Body-Focused Repetitive Behaviors

Overview of Body-Focused Repetitive Behaviors: Types, Treatments & ADHD Links

Body-focused repetitive behaviors include trichotillomania (hair pulling), excoriation (skin picking), and onychophagia (nail biting), among others. Here, learn about the most common BFRBs, available treatments, and connections to ADHD.

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What Are Body-Focused Repetitive Behaviors?

Body-focused repetitive behaviors (BFRBs) refer to recurrent and chronic behaviors inflicted upon the body (like nail biting and hair pulling) that often result in physical damage. Examples of BFRBs include:

  • Trichotillomania (hair-pulling disorder)
  • Excoriation/Dermatillomania (skin-picking disorder)
  • Onychophagia (nail biting)
  • Dermatophagia (skin biting)
  • Rhinotillexomania (nose picking)
  • Cheek/lip biting

In the DSM-5, BFRBs fall under the “other specified obsessive-compulsive and related disorder” category. Only trichotillomania and excoriation appear as separate entries in the DSM-5 with their own diagnostic classifications.

BFRBs can be impulsive because individuals often mindlessly partake in them. These behaviors can also be compulsive, wherein individuals are aware of what they’re doing and often want to stop the behavior but feel that they can’t. Those who have BFRBs report feeling pleasure and/or pain from these habits, and they often dislike the consequences of their behaviors, making it a distressing group of conditions.

Body-Focused Repetitive Behaviors: Common Types

Trichotillomania: Overview and Features

Recurrent hair pulling, resulting in hair loss, characterizes trichotillomania. Additional criteria to merit a diagnosis include:

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  • repeated attempts to decrease or stop hair pulling
  • clinically significant distress or functional impairment associated with hair pulling
  • the behavior/hair loss is not attributable to another medical condition or better explained by another disorder

Other features of trichotillomania include:

  • Hair-pulling rituals. Individuals with trichotillomania don’t necessarily pull hairs at random. Thorough thought and inspection determine which unwanted hair to remove and why. (A hair strand may feel coarse or different from the rest, for example.). Before pulling it, the person often engages in a manual manipulation of the hair (feeling it between the fingers, rubbing it, etc.).
  • Triggered by boredom or anxiety. Hair pulling may be preceded or accompanied by various emotional states, and it may lead to gratification, pleasure, or relief.
  • Manual manipulation post-pulling. Some individuals may run or rub the pulled hair between their fingers or lips, or visually inspect it.

Trichotillomania affects at least 3.7 million people in the United States, according to some estimates.1 The condition appears to affect more women than it does men, though recent research suggests that these behaviors are equally common in both genders.2

Excoriation: Overview and Features

Excoriation, also known as dermatillomania or skin-picking disorder, is characterized by the following diagnostic criteria:

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  • recurrent skin picking resulting in skin lesions
  • repeated attempts to decrease or stop skin picking
  • significant distress or impairment as a result of the behavior
  • the skin picking is not attributable to the physiological effects of a substance and is not better explained by another disorder

Other features of excoriation include:

  • Face, arms, and hands are common skin-picking sites, but individuals may pick at different body parts. Apart from skin-picking, there may be biting, scratching, rubbing, squeezing, and other behaviors.
  • Individuals may pick at healthy skin, though acne and scabs are common triggers. Some individuals report picking in response to a minor skin irregularity or to relieve an uncomfortable bodily sensation. Mirror-checking is also a typical behavior.
  • May use tweezers, pins, and other tools to skin pick.
  • Skin-picking rituals. Individuals may visibly inspect and manually manipulate skin contents post-picking.
  • Skin and face picking may result in further scarring, acne, and lesions.

The lifetime prevalence of excoriation disorder is about 3%, though estimates vary.3 4 It may occur more often in women than in men, though recent research suggests that gender differences are not significant.3

Nail Biting

As common as nail biting is, what makes it a BFRB is the degree to which the individual engages in the behavior and how much it interferes with functioning. Typically, nail biting comes with these features:

  • Biting nails a specific way to achieve a desirable result
  • Favoring teeth over clippers to cut the nail
  • Visual inspection and manipulation (chewing) of the bitten nail
  • Damaged, sore nails and skin

Body-Focused Repetitive Behaviors and ADHD

BFRBs are unexplored attention deficit hyperactivity disorder (ADHD or ADD) comorbidities. Though research lacks on the intersection between the conditions, I see the presence of both all the time in clinical practice. And while BFRBs are conceptualized within an OCD framework, I believe that some behaviors may be related to or driven by ADHD.

Body-Focused Repetitive Behaviors: ADHD Risk Factors

  • Poor impulse control.
  • Inattention. Individuals will say focusing on the behavior grounds and soothes them, putting them in a trance-like state. Time blindness may contribute to how long someone spends on the behavior.
  • Stress associated with ADHD symptoms. Executive dysfunction can cause a lot of stress, and anything that relieves stress will be highly rewarded and reinforced in the ADHD brain.
  • Dopamine deficiency. Non-pleasurable repetitive behaviors still may provide stimulation (their goal-oriented nature also contributes to their appeal), which arouses dopamine-starved ADHD brains.
  • Comorbidity with OCD. BFRBs and OCD are already linked.

Body-Focused Repetitive Behaviors: Treatments and Interventions

If ADHD exists alongside BFRBs, ADHD symptom management should occur first to prevent undermining treatment for the latter.

Habit Reversal Training (HRT)

HRT is used to treat a variety of BFRBs. Three core facets comprise it:

  • Awareness training around the behavior, including its triggers, rituals, and time spent on it, is the first step toward change.
  • Competing response training to replace the behavior. (The options are endless.) Squeeze balls, for example, may keep hands occupied and away from the scalp or face. Wearing gloves or keeping hands in a fist may also help.
  • Social support. Individuals with BFRBs often experience shame and frustration, which makes seeking treatment difficult. Social support is key to reducing distress and improving outcomes.

