Body-Focused Repetitive Behaviors (BFRBs): Hair Pulling, Skin Picking & Evidence-Based Treatment
Specialized Treatment for Trichotillomania, Excoriation Disorder, and Related Behaviors
For individuals struggling with repetitive hair pulling or skin picking, the experience can be both frustrating and difficult to explain. What may begin as an occasional behavior can develop into a persistent pattern that feels increasingly difficult to control. Some individuals are fully aware of the behavior as it occurs, while others find themselves pulling or picking almost automatically, often realizing what has happened only afterward.
Repeated attempts to stop may be followed by temporary improvement, renewed pulling or picking, and growing feelings of frustration, embarrassment, or discouragement. Many people spend years trying to manage these behaviors independently, unaware that specialized, evidence-based treatments are available.
Body-focused repetitive behaviors (BFRBs) are not simply bad habits or a matter of insufficient willpower. They involve complex interactions among sensory experiences, emotional states, learned behavioral patterns, and environmental factors.
At Morris Cognitive Behavioral Consulting (MCBC), we provide specialized treatment for BFRBs using evidence-based behavioral interventions, including Habit Reversal Training (HRT) and the Comprehensive Behavioral Model (ComB). Our approach emphasizes understanding the individual patterns maintaining these behaviors and developing practical, personalized strategies for meaningful, sustainable change.
What Are Body-Focused Repetitive Behaviors (BFRBs)?
Body-focused repetitive behaviors are recurrent behaviors directed toward one’s own body that may result in hair loss, skin damage, or other physical consequences.
Although many people occasionally pull at their hair, pick at their skin, or bite their nails, these behaviors become clinically significant when they are persistent, difficult to control, and associated with physical harm, distress, or interference with daily functioning.
Two of the most widely recognized BFRB disorders are trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder.
Other body-focused repetitive behaviors may include repetitive nail biting, cheek or lip biting, and nail picking.
BFRBs can occur in children, adolescents, and adults. Their presentation varies considerably, and effective treatment requires understanding the specific circumstances in which the behavior occurs.
Trichotillomania: Understanding Hair-Pulling Disorder
Trichotillomania, sometimes referred to as trich or hair-pulling disorder, involves recurrent pulling of one’s own hair, resulting in hair loss, along with repeated attempts to decrease or stop the behavior.
Hair pulling may involve the scalp, eyebrows, eyelashes, or other areas of the body.
Some individuals experience a noticeable urge or sensation before pulling, followed by relief or satisfaction. Others pull with little conscious awareness, particularly while reading, studying, watching television, using electronic devices, or engaging in other sedentary activities.
Hair pulling may be influenced by several factors, including:
Stress, anxiety, frustration, or other emotional experiences
Boredom, fatigue, or periods of inactivity
Sensory preferences involving hair texture, thickness, or appearance
Environmental cues and habitual routines
Situations requiring concentration or sustained attention
The physical sensations associated with pulling
For some individuals, pulling is highly focused and intentional. For others, it occurs automatically. Many experience a combination of both patterns.
Trichotillomania can lead to visible hair loss, efforts to conceal affected areas, avoidance of social situations, and considerable emotional distress.
In some cases, individuals may also bite, chew, or swallow pulled hair. Hair ingestion warrants medical attention because it can lead to serious gastrointestinal complications.
Understanding the specific factors contributing to hair pulling is central to effective treatment.
Dermatillomania and Excoriation Disorder: Understanding Skin Picking
Excoriation disorder, also commonly called skin-picking disorder or dermatillomania, involves recurrent picking at the skin that results in tissue damage, accompanied by repeated attempts to reduce or stop the behavior.
Skin picking may involve the face, scalp, arms, hands, legs, or other areas of the body.
Some individuals pick at acne, scabs, blemishes, or perceived imperfections. Others focus on areas of otherwise healthy skin.
Picking may involve fingers, fingernails, or implements such as tweezers. Episodes can be brief or prolonged and may occur with varying levels of awareness.
Common contributing factors include:
Noticing perceived irregularities in skin texture or appearance
Feeling compelled to smooth, remove, or correct imperfections
Emotional tension, anxiety, or frustration
Boredom or periods of reduced stimulation
Sensory experiences associated with touching or picking
Established routines, such as examining the skin in mirrors
For some individuals, picking provides temporary relief or satisfaction. For others, it occurs almost automatically, without a clearly identifiable emotional trigger.
Repeated picking may result in bleeding, scarring, infections, delayed wound healing, or significant distress about appearance.
Although skin picking and hair pulling share important features, their triggers and maintaining factors are not necessarily identical. Treatment should reflect these differences.
Why Do People Pull Their Hair or Pick Their Skin?
