Understanding the Causes and Treatments of Body-focused Repetitive Behaviors

Understanding Body-Focused Repetitive Behaviors: A Comprehensive Guide to Causes, Symptoms, and Treatment Options

Body-focused repetitive behaviors (BFRBs) represent a complex group of mental health conditions that affect millions of people worldwide, yet they remain widely misunderstood and underdiagnosed. These disorders involve repetitive, compulsive actions directed at one’s own body—such as hair pulling, skin picking, nail biting, and cheek biting—that can cause significant physical damage and profound emotional distress. While almost all people acknowledge at least one BFRB in their lifetime, approximately one out of four people experience more severe forms of these disorders, making them far more common than many realize.

Despite their prevalence, BFRBs often go unrecognized by healthcare professionals and are frequently dismissed as “bad habits” that individuals should simply stop. This misconception fails to acknowledge the neurobiological complexity of these conditions and the genuine struggle faced by those who experience them. Understanding BFRBs is essential not only for those directly affected but also for family members, friends, and healthcare providers who play crucial roles in supporting recovery.

What Are Body-Focused Repetitive Behaviors?

Body-focused repetitive behaviors are any behaviors focused on one’s own body that involve biting, pulling, picking, or scraping one’s own hair, skin, lips, cheeks, or nails that unintentionally lead to physical damage to the body and have been met with multiple attempts to stop the behavior. These behaviors differ significantly from ordinary grooming habits or nervous fidgeting. While many people might occasionally bite their nails when anxious or pick at a scab, BFRBs are characterized by their repetitive, compulsive nature and the individual’s inability to stop despite repeated attempts and negative consequences.

Unlike other obsessive-compulsive related disorders, there is often a pleasurable component to BFRBs as people are engaging in the behavior. This paradoxical experience—where individuals feel both relief and distress—makes these conditions particularly challenging to understand and treat. The behaviors may occur automatically, without conscious awareness, or they may be more focused and intentional, with individuals actively seeking out specific hairs to pull or skin imperfections to pick.

Common Types of BFRBs

The most frequently diagnosed body-focused repetitive behaviors include several distinct but related conditions:

Trichotillomania (Hair-Pulling Disorder): Trichotillomania is a mental health disorder characterized by the repetitive pulling of one’s hair, commonly from the scalp or eyebrows, but can occur on any part of the body that grows hair. Individuals with trichotillomania feel an irresistible urge to pull out their hair and even when trying to resist the urge, feel like they cannot stop, often resulting in patchy bald spots. The condition can cause significant distress and may lead individuals to avoid social situations or wear hats, wigs, or makeup to conceal hair loss.

Excoriation Disorder (Skin-Picking Disorder): This condition involves recurrent picking at one’s own skin, often targeting perceived imperfections, scabs, or blemishes. Symptoms of excoriation disorder involve repeatedly seeking and picking at skin irregularities, often on the face, arms, or scalp, which over time can cause bleeding, open wounds, infections, and scarring. The behavior can range from brief episodes to extended sessions lasting hours, during which individuals may lose track of time.

Onychophagia (Nail Biting): While nail biting is extremely common in the general population, it becomes a clinical concern when it is chronic, causes physical damage, and resists attempts to stop. Nail biting affects 11.4% of people at disorder levels, making it one of the most prevalent BFRBs. Severe nail biting can lead to infections, dental problems, and damage to the nail bed.

Morsicatio Buccarum (Cheek Biting): This involves chronic biting of the inside of the cheeks, lips, or tongue. Lip-cheek biting affects 7.9% of people at disorder levels. The behavior can cause tissue damage, lesions, and increased risk of oral infections.

Dermatophagia (Skin Biting): Dermatophagia affects 8.7% of people and involves compulsively biting one’s own skin, typically around the fingers, hands, or lips. This can result in bleeding, scarring, and infections.

Prevalence and Demographics

Understanding how common BFRBs are helps reduce the stigma and isolation many sufferers experience. BFRBs, such as skin-picking (3.5%) and hair-pulling (1.7%), affect a significant portion of the U.S. population, with an additional 15-25% experiencing subclinical symptoms. Research shows that 59.55% of people report occasionally engaging in subclinical BFRBs, and 12.27% met criteria for a pathological BFRB, suggesting these conditions are far more prevalent than previously recognized.