Comprehensive Behavioral Treatment (ComB)

Somewhat similar to HRT, ComB constitutes four phases of treatment:5

  • Assessment and functional analysis of behaviors, including the factors that trigger and maintain behaviors (sensory, cognitive, affective, motor, place)
  • Identify and target modalities to change problematic habits
  • Implement interventions, including strategies such as mindfulness, awareness training, behavior or sensory substitution techniques, etc.
  • Evaluation to determine effectiveness of interventions

Therapy

  • Cognitive behavioral therapy (CBT) can reduce the problem behavior by helping individuals challenge negative self-talk and shame around BFRBs.
  • Dialectical behavioral therapy (DBT) may help curb unwanted behaviors by improving distress tolerance and stress management.

Medication

There are currently no FDA-approved medications to treat BFRBs. Prescribers often use the following medications, off-label, to target BFRBs and to complement behavior therapies (many of these medications are also used to treat OCD):6

  • SSRIs, which may reduce anxiety
  • Clomipramine, which may reduce hair pulling
  • Fluoxetine, which may reduce skin picking7
  • N-Acetylcysteine8

Stimulants and other medications to treat co-occurring ADHD may reduce BFRBs as well.

Medications are not without risk of side effects, so they must be prescribed only by a skilled psychopharmacologist who has experience working with BFRBs.

Additional Support for Body-Focused Repetitive Behaviors

Support groups can help individuals with BFRBs learn more about their condition, seek help for it, and stay on track with treatments. Find support groups and help through

The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, Nail Biting! Skin Picking! Hair Pulling! Understanding Body-Focused Repetitive Behaviors with ADHD [Video Replay & Podcast #386] with Roberto Olivardia, Ph.D., which was broadcast live on January 26, 2022.

View Article Sources

1 Flessner, C. A., Knopik, V. S., & McGeary, J. (2012). Hair pulling disorder (trichotillomania): genes, neurobiology, and a model for understanding impulsivity and compulsivity. Psychiatry research, 199(3), 151–158. https://doi.org/10.1016/j.psychres.2012.03.039

2 Grant, J. E., Dougherty, D. D., & Chamberlain, S. R. (2020). Prevalence, gender correlates, and co-morbidity of trichotillomania. Psychiatry research, 288, 112948. https://doi.org/10.1016/j.psychres.2020.112948

3 Grant, J. E., & Chamberlain, S. R. (2020). Prevalence of skin picking (excoriation) disorder. Journal of psychiatric research, 130, 57–60. https://doi.org/10.1016/j.jpsychires.2020.06.033

4 Kwon, C., Sutaria, N., Khanna, R., Almazan, E., Williams, K., Kim, N., Elmariah, S., & Kwatra, S. G. (2020). Epidemiology and Comorbidities of Excoriation Disorder: A Retrospective Case-Control Study. Journal of clinical medicine, 9(9), 2703. https://doi.org/10.3390/jcm9092703

5 Mansueto, C. S., Golomb, R. G., Thomas, A. M., & Stemberger, R. M. T. (1999). A comprehensive model for behavioral treatment of trichotillomania. Cognitive and Behavioral Practice, 6(1), 23–43. https://doi.org/10.1016/S1077-7229(99)80038-8

6 Sani, G., Gualtieri, I., Paolini, M., Bonanni, L., Spinazzola, E., Maggiora, M., Pinzone, V., Brugnoli, R., Angeletti, G., Girardi, P., Rapinesi, C., & Kotzalidis, G. D. (2019). Drug Treatment of Trichotillomania (Hair-Pulling Disorder), Excoriation (Skin-picking) Disorder, and Nail-biting (Onychophagia). Current neuropharmacology, 17(8), 775–786. https://doi.org/10.2174/1570159X17666190320164223

7 Lochner, C., Roos, A., & Stein, D. J. (2017). Excoriation (skin-picking) disorder: a systematic review of treatment options. Neuropsychiatric disease and treatment, 13, 1867–1872. https://doi.org/10.2147/NDT.S121138

8 Schwalfenberg G. K. (2021). N-Acetylcysteine: A Review of Clinical Usefulness (an Old Drug with New Tricks). Journal of nutrition and metabolism, 2021, 9949453. https://doi.org/10.1155/2021/9949453

5 Comments & Reviews

  1. I don’t know what organization trich.org represents but the Trichotillomania Learning Center rebranded itself several years ago as The TLC Foundation for Body-Focused Repetitive Behaviors, and their website is bfrb.org. They have much more useful information and resources, plus support groups, verified health/hair/skin service referrals, and a store. I definitely recommend anyone looking for substantive information about BFRBs start there.

  2. I myself pick up the habit of pulling out my hair from seeing a co-worker do it back in 1983. Every time I came in his office he was picking his scalp. I started and overtime, I had bald spots on my scalp. I use to color with a black marker, to hide my bald spots. I did it out because I was bored, it was easy to pick my hair. as I got older it was hard to stop, but I learned to do different things with my hands to avoid touching my hair. Then I read an article that people with Trichotillomania had a deficiency of vitamin B. Sure enough when I took vitamin B complex I was fine, I didn’t pull my hair out even when I was bored. As I write this comment, I realized that sometimes now at home (I’m 55), I seem to do it. I’m more aware that I’m doing it from when I was in my 20’s.

  3. So interesting that Fluoxetine has been shown to help with skin picking – I am looking at this article experiencing compulsive skin picking that was triggered (FROM/AFTER/BY?) taking Fluoxetine. Why might it have the reverse effect for someone?

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