A common misconception is that BFRBs occur exclusively because someone is anxious or stressed.
Although emotional distress can contribute, BFRBs are more complex.
Hair pulling and skin picking may be influenced by emotional, sensory, cognitive, behavioral, and environmental factors. The behavior may serve different functions at different times, even for the same individual.
For example, someone may pull their hair while concentrating on a difficult assignment, pick their skin when feeling overwhelmed, or engage in either behavior during a quiet evening without experiencing obvious anxiety.
The behavior may provide sensory stimulation, reduce discomfort, regulate emotional experiences, or become associated with particular routines and environments.
Over time, these patterns can become increasingly automatic and difficult to interrupt.
Effective treatment focuses not only on stopping the behavior, but on understanding what triggers it, what maintains it, and which strategies are most effective in different circumstances.
Why Is It So Difficult to Stop Hair Pulling or Skin Picking?
Many individuals with BFRBs have repeatedly attempted to stop through willpower, reminders, avoidance, or self-imposed rules.
These efforts may work temporarily but often fail to address the underlying behavioral patterns.
One reason is that pulling and picking may become strongly associated with particular sensations, environments, emotional states, or activities.
In addition, some behaviors occur with limited conscious awareness. Individuals may not recognize that they have begun pulling or picking until the behavior is already underway.
For others, the urge to engage in the behavior can feel intense, and resisting it may initially increase discomfort.
The immediate sensory or emotional consequences of pulling or picking may also reinforce the behavior, making it more likely to occur again.
This helps explain why simply telling someone to stop is rarely effective.
Specialized behavioral treatment addresses these processes directly by increasing awareness, modifying environmental triggers, developing alternative responses, and building more effective ways of managing urges and discomfort.
Evidence-Based Treatment for BFRBs
Research supports behavioral interventions as central components of treatment for trichotillomania and excoriation disorder.
Treatment is most effective when it is individualized to the person’s behavioral patterns, developmental needs, and co-occurring concerns.
At MCBC, treatment may incorporate Habit Reversal Training (HRT), the Comprehensive Behavioral Model (ComB), and complementary cognitive and behavioral strategies.
Habit Reversal Training (HRT)
Habit Reversal Training is an established behavioral treatment for body-focused repetitive behaviors.
HRT helps individuals become more aware of when and how pulling or picking occurs and develop alternative responses that interrupt the behavior.
Core components commonly include:
Awareness Training
Individuals learn to recognize the earliest signs of pulling or picking, including specific hand movements, urges, sensory experiences, and situations associated with the behavior.
This is particularly important when behaviors occur automatically or outside conscious awareness.
Competing Response Training
Individuals learn to use a behavior that is physically incompatible with pulling or picking when they notice an urge or the beginning of the behavior.
The competing response is selected based on the individual’s needs and the specific behavior being addressed.
Stimulus Control
Treatment also involves modifying environmental factors that make pulling or picking more likely.
This may include changing routines, adjusting access to commonly used implements, or introducing physical and environmental cues that support greater awareness.
HRT is not simply about replacing one habit with another. It is a structured behavioral intervention designed to interrupt established patterns and strengthen an individual’s ability to respond differently.
The Comprehensive Behavioral Model (ComB)
The Comprehensive Behavioral Model, commonly referred to as ComB, provides an individualized framework for understanding and treating BFRBs.
Rather than assuming that every instance of hair pulling or skin picking serves the same purpose, ComB examines the multiple factors that may contribute to the behavior.
The model organizes these influences into five domains:
Sensory: Physical sensations, textures, urges, or tactile experiences associated with pulling or picking.
Cognitive: Thoughts, beliefs, expectations, and attention patterns that may contribute to the behavior.
Affective: Emotional states such as anxiety, frustration, excitement, boredom, or sadness.
Motor: Physical movements, postures, and habitual sequences associated with pulling or picking.
Place: Environmental settings, activities, objects, and situations in which the behavior is more likely to occur.
Through this assessment, treatment strategies are selected to address the individual’s specific pattern of triggers and maintaining factors.
For example, someone who pulls hair primarily because of sensory preferences may benefit from different interventions than someone whose pulling occurs during periods of emotional distress or sustained concentration.
ComB allows treatment to move beyond generalized advice and toward a more precise, functional understanding of the behavior.
Cognitive Behavioral Therapy (CBT) and Complementary Strategies
Cognitive Behavioral Therapy may also address thoughts, emotional responses, and behavioral patterns that contribute to BFRBs.
Depending on the individual’s presentation, treatment may incorporate strategies drawn from Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), mindfulness-based approaches, or other behavioral interventions.
These strategies may help individuals develop greater tolerance for urges, respond more flexibly to uncomfortable emotions, reduce self-criticism, and maintain progress during challenging situations.