The rate of BFRDs was higher in women than in men, with about 90 percent of adults who seek help for BFRBs being female. However, this gender disparity may reflect differences in help-seeking behavior and social pressures rather than actual prevalence. Rates of BFRDs were low in older participants, especially after the age of 40, suggesting that symptoms may decrease with age or that older individuals develop better coping mechanisms.

Trichotillomania and Excoriation most often has an onset of adolescence, often coinciding with puberty. Hair-pulling and skin-picking severity peaked at the transition from adolescence to adulthood, with research indicating peak severity around ages 16-18. This timing suggests that hormonal changes, increased stress, and identity development during adolescence may contribute to the emergence or worsening of these behaviors.

The Neurobiological and Psychological Causes of BFRBs

The exact causes of body-focused repetitive behaviors remain an active area of research, but evidence increasingly points to a complex interplay of genetic, neurobiological, psychological, and environmental factors. Understanding these underlying mechanisms is crucial for developing more effective treatments and reducing the shame and self-blame that many individuals with BFRBs experience.

Genetic Factors

Research strongly suggests that BFRBs have a hereditary component. If you have trichotillomania, your genes may account for 32% to 78% of the likelihood that you develop the condition. This substantial genetic contribution indicates that these disorders run in families and that individuals with close relatives who have BFRBs or related conditions may be at increased risk.

Genetic studies implicate several candidate genes such as SLITRK1, SAPAP3, and HOXB8, highlighting the role of synaptic and immune-related mechanisms. The HOXB8 gene is particularly interesting, as research in animal models has shown that mutations in this gene can lead to compulsive grooming behaviors similar to those seen in human BFRBs. However, there is a need for additional genome-wide research conducted on the genetics of TTM and ED, as recent advances in genomics have led to the discovery of risk genes in several psychiatric disorders, including related conditions such as OCD, but to date, TTM and ED have remained understudied.

Neurobiological Mechanisms

These disorders are deeply wired into the brain’s circuitry, functioning more like a neurological process than a conscious choice. Advanced neuroimaging studies have revealed specific brain abnormalities in individuals with BFRBs that help explain why these behaviors are so difficult to control.

Structural abnormalities of subcortical regions involved in affect regulation, inhibitory control, and habit generation appear to play a key role in the pathophysiology of trichotillomania. In one functional neuroimaging study, patients with trichotillomania exhibited dampening of nucleus accumbens responses to reward anticipation, suggesting that the brain’s reward system functions differently in people with BFRBs.

Neuroimaging studies have found disorganization of white matter tracts involved in motor generation and suppression (i.e., bilateral anterior cingulate and right orbitofrontal and inferior frontal cortices) with both disorders. White matter tracts are the brain’s communication highways, transmitting signals between different regions. When these pathways are disrupted, the brain’s ability to inhibit unwanted behaviors becomes impaired.

Findings suggested involvement of the neurotransmitter glutamate, a leading theory of the neurobiology behind obsessive-compulsive disorder. Glutamate is the brain’s primary excitatory neurotransmitter, playing crucial roles in learning, memory, and habit formation. Imbalances in glutamate signaling may contribute to the compulsive nature of BFRBs and explain why these behaviors become so deeply ingrained.

The involvement of multiple brain systems—including those responsible for motor control, reward processing, emotional regulation, and habit formation—helps explain why BFRBs are so complex and why simple willpower is insufficient to stop them. These behaviors are not choices but rather manifestations of underlying neurobiological differences.

Psychological and Emotional Factors

While BFRBs have clear neurobiological underpinnings, psychological and emotional factors play significant roles in triggering and maintaining these behaviors. Many individuals report that their behaviors intensify during periods of stress, anxiety, boredom, or emotional distress. The behaviors may serve as coping mechanisms, providing temporary relief from uncomfortable emotions or helping individuals manage overwhelming feelings.

Contradictory to OCD, BFRB is known to include emotional experiences instead of cognitive phenomenon as behavior precursors such as entrance thoughts, obsessions and mental occupation. This distinction is important: while people with OCD typically experience intrusive thoughts that drive their compulsions, people with BFRBs more often describe emotional states—tension, restlessness, or a physical sensation—that precede their behaviors.

