Body-focused repetitive behaviors

All You Need To Know About BFRB Treatment

You pull, pick, or bite, you've tried to stop, and it keeps coming back. That's not a willpower problem. It's a body-focused repetitive behavior, and there's a treatment made for it. This page covers how BFRB treatment works and where to start.

By Nathan Peterson, LCSW, OCD and BFRB therapist

BFRB: what is it?

BFRB stands for body-focused repetitive behavior. It's a group of behaviors where you pull, pick, bite, or scrape at your own body over and over, to the point of damage, and can't stop even when you try. Common BFRBs include:

Hair pulling (trichotillomania) from the scalp, brows, lashes, or body
Skin picking (dermatillomania, also called excoriation disorder)
Nail biting (onychophagia), and how to stop
Cheek, lip, or tongue biting
Cuticle picking and nose picking

BFRBs often bring a moment of relief or satisfaction. They can happen on purpose, like going after a hair or bump that feels wrong, or on autopilot, like while you scroll or drive. They aren't a form of self-harm, even though older articles describe them that way.

Complications

Left alone, BFRBs can cause problems in a few areas:

Physical: hair loss, skin damage, infections, scarring, damaged nails, and sore or bleeding cuticles
Emotional: shame, frustration, and feeling like something is wrong with you for not being able to stop
Social: hiding spots, avoiding the pool, the gym, haircuts, or close contact because of how your skin, hair, or nails look

BFRBs often show up alongside anxiety, depression, OCD, or ADHD, so it helps to look at the whole picture.

BFRB treatment

The main BFRB treatment is a behavioral therapy called habit reversal training, or HRT. It's a type of CBT made for BFRBs. It works on your hands and your setup, not on arguing with your thoughts.

Habit reversal training

Awareness. You learn when, where, and how you pull, pick, or bite, including the moment right before.
A competing response. When the urge shows up, you do something with your hands that makes the behavior hard, like making a fist, until the urge passes.
Support. Someone you trust helps you notice and cheers on the competing response, if you want that.

The ComB model

The ComB (comprehensive behavioral) model builds on HRT. It looks at what feeds your BFRB, like sensations, thoughts, feelings, habits, and places, and gives you a tool for each one. That's why two people with the same BFRB can end up with different plans.

Acceptance-based skills

Some therapists add acceptance-based skills, so you can let the urge be there without acting on it. You don't have to make the urge go away before you can stop.

Medication

No medication is approved specifically for BFRBs. Some doctors prescribe medication to help, and researchers are still studying which ones help and for whom. That's a conversation for your doctor or psychiatrist, and it usually works best alongside behavioral treatment.

I know, "make a fist when you feel the urge" sounds way too simple for something that's been going on for years. The simple part is the point. The work is doing it every time.

Therapist or BFRB program?

Both work, and you can use both. A therapist who treats BFRBs can tailor HRT to you week by week. The TLC Foundation for BFRBs keeps a provider directory at bfrb.org.

A self-guided BFRB program teaches the same skills at your own pace. It helps if a BFRB specialist is hard to find, has a long waitlist, or costs more than you can do right now. You can also use a program while you wait for a therapist.

For the next three days, write down every time you catch yourself pulling, picking, or biting: where, when, and what you felt right before. (Yes, you'll forget some. Write down that you forgot.)

That list is step one of HRT. If you want the rest laid out for you, that's what the BFRB program below is for.

Guides by BFRB

TrichotillomaniaHair pulling: symptoms, triggers, and causes. DermatillomaniaSkin picking, including scalp and finger picking. Finger and cuticle pickingDermatillomania on the fingers, and how to stop. Stop picking skinPractical steps you can start today. Nail bitingWhy it's hard to stop, and what helps. Trichotillomania treatmentHRT and the ComB model for hair pulling. Skin picking treatmentHow excoriation disorder is diagnosed and treated. Hair pulling testA free test to see where you are.

Common questions about BFRB treatment

Is a BFRB the same as OCD?

No, though they're related. The DSM-5 lists hair pulling and skin picking with OCD and related disorders. OCD rituals are usually about stopping a feared outcome. BFRBs are usually about an urge, a tension, or a sensation that the behavior settles for a moment. Some people have both.

Is a BFRB a form of self-harm?

Usually not. BFRBs aren't about wanting to hurt yourself, and a lot of it happens without noticing. Older articles call BFRBs self-harm, but that's not how they're understood now.

Can you have more than one BFRB?

Yes, and it's common. Someone might pick their skin and bite their nails, or pull hair and chew their cheek. The same treatment skills work across all of them.

What is the best BFRB treatment?

The treatment with the most research behind it is habit reversal training, often as part of the ComB model. It can be done with a therapist, in a self-guided BFRB program, or both.