Body-Focused Repetitive Disorder

Hair Pulling, Skin Picking and Biting: Body-Focused Repetitive Disorders

What Exactly Are BFRBs?

Woman biting her nails.
These are a group of behaviors in which an individual damages his or her appearance or causes physical injury through:
  • Hair pulling to the point of having seriously thinned hair or bald spots, missing eyebrows, or eyelashes
  • Skin picking, resulting in scabs, sores that never heal, holes in the skin, and scarring 
  • Nail and/or cuticle biting, causing bleeding or infected fingertips 
  • Blemish picking or squeezing, causing scarring and infections 
  • Biting the inside of the cheek

These behaviors may be performed when the individual is stressed or excited, or bored or inactive. Hours may be spent in these activities, taking individuals away from family or work activities. Depression, shame, and isolation can also result. BFRBs most often begin in late childhood or in the early teens, and may affect at least 1 out of 20 people. While once thought to be rare and impossible to treat, we now know that neither of these ideas is true. While it is not always easy to find practitioners who can treat these disorders, there are a growing number of resources, and the picture is gradually improving.

BFRBs and the Family

BFRBs can seem extremely mysterious to family members and spouses, who at first, view them merely as bad habits, but then become more concerned when they begin to seriously damage the sufferer's appearance or cause emotional problems. The fact that many sufferers seem to be unaware they are doing these things, or report that the behaviors can be pleasurable or relaxing, can be even more puzzling and upsetting. Fighting sometimes occurs in families over the issue of these seemingly uncontrollable behaviors. Parents may scold or punish children who persist in doing these things, and spouses or significant others, at times, seem to take the sufferer's disorder personally, blaming them for an unsightly appearance. They can sometimes react as if the sufferer is having this problem just to make their lives difficult. These others may take it upon themselves to get the sufferer to stop, constantly calling the behavior to their attention, or simply telling them they must stop, leading to angry scenes and disputes. As one patient told their angry and impatient spouse, "Do you actually imagine for one moment that I want to do these things? Don't you think I'd stop if I could?" Having a BFRB is a frustrating and upsetting experience, and negative attention from others can add to the stress.

Denial is another approach families take, and has prevented many sufferers, especially children, from being allowed to get the help they badly need. When it is impossible to ignore symptoms in a child or an adult, they may be minimized or explained away as being nervous habits, laziness, childish behavior, attempts to get attention, or get even. In the case of children, pediatricians or family physicians can unwittingly aid in this, telling families to "wait and see" or "they will grow out of it."

What Are Other Signs of BFRBs?

Many of the signs of BFRBs can be well hidden, and only revealed by accident. Many sufferers do such things as styling their hair to cover bald spots, wearing wigs or hair weaves, penciling in eyebrows, wearing clothing that hides skin damage, or keeping their hands behind their backs or in their pockets as much as possible, to name a few. Sufferers may go to great lengths to not undress or take their hair down in front of spouses. Children may suddenly refuse to go to school, to avoid being teased or reprimanded by their teachers. Adults may shy away from social situations, work, or job interviews. Feelings of depression are also very common.

When Should Someone Seek Help?

It is important for sufferers to find help when it becomes evident that the behavior is out of control and is starting to limit their lives or affect the sufferer's relationships. It may be clear at this point, that different attempts at stopping have not worked, and are not going to work. Along with these, there may also be emotional problems such as depression, substance abuse, or the avoidance of school, social events, or work that can also be warning signs. Frequent family fights or disputes over the behavior should also be indicators that some type of help is needed.

How Are BFRBs Treated?

There are three main types of help. These are behavioral therapy, medication, and family therapy. Ordinary talk therapy alone has not been shown to be of much help. Behavioral therapy usually consists of two approaches: Habit Reversal Therapy (HRT), which teaches the sufferer a set of alternative behaviors that can help them focus themselves, interrupt, and block the behavior, and Stimulus Control (SC), which teaches them how to identify, change, and control the different triggers present in their routines, environments, and moods that lead to the behaviors. Medication can be of help in some cases, although it does not seem to be equally effective for everyone. It should be regarded as a tool to help with behavior therapy. Medicinal use is advised when the urge to do the behaviors is so strong that the individual feels it's irresistible and cannot follow behavioral therapy instructions. Family therapy can be extremely valuable in a number of ways, and can make important contributions in healing the family, and aiding the sufferer's recovery. First, it can help family members to accept the problem, to not blame the sufferer, and to not become over-involved in the symptoms or treatment. It can also be of help in calming situations where fighting and conflict have resulted. Another contribution family therapy can make is to help those close to the sufferer to be patient about setbacks and lapses, which are not unusual.

How Do You Find Treatment?

When seeking help for BFRBs, it is extremely important to find practitioners who specialize in these disorders, and have the experience necessary to design a treatment program. Many individuals begin with behavioral therapy, usually done by a behaviorally trained marriage and family therapist, psychologist, or social worker, and if medication is necessary, they will then seek out a psychiatrist who understands these problems. There are not great numbers of specialists out there, and a good place to begin seeking referrals is with the Trichotillomania Learning Center ( in Santa Cruz, CA.

This text was written by Fred Penzel, PhD.


Video Resources

  • Bad Hair Life: A Documentary: Without question, the definitive video documentary on TTM. This is a must-see for all those with the disorder, and their significant others.

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