The relationship between BFRBs and anxiety disorders is complex. Current prevalence rates were 19.2% for GAD, 12.8% for OCD, 10.6% for social anxiety, and 27.5% for ‘any anxiety disorder,’ with lifetime prevalence rates of 22.4% for GAD, 13.8% for OCD, 11.0% for social anxiety, and 35.9% for ‘any anxiety disorder’ among people with BFRBs. However, pooled correlations between anxiety and BFRB severity were low to moderate, and while comorbid anxiety disorders are frequently observed in BFRB populations, anxiety severity is only modestly associated with BFRB severity.

Trichotillomania and skin picking frequently co-occur, and both disorders commonly present with co-occurring depression, anxiety, impulsive, and obsessive-compulsive disorders. This high rate of comorbidity suggests shared vulnerability factors and indicates that comprehensive treatment must address not only the BFRB itself but also any co-occurring mental health conditions.

Environmental and Developmental Influences

Environmental factors can trigger the onset of BFRBs or exacerbate existing symptoms. Stressful life events, trauma, significant life transitions, and chronic stress can all contribute to the development or worsening of these behaviors. The adolescent onset of many BFRBs suggests that the hormonal, social, and psychological changes during this developmental period may create vulnerability.

Early childhood experiences may also play a role. Some research suggests that disruptions in early attachment, childhood adversity, or learned behaviors from family members may contribute to BFRB development. However, it’s important to note that BFRBs are not caused by poor parenting or personal weakness—they are legitimate medical conditions with biological underpinnings.

Both subclinical and pathological BFRBs tended to be chronic (i.e., occurring for longer than 1 year), highlighting that these are not temporary habits but persistent conditions that require appropriate intervention and support.

Recognizing the Signs and Symptoms of BFRBs

Early recognition of BFRBs is crucial for timely intervention and improved outcomes. However, many individuals hide their behaviors due to shame or embarrassment, making diagnosis challenging. Understanding the full spectrum of symptoms—physical, behavioral, and emotional—can help identify these conditions and facilitate appropriate treatment.

Physical Signs

The physical manifestations of BFRBs vary depending on the specific behavior but often include visible damage to the body:

Hair loss or thinning: Symptoms of trichotillomania include pulling hair from the scalp, eyelashes, eyebrows, arms and underarms, legs, and/or pubic area, with most developing bald patches, and many examining the hair to see whether the follicle is intact, manipulating it into a particular shape or size, or chewing and swallowing the hair
Skin lesions and scarring: These behaviors can be physically dangerous, leading to hair loss, skin infections, and scarring
Damaged nails and cuticles: Chronic nail biting can result in shortened nails, damaged nail beds, bleeding cuticles, and infections around the nail area
Oral tissue damage: Cheek and lip biting can cause white patches, lesions, and thickened tissue inside the mouth
Infections: Open wounds from picking or pulling can become infected, requiring medical treatment
Gastrointestinal complications: Ingested hair can form into a clump in the digestive tract called a trichobezoar, which can cause constipation or serious gastrointestinal problems

Behavioral Indicators

Beyond physical signs, certain behaviors may indicate the presence of a BFRB:

Spending significant amounts of time engaged in the behavior, sometimes for hours at a time
Repeated unsuccessful attempts to stop or reduce the behavior
Engaging in the behavior automatically, without conscious awareness
Seeking out specific hairs, skin imperfections, or nail irregularities to target
Using tools such as tweezers, needles, or nail clippers to facilitate the behavior
Going to great lengths to disguise their behaviors, wearing hats or wigs to hide hair loss or covering up skin-picking scabs with long sleeves, even during the summer months
Avoiding situations where the behavior or its consequences might be noticed, such as swimming, intimate relationships, or medical appointments

Emotional and Psychological Symptoms

Affected individuals repeatedly pull out their own hair or pick at their skin, and these symptoms not only have a negative impact on these individuals because of the time they occupy but can also lead to considerable physical disfigurement, with concomitant loss of self-esteem and avoidance of social activities and intimate relationships. The emotional toll of BFRBs often includes:

Feelings of shame, guilt, or embarrassment about the behavior
Low self-esteem and negative body image
Social anxiety and avoidance of social situations
Depression and feelings of hopelessness
Frustration at the inability to stop despite repeated attempts
A sense of loss of control over one’s own behavior
Tension or anxiety before engaging in the behavior, followed by relief or pleasure during, and then guilt or regret afterward

Although persons with pathological BFRBs were distressed about their behavior, few experienced functional impairment or sought help for the behavior. This finding highlights a significant treatment gap: many people suffer in silence, unaware that effective treatments exist or too ashamed to seek help.

