focused Repetitive Behaviors?

Body-focused repetitive behaviors, or BFRBs, are repetitive self-grooming behaviors that involve pulling, picking, scraping, or biting at one's hair, skin, or nails. They cause physical damage and come with repeated, unsuccessful attempts to stop. They are different from everyday habits. Plenty of people twirl their hair, play with a necklace, or fidget with their fingers when nervous. A BFRB goes further: it happens often, feels hard to control, causes visible damage or distress, and can interfere with a person's life. People with BFRBs may feel shame about hair loss or skin damage, pull back from social situations at work or school, or avoid relationships entirely.

There is no single cause of BFRBs. Researchers point to a mix of factors. Biology and genetics may play a role, since BFRBs tend to run in families. People with sensory sensitivities may be drawn to the feel, sound, or look of certain hairs, textures, scabs, or skin bumps. Emotions contribute too, including anxiety, stress, boredom, frustration, and even excitement. Over time, the behavior becomes automatic, and like other habit loops, it gets linked to specific places, activities, or times of day. Lastly, people with perfectionistic traits often pick or pull to "fix" something that doesn't feel quite right.

BFRBs often start in childhood or adolescence, but they can affect people of any age or gender. For some people the behavior is brief, and for others it takes up hours of the day. The two most commonly recognized diagnoses are trichotillomania (hair pulling) and excoriation disorder (skin picking). BFRBs also tend to follow two styles. Automatic behavior happens outside of awareness, such as while reading or driving. Focused behavior is more deliberate and is often a response to a feeling or sensation. Other BFRBs are common and just as real, even if they are not a formal diagnosis.

How Are BFRBs Different from OCD?

BFRBs are listed alongside OCD in the diagnostic manual under "obsessive-compulsive and related disorders," so it's easy to assume they are the same thing. They share some features, but they work very differently.

• What starts it: OCD starts with an unwanted, intrusive thought, image, or doubt that triggers fear. A BFRB starts with a sensation, urge, or situation, often with no specific feared thought.
• What the behavior is for: In OCD, compulsions reduce anxiety or prevent a feared outcome. A BFRB meets a sensory or emotional need, relieves tension, or satisfies an urge.
• How it feels: OCD is driven by fear and usually causes significant distress. A BFRB may feel satisfying or relieving in the moment, followed by guilt or shame.
• Awareness: People with OCD are usually fully aware of their compulsions. BFRBs are often automatic, and a person may only notice afterward or when someone points it out.
• Typical form: OCD can show up in many ways, but washing, checking, ordering, and mental rituals are common. BFRBs show up as pulling, picking, biting, and scraping.
• Treatment approach: OCD is treated in several ways, but Exposure and Response Prevention (ERP) is the most common approach. BFRBs are treated with Habit Reversal Training (HRT) and the Comprehensive Behavioral (ComB) model.

Types of Body-Focused Repetitive Behaviors

Trichotillomania (Hair Pulling)

Repeated pulling of hair from the scalp, eyebrows, eyelashes, or other areas, resulting in noticeable hair loss. Some people pull to get a particular texture or length. Others pull when they feel tense or bored, or without noticing at all. As a diagnosis, hair pulling causes significant distress or gets in the way of daily life at school, work, home, or with friends.

Excoriation Disorder (Skin Picking)

Repeated picking at the skin, often at scabs, bumps, blemishes, or areas that feel uneven to the touch. It can lead to sores, scarring, infection, or discoloration. Common areas include the face, arms, legs, scalp, and the skin around the fingers.

Onychophagia (Nail Biting and Nail Picking)

Biting, tearing, or picking at the nails and cuticles. It is often considered the most common BFRB and is easy to dismiss as a "nervous habit." When it causes pain, bleeding, infection, distress, or difficulty stopping, it deserves attention.

Cavitadaxia (Cheek, Lip, and Tongue Biting)

Chewing the inside of the cheeks, lips, or tongue, leading to soreness, scarring, or open sores. For some people it happens automatically, such as while driving or during moments of deep concentration.

Other BFRBs

Other behaviors in this group include scratching or scraping the skin, picking at the scalp, and chewing or tearing at the lips. Not every behavior fits neatly into a category, and that's okay! What matters is how much distress or damage it causes, not what it's called.

The ComB Model: How Treatment Is Organized

One of the most widely used approaches to treating BFRBs is the Comprehensive Behavioral model, or ComB. It starts from a simple idea: BFRBs are complicated, and people pick, pull, or bite for many different reasons. ComB looks at what's driving your behavior and builds a plan around it.

The Five Domains

1. Sensory. What the behavior feels, looks, or sounds like. For example, the feel of a coarse hair or the look of a blemish.
2. Cognitive. The thoughts, beliefs, and rules that go along with it, such as "I'll just fix this one spot" or "I've already ruined it, so I may as well keep going."
3. Affective. The emotions involved, such as boredom, anxiety, tension, or shame.
4. Motor. The physical movements involved, such as bringing fingers to the face or running hands through your hair.
5. Place. The setting, activity, or time of day when the behavior shows up most, such as at the mirror before bed, in the car, or during times of high stress.