Such approaches are generally used to complement, rather than replace, targeted behavioral interventions such as HRT.
Can N-Acetylcysteine (NAC) Help With Hair Pulling or Skin Picking?
N-acetylcysteine (NAC) is a compound that has received research attention as a potential treatment for trichotillomania and excoriation disorder.
NAC influences glutamate-related processes in the brain and has been investigated for its possible effects on repetitive behaviors and urges.
Although some findings are encouraging, the research remains limited, and results have not been consistent across populations.
What Does the Research Show?
In a randomized controlled trial involving adults with trichotillomania, NAC was associated with significantly greater improvement in hair-pulling symptoms compared with placebo.
A separate randomized trial involving adults with excoriation disorder also found improvements in skin-picking symptoms among participants receiving NAC.
However, a controlled study involving children and adolescents with trichotillomania did not find a significant benefit of NAC compared with placebo.
These findings suggest that NAC may be helpful for some adults, but the evidence is not sufficiently consistent to consider it an established treatment for all individuals with BFRBs.
Should I Take NAC for a BFRB?
NAC should not be viewed as a substitute for evidence-based behavioral treatment.
Although it is available as a supplement, that does not mean it is appropriate or risk-free for everyone. Potential adverse effects, medical conditions, medication interactions, and individual circumstances should be considered.
NAC is not FDA-approved specifically for treating trichotillomania or excoriation disorder.
Individuals interested in NAC should discuss the available evidence, potential benefits, and risks with a qualified medical professional before starting it, particularly when considering treatment for children or adolescents.
At MCBC, our psychological treatment focuses on evidence-based behavioral interventions. When medication or supplement-related questions arise, we encourage appropriate consultation and coordination with prescribing or medical professionals.
Are BFRBs the Same as OCD?
Trichotillomania and excoriation disorder are classified among obsessive-compulsive and related disorders. However, they are not the same as obsessive-compulsive disorder (OCD).
In OCD, compulsions are often performed in response to intrusive thoughts, feared consequences, or a perceived need to prevent something distressing from occurring.
In BFRBs, pulling or picking may be associated with sensory experiences, urges, emotional regulation, or automatic behavioral patterns rather than intrusive obsessions.
Although the conditions can co-occur, their treatment approaches are not identical.
Exposure and Response Prevention (ERP) is a well-established treatment for OCD, while Habit Reversal Training and related behavioral interventions are central approaches for BFRBs.
Accurate assessment helps determine whether an individual is experiencing a BFRB, OCD, another condition, or overlapping concerns that require a coordinated treatment approach.
BFRBs in Children and Adolescents
Hair pulling and skin picking can begin during childhood or adolescence, although these behaviors may also emerge or persist in adulthood.
Children may have difficulty identifying the sensations, emotions, or circumstances associated with their behavior.
Parents may understandably become concerned about visible hair loss, skin damage, or the child’s apparent inability to stop.
However, repeated reminders, criticism, punishment, or close monitoring can increase tension and shame without addressing the factors maintaining the behavior.
Treatment for younger individuals often incorporates developmentally appropriate awareness training, behavioral strategies, and parent involvement.
Parents can learn how to support treatment goals, reinforce skill use, and respond constructively without making pulling or picking the focus of constant family attention.
The degree of parent involvement depends on the child’s age, developmental level, motivation, and individual needs.
What If I Have Been Pulling or Picking for Years?
Many individuals seek treatment after struggling with BFRBs for a considerable period of time.
Some have tried numerous strategies independently, while others have participated in therapy that focused primarily on anxiety or stress without directly addressing the pulling or picking behavior.
A longstanding history does not mean that treatment cannot be beneficial.
However, progress may require identifying patterns that have become deeply established and developing strategies that can be applied consistently across different situations.
Treatment goals are individualized and may include reducing the frequency or severity of the behavior, minimizing physical consequences, improving awareness and self-management, and reducing interference with daily life.
Progress is not always linear. Temporary increases in pulling or picking do not necessarily mean treatment has failed.
An important part of treatment involves learning to respond effectively to setbacks without returning to cycles of self-criticism and discouragement.
Our Approach at Morris Cognitive Behavioral Consulting
At Morris Cognitive Behavioral Consulting, we recognize that effective treatment for body-focused repetitive behaviors requires more than generalized coping strategies or advice to stop.
Our approach is active, collaborative, and individualized.
Treatment begins with a careful assessment of the circumstances in which pulling or picking occurs, including sensory experiences, emotional states, cognitive patterns, environmental triggers, and established behavioral routines.
Using interventions such as Habit Reversal Training and the Comprehensive Behavioral Model, we work with clients to identify meaningful treatment goals and develop practical strategies tailored to their needs.