Diagnostic Criteria

Based on criteria set forth by the Diagnostic and Statistical Manual of Mental Disorders (DSM), the current edition, the DSM 5-TR, sets three primary criteria for the diagnosis of Trichotillomania – repeated hair-pulling resulting in hair loss, repeated attempts to decrease or stop, and that the behavior causes clinically significant distress or impairment. Criteria for Excoriation is similar, with the primary criteria being recurrent skin picking resulting in skin lesions, repeated attempts to decrease or stop the behavior, and cause clinically significant distress or impairment in functioning.

For a formal diagnosis, the behavior must not be better explained by another mental health condition, substance use, or medical condition. The symptoms must cause significant distress or impairment in social, occupational, or other important areas of functioning.

Comprehensive Treatment Approaches for BFRBs

Effective treatment for body-focused repetitive behaviors typically involves a combination of therapeutic approaches tailored to the individual’s specific needs, symptoms, and circumstances. While there is no one-size-fits-all solution, research has identified several evidence-based treatments that can significantly reduce symptoms and improve quality of life.

Behavioral Therapies: The First-Line Treatment

Behavioral therapy currently appears to be the most effective treatment for both trichotillomania and excoriation disorder. The evidence-based treatments for BFRBs all fall under the umbrella of Cognitive Behavioral Therapy (CBT). Several specific behavioral interventions have demonstrated effectiveness:

Habit Reversal Training (HRT)

One of the two primary interventions for BFRBs is Habit-Reversal Training (HRT). This structured approach has been extensively researched and is considered the gold standard behavioral treatment for BFRBs. In this treatment, patients focus on engaging in behaviors that prevent them from doing the BFRB through psychoeducation and functional analysis, awareness training, stimulus control, and competing response training.

HRT typically involves several key components:

Awareness Training: Helping individuals recognize when they are engaging in or about to engage in the behavior, including identifying triggers and early warning signs
Competing Response Training: Teaching individuals to engage in an alternative behavior that is physically incompatible with the BFRB when they feel the urge to pull, pick, or bite
Motivation Enhancement: Reviewing the negative consequences of the behavior and the benefits of stopping to maintain commitment to change
Stimulus Control: Modifying the environment to reduce triggers and make the behavior more difficult to perform
Social Support: Involving family members or friends in the treatment process to provide encouragement and accountability

A systematic review found best evidence for habit reversal training and decoupling as effective treatments for BFRBs. Research consistently demonstrates that HRT can produce significant reductions in BFRB symptoms, though outcomes vary among individuals.

Comprehensive Behavioral Treatment Model (ComB)

The other therapy for BFRBs is the Comprehensive Behavioral Treatment Model (ComB). This approach expands on HRT by addressing the full range of factors that may contribute to BFRBs, including sensory, cognitive, affective, motor, and environmental variables. ComB recognizes that different individuals may have different reasons for engaging in BFRBs and tailors interventions accordingly.

ComB assesses five domains that may maintain BFRBs:

Sensory: Addressing the physical sensations that trigger or maintain the behavior
Cognitive: Challenging thoughts and beliefs related to the behavior
Affective: Managing emotions that trigger pulling or picking
Motor: Addressing automatic or habitual aspects of the behavior
Environmental: Modifying situations and contexts that trigger the behavior

Acceptance and Commitment Therapy (ACT)

Research has shown that Acceptance and Commitment Therapy (ACT) can help bolster treatments and can also be a stand-alone treatment, helping people to identify their values and then act in accordance with those values, rather than the disorder. ACT focuses on accepting uncomfortable thoughts and feelings rather than trying to control or eliminate them, while committing to actions aligned with personal values.

For BFRBs, ACT helps individuals:

Accept urges to engage in the behavior without acting on them
Recognize that discomfort is temporary and tolerable
Identify what truly matters to them in life
Take committed action toward their values, even when experiencing urges
Develop psychological flexibility and resilience

Dialectical Behavior Therapy (DBT)

DBT has four components – interpersonal effectiveness, emotion regulation, mindfulness, and distress tolerance – all of which can aid in recovery with BFRBs. Originally developed for borderline personality disorder, DBT skills have proven valuable for managing the emotional dysregulation often associated with BFRBs.

