Body-focused repetitive behaviors (BFRBs), such as excessive hair-pulling, skin-picking and nail-biting, can take a heavy emotional and physical toll. Here, some basic information on these troubling behaviors…

The main BFRBs are trichotillomania (hair-pulling)…excoriation (skin-­picking)…and onychophagia (nail-­biting), but other BFRBs include dermatillomania (picking at pimples, scabs, etc.) and morsicatio buccarum (biting inside the mouth). And there can be other variations. These behaviors can take up hours each day. And wigs and cosmetics are sometimes required to cover up the damage.

BFRBs typically start in early adolescence and may persist into adulthood. They appear to be substantially more common in women than men, although this may reflect male reluctance to seek treatment. 

The habits can cause a variety of health problems. Bald patches or areas of raw, scabby skin may develop, followed by possible infection. Consequences may even be life-threatening: Around 15% of people with trichotillomania eat the hair they pluck (trichophagia), which sometimes accumulates into an indigestible mass that requires surgery.  

But there’s also a heavy emotional price. The unsightliness resulting from BFRBs is bad enough, but the embarrassment and stigma associated with self-damaging behavior that one can’t control makes things worse (one skin-picker described the condition as “my shameful, confusing, unstoppable, dirty little secret”). Intimate relationships can become difficult, if not impossible, and some people withdraw completely. Depression and anxiety disorders frequently occur along with BFRBs.

People experience the urge to pull, pick or bite in different ways. Some describe tension and discomfort that grow until they’re relieved by pulling hair or picking at skin. (“I tried really hard to stop pulling, but the thought was always there. I would eventually crack and pull like mad,” said one sufferer). Others engage in these activities because they provide pleasurable sensations that relieve stress or boredom. (“Picking on my skin became a self-soothing activity that I would go to whenever anxious or stressed. It turned into something I could not control,” said another patient). Many are aware of the urge and the behavior, while some act without realizing it, even during their sleep.   

While these behaviors share some of the same symptoms as obsessive-compulsive disorder (OCD) and anxiety disorder, they are not the same thing. The causes are uncertain. No aspect of environment, pattern of upbringing, childhood trauma or personality trait has been shown to increase risk for these actions. Some research suggests that genetics plays a role. 

Source: David A. F. Haaga, PhD, professor of psychology at American University, Washington, DC, and a member of the scientific advisory board of the TLC Foundation for Body-Focused Repetitive Behaviors (BFRB.org). He conducts research on smoking cessation, depression and trichotillomania and is interested in cognitive behavioral therapy processes and outcomes.