More Than a Bad Habit: Understanding Skin Picking, Hair Pulling, and Nail Biting

Body-focused repetitive behaviors (BFRBs), such as skin picking, nail biting, and hair pulling are common.

Body-focused repetitive behaviors (BFRBs) are quite prevalent, with studies indicating that between 23% and 60% of individuals report participating in at least one BFRB. Of these, roughly 0.5% to 4.4% meet the criteria for a diagnosable clinical BFRB disorder.

Research highlights that BFRBs are more commonly observed in females. These behaviors typically begin during late childhood or early adolescence, particularly between the ages of 11 and 15. They frequently coexist with other mental health issues, such as anxiety, depression, or obsessive-compulsive disorder (OCD).

The physical consequences of BFRBs can be severe, leading to hair loss, open wounds, scars, infections, and tissue damage. These outcomes often contribute to feelings of shame and embarrassment among individuals affected.

Many people who engage in BFRBs report experiencing a strong urge or physical tension that triggers the behavior, which may provide temporary relief or gratification, followed by feelings of distress.

Although the underlying causes of BFRBs are not fully understood, they are thought to be influenced by a combination of genetic predispositions and challenges related to emotional regulation.

What causes body-focused repetitive behaviors? Healthcare providers are still trying to understand why some people develop BFRB (Body-Focused Repetitive Behavior) disorders, like hair-pulling or skin-picking. 

Research points to a few possible reasons:

Brain Structure and Genetics: The way certain parts of the brain work, especially those related to emotions and rewards, might play a role in these behaviors. How our brains develop and function can be influenced by our genes. Genetics might also impact the balance of important chemicals in the brain that help control mood and impulses, like serotonin and dopamine.

Emotional Regulation: People may engage in these behaviors as a way to deal with negative feelings, such as discomfort, embarrassment, boredom, or unhappiness. It’s like their body’s way of coping with tough emotions.

Distraction: BFRBs might serve as a distraction for individuals feeling overwhelmed or under-stimulated. When faced with stress or uncomfortable situations, these behaviors could help take their mind off what’s happening around them.

Overall, while we don’t have all the answers, these factors can help explain why some people might struggle with BFRB disorders.

If this sounds familiar, you’re not alone—and more importantly, this isn’t just something you have to ‘try harder’ to stop. There are actually specific, evidence-based approaches designed to help you manage these urges in a realistic and compassionate way. One of the most effective is called Habit Reversal Training (HRT).

Habit Reversal Training (HRT) is the frontline behavioral therapy for Body-Focused Repetitive Behaviors (BFRBs). It uses awareness training (identifying triggers), competing response training (substituting incompatible actions), and stimulus control to manage urges.

Key Components of HRT for BFRBs:

Awareness Training: Identifying when, where, and why the behavior occurs, including recognizing the "premonitory urge" or tension before the action.

Competing Response Training: Practicing a substitute behavior that makes the BFRB physically impossible, such as clenching fists, sitting on hands, or gripping an object, usually for 60 seconds.

Stimulus Control: Modifying the environment to reduce triggers, such as wearing gloves, using Band-Aids, or removing tools used for picking.

Social Support: Involving family or friends to provide positive reinforcement for using skills rather than just punishing the behavior. 

No one wants to feel out of control when it comes to their own actions. For those struggling with body-focused repetitive behavior (BFRB) disorders, stopping these behaviors can seem impossible.

Fortunately, you don’t have to face this challenge alone. Working with a mental health care provider can help you find effective solutions.

Many individuals find success in managing their symptoms through therapy and/or medication. It may take several months before you start to feel better and notice improvements. However, your care team will be there to support you in managing BFRBs throughout your life.