What Are BFRBs? Understanding Hair Pulling, Skin Picking, and More
BFRBs · Series part 1
What Are BFRBs? Why Skin Picking and Hair Pulling Aren't "Just Bad Habits"
If you pick your skin, pull your hair, or bite your nails past the point you want to, and you have promised yourself a hundred times you would stop, this post is for you. What you are dealing with has a name, it is common, and it is treatable.
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Key takeaways
- BFRB stands for body-focused repetitive behavior: hair pulling, skin picking, nail biting, and cheek or lip biting are the most common.
- They are recognized mental health conditions on the obsessive-compulsive spectrum, not habits, hygiene issues, or a willpower problem.
- They are far more common than most people realize; nearly everyone with a BFRB believes they are the only one.2
- Behavioral therapy, especially the ComB model and habit reversal training, has real evidence behind it.3
Most people who reach out to me about picking or pulling have never said the words out loud before. They have hidden it from partners, worn long sleeves in summer, penciled in eyebrows, and quietly assumed it was a personal failing. So before anything else, let me say the most important thing clearly: a BFRB is not a character flaw, and "just stop" was never the treatment.
First, what actually counts as a BFRB?
Body-focused repetitive behaviors are repetitive, grooming-type behaviors directed at your own body that you have tried to reduce or stop, and that cause damage, distress, or interference with your life. The umbrella includes:
- Trichotillomania (hair pulling): pulling hair from the scalp, eyebrows, eyelashes, or anywhere else, sometimes with rituals around selecting or handling the hair afterward.
- Excoriation disorder (skin picking, sometimes called dermatillomania): picking at skin, scabs, bumps, or cuticles, often around the face, arms, or hands.
- Onychophagia (nail biting): biting nails or the skin around them past the point of damage.
- Cheek, lip, and tongue biting or chewing: less talked about, just as real.
In the DSM-5, trichotillomania and excoriation disorder sit in the obsessive-compulsive and related disorders chapter, which is a formal way of saying the field recognizes these as genuine clinical conditions, related to OCD but distinct from it.1 Many people have more than one BFRB, and the target often shifts over time, which is one reason treatment focuses on the underlying pattern rather than a single behavior.
How common are BFRBs? (More than you think)
Because BFRBs thrive on secrecy, almost everyone with one underestimates how common they are. The research says otherwise. Roughly 1 to 2 percent of people meet criteria for trichotillomania in their lifetime, and around 2 to 3 percent for skin picking disorder.1 When researchers surveyed a general, non-clinical adult sample, close to a quarter reported some probable BFRB, with subclinical picking, biting, and pulling far more widespread than the diagnostic numbers suggest.2
Put plainly: in any full waiting room, office, or classroom, you are not the only one. You are probably not even the only one hiding it the same way you do.
Why "just stop" never worked
Here is the piece that changes how people see themselves. A BFRB is not random and it is not sabotage. The behavior is doing a job. For some people it discharges tension or anxiety; for others it fills understimulation and boredom; for others it is intensely sensory, a response to a bump, a rough edge, a hair that feels different, something that is "not right" until it is fixed. The behavior brings a moment of relief or satisfaction, which is exactly why the brain keeps reaching for it, and then shame arrives, and shame is itself a trigger. That loop, urge, behavior, relief, shame, repeat, is why white-knuckling fails and why failing at white-knuckling proves nothing about your character.
It is also worth naming what a BFRB is not. It is not self-harm in the clinical sense: the intent is not to cause pain, and the damage is an unwanted side effect of a regulating behavior, not the goal. And it is not a hygiene or vanity issue. Getting the framing right matters, because the wrong frame leads to the wrong fix.
Recognizing yourself in this? You can book a free 15-minute consultation, no pressure, and we can talk about what you're experiencing.
BFRBs, ADHD, and autism
BFRBs show up at notably high rates alongside ADHD, autism, anxiety, and OCD. For many neurodivergent adults, picking or pulling is tangled up with sensory needs, understimulation, and stimming, which means generic advice built for neurotypical nervous systems ("keep your hands busy!") often lands as both useless and condescending. This intersection is a specialty of mine, and it is where a lot of this series is headed: later posts will look closely at BFRBs and ADHD, BFRBs and autistic sensory experience, and the shame spiral that keeps all of it hidden.
What actually helps
The good news is that BFRBs are among the conditions where a specific, named, research-backed approach exists, and it looks nothing like willpower.
The ComB model
The Comprehensive Behavioral model, developed by Charles Mansueto and colleagues, starts from the idea that every person's BFRB has its own profile of triggers across five domains: sensory, cognitive, affective, motor, and place (environment).4 We map exactly when, where, and why your behavior happens, then build strategies matched to your profile rather than pulled off a shelf. A randomized clinical trial of ComB for trichotillomania found greater improvement than waitlist control,4 and, just as importantly for my clients, ComB is built to respect what the behavior does for you, including sensory needs, instead of just forbidding it. This is the model I use, and I will walk through it step by step later in this series.
Habit reversal training (HRT)
HRT is the most-studied behavioral treatment for BFRBs: awareness training, stimulus control, and competing responses. Meta-analytic reviews report large treatment effects for hair pulling and skin picking,3 and HRT components are woven into most modern BFRB therapy, including ComB. Newer approaches add acceptance and commitment therapy or DBT skills for the emotional side of the loop.