We also recognize that BFRBs may occur alongside anxiety disorders, OCD, ADHD, executive functioning difficulties, and other psychological or medical concerns.
Rather than approaching these concerns in isolation, we consider how they interact and influence treatment.
Our goal is to help individuals develop greater awareness, flexibility, and confidence in managing their behavior while reducing the distress and interference associated with BFRBs.
Frequently Asked Questions About BFRBs
Can trichotillomania or skin-picking disorder be treated successfully?
Evidence-based behavioral interventions can significantly reduce symptoms and improve functioning for many individuals with trichotillomania or excoriation disorder.
However, treatment outcomes vary, and no intervention guarantees complete elimination of the behavior.
The goal is to develop individualized strategies that support meaningful, sustainable improvement.
Is hair pulling or skin picking a form of self-harm?
Although BFRBs can cause physical injury, they are generally distinguished from nonsuicidal self-injury by the function and intent of the behavior.
Hair pulling and skin picking often involve sensory reinforcement, habitual patterns, or attempts to regulate internal experiences rather than a deliberate intention to cause injury.
Because these behaviors can overlap with other concerns, careful assessment is important.
Why do I pull or pick even when I am not anxious?
BFRBs do not always occur in response to anxiety.
They may be associated with boredom, concentration, sensory experiences, fatigue, environmental cues, or automatic behavioral patterns.
Understanding these different triggers is an important part of treatment.
What is the difference between Habit Reversal Training and ComB?
Habit Reversal Training focuses on increasing awareness, developing competing responses, and modifying situations that contribute to pulling or picking.
The Comprehensive Behavioral Model provides a broader framework for identifying sensory, cognitive, emotional, motor, and environmental influences.
These approaches can complement one another within an individualized treatment plan.
Does NAC work for trichotillomania or dermatillomania?
Some randomized trials have found benefits of NAC for adults with trichotillomania or excoriation disorder.
However, findings are mixed, and a controlled study in children and adolescents with trichotillomania did not demonstrate significant benefit.
NAC is not FDA-approved for BFRBs, and individuals should consult a medical professional before considering it.
Can BFRBs be treated through virtual therapy?
Yes. Behavioral interventions such as Habit Reversal Training can be delivered through virtual therapy, and emerging research supports the feasibility and potential effectiveness of therapist-guided telehealth treatment for BFRBs.
Suitability depends on the individual’s age, clinical presentation, treatment needs, and ability to participate effectively in the virtual format.
How long does treatment take?
Treatment duration depends on the severity and complexity of the behavior, how long it has been present, co-occurring concerns, and the individual’s response to intervention.
Some individuals make meaningful progress during a focused course of behavioral treatment, while others benefit from longer-term support and relapse-prevention planning.
When should I seek professional help?
Professional consultation may be beneficial when hair pulling or skin picking causes noticeable hair loss, skin damage, emotional distress, repeated unsuccessful attempts to stop, or interference with relationships, work, school, or daily activities.
Individuals do not need to wait until symptoms become severe before seeking specialized treatment.
Moving Beyond the Cycle of Pulling and Picking
Living with a body-focused repetitive behavior can be exhausting, particularly when repeated efforts to stop have led to frustration or disappointment.
Yet these behaviors are understandable within a behavioral framework, and specialized treatment can provide a more effective path forward.
At Morris Cognitive Behavioral Consulting, we emphasize identifying the factors maintaining pulling and picking, developing individualized strategies, and helping clients build greater confidence in managing their behavior.
Meaningful change begins with understanding the pattern, not simply trying harder to stop it.
To learn more about our specialized treatment for trichotillomania, excoriation disorder, and related body-focused repetitive behaviors, please contact our practice.
Selected Clinical References
Bloch, M. H., Panza, K. E., Grant, J. E., Pittenger, C., & Leckman, J. F. (2013). N-acetylcysteine in the treatment of pediatric trichotillomania: A randomized, double-blind, placebo-controlled add-on trial. Journal of the American Academy of Child & Adolescent Psychiatry, 52(3), 231–240.
Grant, J. E., Odlaug, B. L., & Kim, S. W. (2009). N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: A double-blind, placebo-controlled study. Archives of General Psychiatry, 66(7), 756–763.
Grant, J. E., Chamberlain, S. R., Redden, S. A., Leppink, E. W., Odlaug, B. L., & Kim, S. W. (2016). N-acetylcysteine in the treatment of excoriation disorder: A randomized clinical trial. JAMA Psychiatry, 73(5), 490–496.
The TLC Foundation for Body-Focused Repetitive Behaviors. Expert Consensus Treatment Guidelines: Body-Focused Repetitive Behaviors.