DBT skills particularly relevant to BFRBs include:

Mindfulness: Increasing awareness of present-moment experiences, including urges and triggers
Distress Tolerance: Developing skills to tolerate uncomfortable emotions without resorting to BFRBs
Emotion Regulation: Learning to identify, understand, and manage intense emotions
Interpersonal Effectiveness: Improving relationships and communication, which can reduce stress and isolation

Decoupling

Decoupling is a behavioral self-help intervention for body-focused repetitive behavior in which the user is instructed to modify the original dysfunctional behavioral path by performing a counter-movement shortly before completing the self-injurious behavior, which is intended to trigger an irritation, which enables the person to detect and stop the compulsive behavior at an early stage. Decoupling was shown to be superior to habit reversal training in treating BFRB in one direct comparison study in 2021, suggesting it may be a valuable alternative or complement to traditional HRT.

Pharmacological Treatments

While behavioral therapies remain the first-line treatment for BFRBs, medications may be helpful for some individuals, particularly those with severe symptoms or co-occurring mental health conditions. So far, the FDA has not approved any pharmacological treatment for TTM, meaning all medication use for BFRBs is off-label. Behavioral therapeutic approaches have proven to be more effective than pharmacotherapy in most patient cases.

N-Acetylcysteine (NAC)

Excoriation disorder and trichotillomania have been treated with inositol and N-acetylcysteine. NAC is an amino acid supplement that modulates glutamate, the neurotransmitter implicated in BFRBs. Several studies have shown promising results, with some individuals experiencing significant symptom reduction. NAC is generally well-tolerated with minimal side effects, making it an attractive option for many patients.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine or sertraline, which are commonly used in depression, are generally not effective for BFRBs, and while SSRIs may help with underlying anxiety or depression, they often do not disrupt the core repetitive behavior. However, for individuals with significant co-occurring anxiety or depression, SSRIs may still play a role in comprehensive treatment by addressing these comorbid conditions.

Glutamate Modulators

Treatment with the drug memantine was associated with significant improvements compared to a placebo for patients with trichotillomania and excoriation disorders. Memantine, typically used for Alzheimer’s disease, modulates glutamate activity in the brain. Response to treatment with SSRI is relatively low in BFRB and glutamatergic modulators and dopamine receptors come to forefront during treatment, highlighting the importance of targeting the correct neurotransmitter systems.

Other Medications

Clomipramine or olanzapine are used only in treatment-refractory cases, and research has shown some evidence of effectiveness, but these medications can cause unwanted side effects, including agitation, dizziness, and increased risk of infection. These medications are typically reserved for severe cases that have not responded to other treatments.

Medications that have shown promise include selective serotonin reuptake inhibitors (SSRIs), clomipramine, naltrexone, and olanzapine, particularly for individuals with co-occurring conditions. The opioid antagonist naltrexone may be helpful for some individuals, potentially by reducing the pleasurable or rewarding aspects of the behavior.

Self-Help Strategies and Lifestyle Modifications

In addition to professional treatment, various self-help strategies can support recovery from BFRBs:

Environmental modifications: Removing or covering mirrors, keeping hands busy with fidget toys or stress balls, wearing gloves or bandages, and keeping nails trimmed short
Tracking and monitoring: Keeping a journal of when and where behaviors occur to identify patterns and triggers
Stress management: Practicing relaxation techniques such as deep breathing, progressive muscle relaxation, yoga, or meditation
Physical exercise: Regular physical activity can reduce stress and provide an alternative outlet for tension
Sleep hygiene: Ensuring adequate sleep, as fatigue can reduce self-control and increase vulnerability to BFRBs
Support groups: Joining a support group to connect with others with BFRBs can reduce isolation and provide practical coping strategies

Treatment Challenges and Considerations

Cognitive behavioral therapy is a first-line treatment, but finding therapists well-versed in the disorders can be difficult, with people often feeling that they have to educate the clinician. This treatment gap represents a significant barrier to care. Despite their prevalence and the considerable public health burden they pose, BFRBs remain under-recognized, underfunded, and under-researched, and while treatment exists, a larger treatment gap persists, worse than that seen in OCD, leaving many individuals without adequate care or support.

While for some, these options are highly effective, overall, they have a long-term success rate of less than 20 percent. This sobering statistic highlights the need for continued research into more effective treatments and the importance of personalized treatment approaches that address each individual’s unique constellation of symptoms and contributing factors.

