Body-focused repetitive behaviors (BFRBs) are repetitive self-grooming behaviors, such as hair pulling, skin picking, nail biting and cheek biting, that can damage the body and are hard to stop despite repeated attempts. DSM-5-TR places trichotillomania and excoriation disorder with the obsessive-compulsive and related disorders.

Two BFRBs have their own diagnoses: trichotillomania, or hair-pulling disorder, and excoriation, or skin-picking disorder. Others, such as nail biting, lip biting and cheek chewing, are classified as other specified obsessive-compulsive and related disorders when they cause distress or harm. They are more common than most people assume. In a survey of 10,169 US adults, 1.7% had current trichotillomania, at almost the same rate in men and women, and a companion survey of the same size found 2.1% had current skin picking disorder. Most people with a BFRB also live with something else: anxiety and low mood are the most frequent companions, which is why therapy for the worry that runs underneath everything is often part of the same plan. None of this is vanity, and none of it is a failure of willpower.

Five BFRBs, and what they look like

What the evidence means for treatment

Who notices, and who does not

BFRBs are built for concealment, so the people closest to the behavior often see only its edges. That is part of why so many adults go years without a name for it.

BFRBs persist because they work, briefly. Pulling or picking can ease tension, boredom or restlessness, or bring a moment of satisfaction, and much of it happens automatically, outside awareness. The relief reinforces the behavior, and the shame afterward adds stress that feeds the next episode.

BFRBs share a DSM-5-TR chapter with OCD, but they are not OCD. OCD compulsions usually aim to neutralize an intrusive fear or thought, while BFRBs are typically driven by urges, sensations or tension and can feel satisfying in the moment. The treatments differ as well, which makes the distinction practical.

The TLC Foundation for BFRBs, the patient organization dedicated to these conditions, notes that BFRBs are classified as other specified obsessive-compulsive and related disorders rather than as OCD itself, and it names cognitive behavior therapy as the treatment of choice. Habit reversal training and the Comprehensive Behavioral model (ComB) are the core methods, sometimes combined with acceptance and commitment therapy or dialectical behavior therapy skills.

BFRBs are also not self-harm in the usual clinical sense. The behavior is aimed at relief, regulation or a sense of evenness, not at causing pain, even though it can leave real damage. The distinction matters because the treatments differ completely. A clinician who knows the whole obsessive-compulsive spectrum, from BFRBs to scrupulosity OCD treatment, will reach for different tools for each.

Matching across CEREVITY's nationwide network of independent licensed clinicians is done by specialization, so a BFRB question goes to a clinician trained in behavioral treatment for it. You can read about clinician matching and method before committing to anything.

The professional who pulls during deadlines

The patternEpisodes cluster during long reading sessions, late-night work and video calls with the camera off. Hairstyles and camera angles are chosen around the damage, and a demanding week reliably means more pulling.

What we addressAwareness training maps the high-risk moments, a competing response gives the hands a job at exactly those moments, and the desk and screen setup are changed to interrupt the chain. Where pressure itself is the engine, clinical care for pressure that never lets up runs alongside.

The picker whose skin keeps the secret

The patternPicking happens at the bathroom mirror at night and in the car. Scars are covered, summer clothing is avoided, and the dermatologist treats the skin without anyone naming the behavior. Anxiety and low mood have built up around it.

What we addressA ComB-style plan identifies the sensory, emotional and situational triggers for this person and builds a strategy for each. When anxiety or depression is part of the picture, depression care for high performers becomes part of the same treatment.

BFRB treatment with the strongest evidence is behavior therapy, led by habit reversal training: awareness training, a competing response and stimulus control. A meta-analysis of 11 randomized trials found a large effect for behavior therapy in trichotillomania. CEREVITY clinicians provide habit reversal, ComB-informed and acceptance-based treatment by telehealth.

Modality 01

Habit reversal training (HRT)

Builds awareness of each episode and its warning signs, then trains a competing response that makes pulling or picking physically harder in the moment.

Modality 02

Comprehensive Behavioral model (ComB)

Individualizes treatment around the sensory, cognitive, emotional, motor and place factors that trigger and maintain the behavior for each person.

Modality 03

Acceptance and commitment therapy (ACT)

Helps people let urges come and go without acting on them, and works directly on the shame that keeps the behavior hidden.

Modality 04

Stimulus control

Redesigns the settings where episodes cluster, from lighting and mirrors to tools and screens, so the habit loses its easiest openings.

Modality 05

Medication coordination

Medication is sometimes used before or alongside behavior therapy. Prescribing stays with your physician or psychiatrist.

Private-pay, nationwide, and built around discretion

At CEREVITY, our online individual therapy sessions are structured as a direct investment in your mental agility and overall well-being. The investment includes:

View rates & investment options

The cost of a hidden BFRB going unaddressed

Consider what is at stake when a hidden BFRB goes unaddressed:

What hiding costs

Years of concealment add up: avoided haircuts, beaches and intimacy, time spent covering damage, and the background effort of keeping a secret from the people closest to you. The behavior is treatable; the secrecy is often the heavier part.

Session formats that fit behavior therapy

Sessions run by secure telehealth across all 50 states, from home, where many episodes actually happen. Behavior therapy usually runs as the standard weekly session. Some people use 90-minute therapy sessions to build the full trigger map, or the 3-hour intensive format to start quickly. View our current rates here.

BFRBs are common and rarely come alone. Grant, Dougherty and Chamberlain surveyed 10,169 US adults and found that 1.7% had current trichotillomania, at almost identical rates in men (1.8%) and women (1.7%), with a mean age of onset of 17.7 years; 79% had at least one other mental health condition, most often anxiety or depressive disorders, OCD, PTSD or ADHD. In a companion survey of 10,169 adults, Grant and Chamberlain found 2.1% had current skin picking disorder and 3.1% had it at some point in their lives, with generalized anxiety disorder (63.4%) and depression (53.1%) the most common companions.

► What the research reports

1.7%

of US adults had current trichotillomania, at similar rates in men and women.

Grant, Dougherty and Chamberlain, Psychiatry Research, 2020

2.1%

of US adults had current skin picking disorder; 3.1% had it at some point in life.

Grant and Chamberlain, Journal of Psychiatric Research, 2020

1.41

pooled effect size for behavior therapy in trichotillomania, a large effect.

McGuire et al., Journal of Psychiatric Research, 2014

Individualized treatment has its own early evidence. In the first randomized trial of the Comprehensive Behavioral model, 36 adults with trichotillomania received 12 sessions of ComB or a minimal-attention control. ComB reduced self-reported symptoms with a moderate-to-large effect, and 27% of the ComB group, against none of the controls, had stopped pulling completely by week 12, although interviewer-rated measures did not differ significantly. The trial is small, and its authors call for more research; the larger body of habit reversal evidence is what makes behavior therapy the treatment of choice.