Where medical care fits
Some people also explore medication for BFRBs or for co-occurring anxiety, ADHD, or OCD. That side belongs with a doctor or psychiatric provider, not a therapist, so it is not mine to advise on, and with your permission I am glad to coordinate with your prescriber so the two sides of your care work together.
The short version
BFRBs are common, treatable, and nobody's fault. The treatments that work start by understanding what the behavior does for you, then build individualized strategies, sensory substitutes, environmental changes, competing responses, emotional skills, for each trigger. Willpower is not on the list, because willpower was never the treatment.
What working with me looks like
I offer BFRB therapy online for adults, using the ComB model, and I am licensed in Texas, Maine, New Hampshire, and Montana. Sessions happen on a secure, HIPAA-compliant video platform, one link, no waiting room, and you can join from anywhere private in your state. In practice, we map your specific pattern, build strategies that fit your sensory system and your actual life, address the shame that keeps the loop running, and fold in any co-occurring ADHD, autism, anxiety, or OCD rather than treating the BFRB in a vacuum. A free 15-minute consultation is a low-pressure way to see whether it feels like a fit.
Helpful next steps
- Wondering if what you do "counts"? If you've tried to stop and it's causing distress or damage, it counts enough to deserve support.
- Ready to talk it through? Book a free 15-minute consultation or call/text (512) 790-0019.
- Not in Texas, Maine, New Hampshire, or Montana? The TLC Foundation for BFRBs keeps a directory of trained providers.
You don't have to keep hiding this
A free 15-minute consultation is just a conversation, no commitment, no judgment, about what's going on and whether therapy could help.
Book a free 15-min consultationFrequently asked questions
What are body-focused repetitive behaviors (BFRBs)?
BFRBs are repetitive, self-grooming behaviors directed at the body, most commonly hair pulling (trichotillomania), skin picking (excoriation disorder), and nail biting, that a person has tried to stop and that cause distress or physical damage. They are recognized mental health conditions related to the obsessive-compulsive spectrum, not habits or a lack of willpower.
Is skin picking or hair pulling a form of self-harm?
No. BFRBs are classified differently from self-harm because the goal is not to cause pain. Most people pick or pull to regulate something, such as tension, understimulation, sensory discomfort, or a not-quite-right feeling, and the damage is an unwanted side effect. That difference matters, because effective treatment targets what the behavior is doing for you, not the damage itself.
Can therapy help me stop skin picking or hair pulling?
Yes. Behavioral therapies, especially habit reversal training and the Comprehensive Behavioral (ComB) model, have research support for BFRBs. Rather than relying on willpower, they map your specific triggers across sensory, emotional, cognitive, motor, and environmental domains and build individualized strategies for each. Sagebrush Counseling offers ComB-based BFRB therapy online for adults in Texas, Maine, New Hampshire, and Montana.
About Sagebrush Counseling
Online therapy for adults · BFRBs, OCD, anxiety & neurodivergence
Sagebrush Counseling is a telehealth practice specializing in BFRBs, OCD, anxiety, and neurodivergence in adults, with particular attention to how sensory and neurodivergent experiences shape picking and pulling. BFRB work uses the research-backed ComB model, and the approach throughout is affirming, practical, and direct, delivered entirely online.
Sessions are available for adults in Texas, Maine, New Hampshire, and Montana; join from anywhere in your state. Call or text (512) 790-0019, email contact@sagebrushcounseling.com, or book a free consultation.
References
- International OCD Foundation. Body-Focused Repetitive Behaviors (BFRBs): overview, diagnostic criteria, and prevalence estimates for trichotillomania and excoriation disorder. iocdf.org
- Solley K, Turner C. Prevalence and correlates of clinically significant body-focused repetitive behaviours in a non-clinical sample. Comprehensive Psychiatry, 2018. pubmed.ncbi.nlm.nih.gov
- Lee MT, et al. Habit Reversal Therapy in Obsessive Compulsive Related Disorders: A Systematic Review of the Evidence and CONSORT Evaluation of Randomized Controlled Trials. Frontiers in Behavioral Neuroscience, 2019; see also McGuire JF, et al., Clinical Psychology Review, 2017. frontiersin.org
- Carlson EJ, Malloy EJ, Brauer L, Golomb RG, Grant JE, Mansueto CS, Haaga DAF. Comprehensive Behavioral (ComB) Treatment of Trichotillomania: A Randomized Clinical Trial. Behavior Therapy, 2021. sciencedirect.com
- The TLC Foundation for Body-Focused Repetitive Behaviors. Education, research, and a directory of trained BFRB treatment providers. bfrb.org
This article is for educational purposes and is not a substitute for individualized professional care. It does not diagnose any condition and is not medical advice; decisions about medication belong with a qualified prescriber. If you are in crisis or having thoughts of self-harm, call or text the 988 Suicide & Crisis Lifeline any time, and call 911 if you are in immediate danger.
More in this series: BFRB therapy at Sagebrush · Related reading: Digital hoarding: why you can't delete anything (and when it matters).