Treatment is often most effective when it addresses not only the BFRB itself but also any co-occurring conditions, underlying emotional issues, and environmental stressors. A comprehensive, individualized approach that combines multiple treatment modalities typically yields the best outcomes.

The Impact of BFRBs on Daily Life and Relationships

Body-focused repetitive behaviors can profoundly affect multiple aspects of an individual’s life, extending far beyond the physical damage they cause. Understanding these impacts is crucial for developing empathy and providing appropriate support.

BFRBs frequently cause extreme emotional distress, particularly if the disorder is undiagnosed or kept secret, and when severe, can impair someone’s ability to socialize or to function at work. Many individuals with BFRBs report avoiding social situations, intimate relationships, and activities where their behavior or its consequences might be noticed.

The social impact includes:

Avoiding dating or intimate relationships due to shame about visible damage
Declining invitations to social events, particularly those involving swimming, sports, or other activities where hair loss or skin damage might be visible
Experiencing difficulty maintaining friendships due to isolation and secrecy
Feeling misunderstood by others who view the behavior as a “bad habit” that should be easy to stop
Struggling with trust and openness in relationships due to fear of judgment

Occupational and Academic Impact

BFRBs can significantly interfere with work and school performance:

Time spent engaging in the behavior can reduce productivity and interfere with completing tasks
Difficulty concentrating due to preoccupation with urges or attempts to resist them
Avoiding job opportunities or career advancement that might involve public speaking or increased visibility
Missing work or school due to shame about visible damage or time spent engaging in the behavior
Reduced confidence in professional settings

Emotional and Psychological Toll

The psychological burden of living with a BFRB extends beyond the behavior itself:

Chronic shame and self-blame for being unable to stop
Feelings of being “damaged” or “broken”
Loss of self-esteem and confidence
Anxiety about others discovering the behavior
Depression related to the chronic nature of the condition and its impacts
Frustration with the cyclical nature of the behavior—periods of improvement followed by relapse
Grief over lost time, opportunities, and experiences due to the disorder

Financial Costs

BFRBs can also impose significant financial burdens:

Costs of wigs, hairpieces, makeup, or clothing to conceal damage
Medical expenses for treating infections, scarring, or other complications
Costs of therapy and medications
Lost income due to reduced work productivity or missed opportunities
Expenses for tools or products used to facilitate the behavior

Supporting Someone with a BFRB: A Guide for Family and Friends

Family members, friends, and loved ones play crucial roles in supporting individuals with BFRBs. However, knowing how to help can be challenging, especially when the behavior seems incomprehensible or frustrating. Understanding how to provide effective, compassionate support can make a significant difference in recovery.

What to Do: Helpful Approaches

Educate yourself: Learn about BFRBs to understand that they are legitimate medical conditions, not bad habits or signs of weakness
Listen without judgment: Create a safe space for your loved one to talk about their struggles without fear of criticism or shame
Validate their experience: Acknowledge that BFRBs are difficult to control and that their struggle is real
Encourage professional help: Support them in seeking treatment from a mental health professional experienced in treating BFRBs
Offer practical support: Help them implement environmental modifications or accompany them to appointments if they wish
Celebrate progress: Acknowledge improvements, no matter how small, and recognize that recovery is not linear
Be patient: Understand that change takes time and that setbacks are a normal part of recovery
Respect their autonomy: Allow them to make their own decisions about treatment and recovery

What to Avoid: Unhelpful Responses

Don’t tell them to “just stop”: This oversimplifies the condition and implies that they lack willpower or motivation
Avoid constant monitoring: While well-intentioned, constantly watching or commenting on their behavior can increase stress and shame
Don’t express disgust or frustration: Negative reactions reinforce shame and may worsen the behavior
Avoid making it about you: While BFRBs affect loved ones, remember that the person with the condition is struggling most
Don’t compare them to others: Each person’s experience with BFRBs is unique
Avoid ultimatums: Threats or ultimatums rarely motivate lasting change and can damage relationships
Don’t minimize the condition: Dismissing BFRBs as “not that bad” or “just a habit” invalidates their experience

Supporting Children and Adolescents with BFRBs

When BFRBs affect children or teenagers, parents and caregivers face unique challenges. Early case reports of trichotillomania suggested that hair pulling in very young children tended to resolve spontaneously without the need for intervention, and the clinical profile of childhood hair pulling seemed similar to that for adults, however, very young (defined as preschool-age) children had less impairment and fewer comorbid conditions.