For each person, some domains matter more than others. Treatment targets the domains that are most active for you.

The Phases of Treatment

• Phase 1: Assessment and self-monitoring. The first step is understanding the behavior. A therapist may ask you to describe when, where, and how often it happens, and what comes before and after. You may be asked to track it for a week or two to build awareness.
• Phase 2: Case formulation and treatment planning. Using what you've tracked, you and your therapist identify which of the five domains drive your behavior. This becomes a personalized plan for you or your child.
• Phase 3: Intervention. Strategies are matched to each domain. That may mean changing the bathroom lighting or covering mirrors if picking happens there, learning a competing response through habit reversal, or building coping skills with your therapist to manage stress, boredom, or difficult feelings.
• Phase 4: Evaluation and adjustment. You and your therapist review progress regularly: what's working, what isn't, what to adjust, and any new triggers to add to your plan. Setbacks are treated as information, never failure!
• Phase 5: Maintenance and relapse prevention. Once things improve, treatment shifts to maintenance: planning for stressful periods, spotting early warning signs, and having a plan for getting back on track after a setback.

This article is for educational purposes only. It does not replace professional medical advice, diagnosis, or therapy.

Tips to Help with BFRBs

These tips work best alongside professional support, and they're a good place to start.

1. Give your hands something else to do. Keep fidget tools, putty, textured objects, or a smooth stone within reach, especially in the places and moments you feel most vulnerable. These tools can satisfy the sensory need without causing harm. Avoid anything painful, which can add stress and intensify sensations rather than calm them.
2. Change the environment. Make the behavior harder to do. That might mean acrylic nails at a length that's hard to pick or bite with, wearing a hat or gloves at the times of day you're most likely to pull or pick, or dimming the lights and covering mirrors before bed.
3. Practice a competing response. When the urge hits, do a gentle alternative action with your hands for about two minutes while it passes. A therapist at DK Counseling can help you choose a response that works for you.
4. Build in stress relief. Stress is a common trigger, so find outlets and hobbies that work for you, such as walking, listening to music, cooking, or journaling.
5. Be kind to yourself. Shame and self-criticism fuel the cycle rather than stop it. A slip does not erase progress. Try talking to yourself the way you would talk to a friend.
6. Find your people. Support groups and a therapist at DK Counseling can help you understand yourself and feel less alone.

Frequently Asked Questions

Is a BFRB the same as OCD?

No. They are related and often listed together in diagnostic manuals, but they are different conditions. OCD compulsions usually respond to intrusive thoughts and fears. BFRBs are driven by urges, sensations, emotions, or habits. Some people have both.

What causes BFRBs?

There is no single cause. Genetics, sensory factors, emotions, and habit patterns can all play a part. BFRBs are not caused by bad parenting or personal weakness.

Can children outgrow BFRBs?

Some do, especially young children who twirl or pull their hair. But if the behavior continues, causes damage, or comes with distress, we encourage seeking therapy or an evaluation rather than waiting. There is never any shame in getting help!

Is it self-harm?

Most people with BFRBs are not trying to hurt themselves, and many do it automatically without noticing. But the behavior can still cause physical damage, and in some cases it overlaps with self-injury. If you or someone you love has urges to hurt yourself on purpose, please reach out to a mental health professional or our office. If you are in crisis, call or text 988 (Suicide and Crisis Lifeline) or call 911.

What if I slip back after doing well?

Setbacks are common and never a sign of failure! A setback during a stressful time doesn't mean treatment isn't working. Go back to the plan you built with your therapist, review it when urges come up, and lean on your support system if you need an extra boost.

How long does treatment take?

It varies from person to person. Many people notice improvement within the first few months of consistent practice, though BFRBs can flare during stress. Keep practicing the skills you build with your therapist. You don't have to stop completely for treatment to work. Many people aim for meaningful reduction, with less damage and less distress. Progress might look like fewer episodes, shorter ones, more control, or stopping entirely. Our team at DK Counseling never expects a perfect record.

Care at DK Counseling

Living with a body-focused repetitive behavior can feel overwhelming and isolating, but you never have to carry it alone. DK Counseling Services supports children, teens, adults, couples, and families in Alpharetta, Roswell, Milton, and North Fulton. Our team offers therapy along with psychiatry and psychological testing, so your care stays coordinated in one place.

To get started, email info@dkctherapy.com or call our Alpharetta office at (678) 852-4224. You deserve support without shame.

Additional Support

For more information, DK's therapists who specialize in BFRBs recommend the Picking Me Foundation, a nonprofit dedicated to raising awareness of BFRBs. It offers education, management tools, creative outlets, support groups, events, and campaigns that build a judgment-free space for people to share their stories.

If you can't access therapy right now but want to build long-term skills for managing BFRBs, our team recommends The BFRB Recovery Workbook: Effective Recovery for Hair Pulling, Skin Picking, Nail Biting, and Other Body-Focused Repetitive Behaviors. The workbook offers evidence-based behavioral tools to help you understand, manage, and reduce these behaviors.