Co-morbid Conditions:

Body Focused Repetitive Behaviors

About Body-Focused Repetitive Behaviors (BFRBs)

Body-focused repetitive behaviors (BFRBs) are a group of conditions characterized by recurrent behaviors directed toward the body, such as hair pulling, skin picking, or nail biting. Common examples include trichotillomania and excoriation disorder.

These behaviors are performed in response to urges, tension, or sensory experiences, and often provide temporary relief or satisfaction, but can lead to physical damage, emotional distress, and impairment in functioning.

BFRBs are distinct from self-harm and are not driven by a desire to cause pain, but rather are associated with differences in impulse control, sensory regulation, and emotional processing.

Hair Pulling (trichotillomania) is characterized by:

  • Recurrent pulling out of one’s hair, resulting in hair loss
  • Repeated attempts to decrease or stop hair pulling
  • Hair pulling that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
  • Hair pulling or hair loss that is not attributable to another medical condition (e.g., a dermatological condition)
  • Hair pulling that is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder)

Skin picking (excoriation) is characterized by:

  • Recurrent skin picking resulting in skin damage or lesions
  • Repeated attempts to decrease or stop picking
  • Skin picking causing clinically significant distress or impairment in social, occupational, or other important areas of functioning
  • Skin picking that is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies)
  • Skin picking that is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury)

Additional BFRBs that are not formally classified, include compulsive:

  • Nail biting (onychophagia)
  • Lip biting/picking
  • Cheek Chewing
  • Nose picking

These presentations include:

  • Recurrent, repetitive behaviors that result in unintended injury/damage
  • Repeated attempts to decrease or stop behaviors
  • Symptoms causing clinically significant distress or impairment in social, occupational, or other important areas of functioning
  • Symptoms that are not better explained by trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, stereotypic movement disorder, or nonsuicidal self-injury

Comorbidity with OCD

Obsessive-compulsive disorder (OCD) and body-focused repetitive behaviors (BFRBs)—including hair pulling (trichotillomania) and skin picking (excoriation disorder)—are related conditions within the obsessive-compulsive and related disorders spectrum. Both involve repetitive behaviors that may feel difficult to control and are associated with distress and impairment in daily functioning.

While OCD is characterized by intrusive, unwanted thoughts (obsessions) and compulsive behaviors performed to reduce anxiety, BFRBs are typically driven by sensory urges, tension, or automatic habits rather than fear-based obsessions.

Despite these differences, research highlights shared underlying mechanisms, including differences with inhibitory control, heightened emotional sensitivity, and use of repetitive behaviors to regulate internal discomfort.

Treating BFRBs

Treatment for body-focused repetitive behaviors (BFRBs) focuses on behavioral therapies to manage urges, with habit reversal training (HRT) and the comprehensive behavioral (ComB) model being the most effective. These approaches involve awareness training, identifying triggers (sensory, cognitive, environmental), and replacing behaviors with incompatible actions.

Habit reversal training (HRT) is an evidence-based behavioral therapy used to treat body-focused repetitive behaviors (BFRBs) such as hair pulling and skin picking. HRT helps individuals increase awareness of their urges and behaviors, and teaches them to replace these actions with safer, competing responses.

Core concepts include:

  • Awareness training to identify triggers, urges, and patterns
  • Competing response training to substitute the behavior with an incompatible action
  • Stimulus control to modify environments and reduce triggers

HRT is often incorporated into broader approaches like cognitive behavioral therapy (CBT) and is considered a first-line treatment for BFRBs.

The comprehensive behavioral (ComB) model is an evidence-based treatment for body-focused repetitive behaviors (BFRBs) such as hair pulling and skin picking. The ComB model builds on habit reversal training by identifying unique factors that drive an individual’s behavior and tailoring interventions accordingly.

The model focuses on five key domains that may contribute to BFRBs:

  • Sensory (e.g., urges related to touch, texture, or physical sensations)
  • Cognitive (e.g., thoughts, beliefs, or urges)
  • Affective (e.g., emotions like anxiety, boredom, or tension)
  • Motor (e.g., habitual movements or muscle memory)
  • Place/Environment (e.g., specific settings or situations where behaviors occur)

By addressing these domains, the ComB model creates a personalized treatment plan that targets the underlying reasons for the behavior, promoting more effective and sustainable behavioral change.

For more information on the treatment of BFRBs, please visit:

IOCDF.org

Resources

BFRB Changemakers: https://bfrbchangemakers.org

Body Focused Process Addictions: https://bodyfocusedprocessaddictions.com 

Habit Aware: https://habitaware.com 

IOCDF BFRB Special Interest Group: https://iocdf.org/special-interest-groups/bfrbs/  

Picking Me Foundation: https://pickingme.org 

Stop Picking: https://www.stoppicking.com 

Stop Pulling: https://www.stoppulling.com

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