For parents of children with BFRBs:

Seek professional evaluation to determine whether intervention is needed
Avoid punishment or shame-based approaches, which can worsen the behavior
Work with schools to ensure understanding and appropriate accommodations
Help children develop healthy coping strategies for stress and emotions
Model self-compassion and healthy emotional regulation
Protect children from bullying or teasing related to their BFRB
Maintain open communication and create a supportive home environment

Living Well with BFRBs: Recovery and Hope

While BFRBs can be chronic and challenging conditions, recovery is possible, and many individuals achieve significant improvement or complete remission of symptoms. Understanding what recovery looks like and maintaining hope are essential components of the healing journey.

Redefining Recovery

Recovery from BFRBs doesn’t necessarily mean never experiencing urges or never engaging in the behavior again. Instead, recovery often involves:

Significant reduction in the frequency and intensity of behaviors
Improved ability to manage urges and resist engaging in the behavior
Reduced distress and shame related to the condition
Better quality of life and functioning in social, occupational, and personal domains
Increased self-compassion and acceptance
Development of healthy coping strategies for stress and emotions
Greater understanding of triggers and warning signs
Ability to quickly recover from setbacks without spiraling into shame or hopelessness

Building a Recovery-Oriented Lifestyle

Long-term recovery from BFRBs often involves lifestyle changes that support overall mental health and well-being:

Stress management: Developing a toolkit of healthy stress-reduction techniques
Self-care practices: Prioritizing sleep, nutrition, exercise, and activities that bring joy
Mindfulness and awareness: Cultivating present-moment awareness to catch urges early
Connection and community: Building supportive relationships and reducing isolation
Purpose and meaning: Engaging in activities aligned with personal values and goals
Ongoing learning: Staying informed about new research and treatment approaches
Self-compassion: Treating oneself with kindness and understanding, especially during setbacks

Managing Setbacks and Relapses

Setbacks are a normal part of recovery from BFRBs. Rather than viewing them as failures, they can be opportunities for learning and growth:

Identify what triggered the setback to prevent future occurrences
Practice self-compassion rather than self-criticism
Return to helpful strategies and techniques that have worked in the past
Reach out for support from therapists, support groups, or loved ones
Remember that a setback doesn’t erase previous progress
Use the experience to refine your recovery plan

Advocacy and Awareness

Many individuals find meaning and empowerment through advocacy and raising awareness about BFRBs. In view of the often-irreversible somatic sequelae (e.g. scars) BFRBs/BFRDs deserve greater diagnostic and therapeutic attention by clinicians working in both psychology/psychiatry and somatic medicine (especially dermatology and dentistry). Advocacy efforts can include:

Sharing personal stories to reduce stigma and increase understanding
Supporting research initiatives and organizations dedicated to BFRBs
Educating healthcare providers about these conditions
Participating in awareness campaigns and events
Connecting with others through support groups and online communities
Advocating for better access to specialized treatment

The Future of BFRB Research and Treatment

The field of BFRB research is evolving rapidly, with new discoveries about the neurobiological underpinnings of these conditions and innovative treatment approaches on the horizon. Understanding current research directions offers hope for improved outcomes in the future.

Emerging Research Areas

Current research is exploring several promising avenues:

Genetics and genomics: Large-scale genetic studies to identify risk genes and understand hereditary factors
Neuroimaging: Advanced brain imaging techniques to better understand the neural circuits involved in BFRBs
Biomarkers: Identifying biological markers that could predict treatment response or subtype individuals for personalized treatment
Neurotransmitter systems: Investigating the roles of glutamate, dopamine, and other neurotransmitters in BFRBs
Immune system involvement: Exploring potential connections between immune function and BFRBs
Developmental trajectories: Understanding how BFRBs change across the lifespan

Innovative Treatment Approaches

Several novel treatment approaches are being investigated:

