Breaking the Cycle: Managing Body-Focused Repetitive Behaviors (BFRBs)

If you’ve ever found yourself absentmindedly biting your nails, twirling your hair, or picking at skin imperfections in the mirror, you’re just like the rest of us. Most people engage in some kind of grooming behavior, but for some, these behaviors are more than a habit. Nail or lip biting, hair twirling and pulling, skin picking, and cheek biting are often seen as harmless habits, but they can turn into compulsive, distressing behaviors known as Body-Focused Repetitive Behaviors (BFRBs). BFRBs can significantly impact emotional well-being, self-esteem, and physical health.

At Houston Anxiety and Wellness Center we work with many individuals of all ages struggling with BFRBs. Often these behaviors are clouted in secrecy and shame. We help our clients explore and overcome the reasons they engage in these often self soothing behaviors. Treating BFRBs requires specific knowledge, unconditional compassion, and specialized training in the right treatment.

What Are BFRBs?

BFRBs are compulsive grooming behaviors that cause both physical and emotional damage. These behaviors can be difficult to control, and often leading to embarrassing and painful consequences like bleeding nail beds, scabs that won’t heal, and bald spots. Some of the most common types of BFRBs include:

1. Trichotillomania (Hair-Pulling Disorder) – The urge to pull out hair from the scalp, eyebrows, eyelashes, arms, legs, or other body areas.
2. Dermatillomania (Excoriation or Skin-Picking Disorder) – Persistent skin picking, leading to wounds, scarring, or infections.
3. Onychophagia (Chronic Nail-Biting) – Severe nail-biting that causes damage to the nails and cuticles.
4. Lip and Cheek Biting – Biting the inside of the cheeks or lips, sometimes to the point of open sores.
5. Dermatophagia – Compulsively biting or chewing the skin, often on fingers or hands.

These behaviors might seem like simple habits, however they are actually complex, ingrained patterns that can be difficult to stop without proper intervention.

How Are BFRBs Diagnosed?

BFRBs fall under Obsessive-Compulsive and Related Disorders in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders). However, they are distinct from OCD. Unlike OCD, which is driven by intrusive thoughts and compulsions performed to reduce anxiety, BFRBs are often triggered by sensory experiences or emotional states. These behaviors can be conscious or unconscious. 

A diagnosis of a BFRB generally includes the following criteria:

• Repetitive behavior (pulling, picking, biting, etc.) that results in damage to the body
• Repeated attempts to stop or reduce the behavior without success
• Significant distress or impairment in daily life due to the behavior
• The behavior is not due to another medical or psychiatric condition (e.g., scabies, psychosis)

Many individuals with BFRBs report engaging in these behaviors more frequently during times of stress, boredom, or intense concentration. 

Treatment Approaches for BFRBs

Several treatment approaches have been found to be effective in reducing these behaviors.

Cognitive Behavioral Therapy (CBT)

CBT, specifically Habit Reversal Training (HRT), is one of the most widely used treatments. This involves:

• Awareness Training – Recognizing triggers and behavioral patterns.
• Competing Response Training – Learning alternative behaviors that physically prevent engagement in the BFRB (e.g., clenching fists instead of pulling hair).
• Stimulus Control – Modifying the environment to reduce triggers (e.g., wearing band-aids, using fidget toys).

Acceptance and Commitment Therapy (ACT)

ACT helps individuals accept distressing emotions rather than trying to suppress them. Mindfulness techniques and values-based decision-making are key components in reducing engagement in BFRBs.

Medication

There is no FDA-approved medication specifically for BFRBs, but some individuals find that SSRIs (commonly used for anxiety and OCD) or N-acetylcysteine (NAC), a supplement that influences glutamate regulation in the brain, can help reduce urges.

Comprehensive Behavioral Model (ComB)

This model addresses five core factors contributing to BFRBs:

1. Sensory – The physical sensations associated with the behavior.
2. Cognitive – Thoughts that trigger engagement in the behavior.
3. Affective – Emotional states that drive the behavior.
4. Motor – The physical movements involved in the behavior.
5. Place – Environmental triggers that encourage the behavior.

Treatment is then tailored and individualized to the specific factors influencing a person’s unique engagement in the BFRB.

Management Strategies: Practical Steps You Can Take

If you or a loved one struggles with a BFRB, there are effective steps you can take to help manage it.

1. Increase Awareness

Tracking behaviors in a BFRB journal can help identify patterns. Recording when, where, and why the behavior occurs increases self-awareness and provides insight into triggers.

2. Create Barriers

• Wearing gloves or band-aids can help prevent skin picking.
• Headbands or hats can reduce hair-pulling opportunities.
• Bitter-tasting nail polish can deter nail-biting.

3. Replace the Behavior

• Using fidget toys or stress balls can keep hands busy.
• Chewing gum can help reduce lip and cheek biting.
• Wearing textured bracelets or rings can redirect sensory input.

4. Reduce Stress

Since stress is a common trigger, prioritizing stress management is crucial. Effective strategies include:

• Deep breathing exercises
• Progressive muscle relaxation
• Regular physical activity
• Mindfulness or yoga practices

5. Seek Support

Connecting with others who experience BFRBs can reduce feelings of isolation. Online support groups and therapy communities can provide encouragement and shared strategies.

6. Practice Self-Compassion

Managing a BFRB is a process, and setbacks are normal. Instead of self-criticism, practice self-kindness and recognize progress, no matter how small.

BFRBS are more than just habits—they are complex conditions that require understanding and structured intervention. If you or someone you care about is struggling, know that help is available, and change is possible. Through increased awareness, targeted behavioral strategies, and professional support, individuals with BFRBs can regain control and improve their quality of life.

If this post was helpful, consider sharing it with someone who might benefit. And if you’re struggling with a BFRB, reach out to us or another trained mental health professional. We can expertly guide you, while collaborating and individualizing your BFRB treatment plan so we are truly getting to the root of the problem.