Digital therapeutics: Smartphone apps and online platforms that deliver evidence-based interventions and provide real-time support
Neurostimulation: Techniques such as transcranial magnetic stimulation (TMS) that directly modulate brain activity
Novel pharmacological targets: Emerging treatments targeting glutamate modulation and the endocannabinoid system offer promising avenues
Precision medicine: A precision medicine initiative recently launched by The TLC Foundation for Body-Focused Repetitive Behaviors is the largest effort yet to understand the neurobiology of BFRBs and find more effective treatments
Combined interventions: Research into optimal combinations of behavioral, pharmacological, and other treatments

Improving Access to Care

Improved dissemination of information about psychotherapy and medication shown to be effective for these disorders is warranted because their availability remains limited. Efforts to improve access include:

Training more mental health professionals in evidence-based BFRB treatments
Developing telehealth options to reach underserved populations
Creating standardized treatment protocols and training materials
Increasing insurance coverage for BFRB-specific treatments
Establishing specialized BFRB treatment centers
Developing self-help resources and guided interventions

Resources and Support for BFRBs

Numerous organizations and resources are available to support individuals with BFRBs and their loved ones:

Professional Organizations

International OCD Foundation (IOCDF): Provides comprehensive information about BFRBs, treatment resources, and an annual conference. The IOCDF absorbed the TLC Foundation for BFRBs and continues its important work supporting the BFRB community. Visit https://iocdf.org for more information.
Anxiety and Depression Association of America (ADAA): Offers educational resources about BFRBs and helps connect individuals with qualified mental health professionals. Learn more at https://adaa.org.

Finding Treatment

Although the behaviors or consequences of the behaviors might first be noticed by a hair stylist, dermatologist, or dentist, individuals exhibiting these behaviors are most appropriately referred to a licensed mental healthcare provider for diagnostic evaluation and treatment, and preferably one who has experience and specializes in treating OCRDs. When seeking treatment:

Look for therapists specifically trained in treating BFRBs
Ask about experience with habit reversal training, ComB, or other evidence-based approaches
Consider telehealth options if local specialists are unavailable
Don’t hesitate to seek a second opinion if treatment isn’t helping
Be patient in finding the right therapeutic fit

Online Communities and Support

Online communities can provide valuable peer support, reduce isolation, and offer practical coping strategies. Many individuals find comfort in connecting with others who truly understand their experiences. However, it’s important to ensure that online communities promote evidence-based treatment and recovery-oriented perspectives.

Conclusion: Moving Forward with Hope and Understanding

Body-focused repetitive behaviors are complex, challenging conditions that affect millions of people worldwide. BFRBs are among the most poorly understood, misdiagnosed, and undertreated groups of disorders, and may affect at least 1 out of 20 people. Yet despite their prevalence and impact, these conditions remain shrouded in shame, secrecy, and misunderstanding.

Understanding that BFRBs are legitimate medical conditions with neurobiological underpinnings—not character flaws or bad habits—is the first step toward compassionate, effective treatment. These disorders involve complex interactions between genetic vulnerability, brain structure and function, psychological factors, and environmental influences. They are not choices, and individuals who struggle with them deserve understanding, support, and access to evidence-based treatment.

While BFRBs can be chronic and challenging, recovery is possible. Evidence-based treatments, particularly behavioral therapies like habit reversal training and comprehensive behavioral treatment, can significantly reduce symptoms and improve quality of life. Emerging research continues to deepen our understanding of these conditions and points toward new treatment possibilities.

For individuals living with BFRBs, the journey toward recovery often involves not only reducing the behaviors themselves but also healing from the shame, isolation, and self-blame that so often accompany these conditions. It requires developing self-compassion, building supportive relationships, and creating a life aligned with personal values and goals. Recovery is not about perfection but about progress, resilience, and reclaiming one’s life from the grip of these behaviors.

For loved ones, understanding and support can make an enormous difference. Creating safe spaces for open communication, educating oneself about these conditions, and offering compassionate, non-judgmental support helps reduce isolation and facilitates healing.

As awareness grows, research advances, and treatment access improves, there is genuine hope for better outcomes for individuals with BFRBs. By continuing to increase understanding, reduce stigma, support research, and advocate for better treatment access, we can ensure that fewer people suffer in silence and more receive the help they need and deserve.

If you or someone you know struggles with body-focused repetitive behaviors, remember that you are not alone, these conditions are treatable, and help is available. Reaching out to a mental health professional experienced in treating BFRBs is an important first step toward recovery and a better quality of life. With appropriate treatment, support, and self-compassion, it is possible to break free from the cycle of these behaviors and build a fulfilling life.

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