Body Focused Repetitive Behavior: Symptoms, Types, Causes and Treatment

Body Focused Repetitive Behaviors (BFRBs) are a group of compulsive, often unconscious habits that can have a profound impact on physical health, emotional well-being, and quality of life. These behaviors—such as hair pulling, skin picking, and nail biting—are much more common than many realize, often starting in childhood or adolescence and sometimes becoming lifelong struggles. Understanding the symptoms, types, causes, and treatment options for BFRBs is crucial for those affected and for clinicians aiming to provide effective support.

Symptoms of Body Focused Repetitive Behavior

When it comes to BFRBs, the line between an occasional habit and a clinically significant problem can be thin. While many people bite their nails or pick their skin from time to time, BFRBs are marked by repetitive, persistent behaviors that can cause physical harm and emotional distress.

Symptom	Description	Impact	Source
Repetition	Ongoing, habitual behavior	Habit formation, hard to stop	2 7
Physical Damage	Injury to skin, nails, or hair	Scarring, infection, pain	2 3 5
Impairment	Disruption of daily life/QoL	Social withdrawal, distress	2 7
Loss of Control	Difficulty stopping behavior	Feelings of helplessness	6 9

Table 1: Key Symptoms

Recognizing the Signs

BFRBs are more than just “bad habits.” They are repetitive actions, often performed unconsciously, that result in visible damage to the body. Common signs include:

• Noticeable physical damage: Individuals may have bald patches, wounds, scars, or damaged nails and cuticles 2 3 5.
• Distress and embarrassment: Many feel ashamed or frustrated by their inability to stop, leading to attempts to hide the behavior or its effects 2 7.
• Functional impairment: These behaviors can interfere with work, school, relationships, and self-esteem, sometimes leading to avoidance of social situations 2 7.
• Failed attempts to stop: Most people with BFRBs have tried—and failed—to control or stop the behavior, experiencing a sense of loss of control 6 9.

Physical and Psychological Impact

The consequences of BFRBs can be both visible and invisible. Physically, repeated picking, biting, or pulling can lead to infections, bleeding, and permanent scarring 2 3 5. Psychologically, the behaviors are linked to increased anxiety, depression, and even obsessive-compulsive symptoms. Quality of life is often reduced, not just from the behavior itself, but from the emotional toll it takes 2 7.

Chronicity and Awareness

BFRBs can persist for years, sometimes beginning in childhood and continuing into adulthood. Many individuals perform these behaviors automatically—often while distracted, bored, or stressed—without full conscious awareness 5 7. This automaticity makes BFRBs particularly challenging to address.

Types of Body Focused Repetitive Behavior

BFRBs are an umbrella category, encompassing several distinct but related behaviors. Each has its own features, but all share the common thread of being focused on the body.

Type	Definition	Commonality	Source
Skin Picking	Repetitive picking at skin	Highly prevalent	2 3 5 7
Hair Pulling	Pulling out hair (trichotillomania)	Less common	2 3 5 7
Nail Biting	Chronic biting of fingernails	Very common	1 2 3 7
Cheek/Lip Biting	Biting inside of mouth or lips	Common but overlooked	2 5 7

Table 2: Main BFRB Types

Skin Picking (Excoriation Disorder)

Skin picking involves repetitive picking, scratching, or digging at the skin, often leading to open wounds, scarring, and sometimes infection. It is among the most common and can be especially damaging both physically and psychologically 2 3 5 7.

Hair Pulling (Trichotillomania)

Trichotillomania is characterized by compulsive pulling out of scalp, eyebrow, eyelash, or other body hair. Visible hair loss and bald patches are common, and many people experience embarrassment or shame as a result 2 3 5 7.

Nail Biting (Onychophagia)

Nail biting is one of the most widespread BFRBs. While often dismissed as a minor habit, chronic nail biting can cause significant damage to nails and cuticles, leading to pain, infection, and social embarrassment 1 2 3 7.

Cheek and Lip Biting

This involves biting or chewing the inside of the cheeks or lips, sometimes resulting in sores, calluses, or bleeding. Though less frequently discussed, cheek and lip biting are relatively common and can be just as distressing as other BFRBs 2 5 7.

Other Body-Focused Behaviors

Other less common BFRBs include nail picking and thumb sucking, particularly in children. These behaviors may evolve or shift over time, sometimes overlapping or co-occurring in the same individual 3 10.

Causes of Body Focused Repetitive Behavior

Understanding why BFRBs develop is complex. They are believed to arise from an interplay of psychological, neurological, and environmental factors.

Cause	Description	Evidence/Model	Source
Emotional Dysregulation	Difficulty managing emotions	ER model, comorbidity	6 8 9
Sensory Factors	Abnormal sensitivity or seeking sensation	Sensory processing	4
Cognitive-Behavioral	Maladaptive habits, planning styles	CB model, FA model	6 8
Biological	Potential neurological/heritability aspects	Tic/OCD spectrum	12

Table 3: Major Causes

Emotional Regulation and Coping

A leading theory is that BFRBs function as maladaptive strategies for emotion regulation. Individuals may turn to these behaviors in response to negative feelings such as anxiety, boredom, or frustration, seeking temporary relief 6 8 9. The emotion regulation (ER) model is well-supported by research, which shows strong links between BFRBs and difficulties in managing distressing emotions 6 9.

Sensory and Physiological Factors

Some people with BFRBs have abnormal sensory processing, such as increased sensitivity to touch or the sensation of their behavior. These sensory differences may contribute to both the urge to engage in BFRBs and the difficulty in stopping 4. Sensation avoidance and seeking patterns can also differentiate between clinical and subclinical cases 4.

Cognitive-Behavioral Patterns

The cognitive-behavioral model suggests that BFRBs are learned habits reinforced over time by temporary relief or satisfaction. Maladaptive planning styles, perfectionism, and high internal standards can also play a role, especially when combined with an unwillingness to relax or accept imperfection 6 8. The "frustrated action" (FA) model highlights how BFRBs may arise in response to impatience, boredom, or dissatisfaction, rather than overt stress 8.

Biological and Genetic Influences

Some evidence suggests BFRBs may be related to other disorders, such as tics or obsessive-compulsive disorder (OCD), and may run in families. The cognitive psychophysiological (CoPs) model treats BFRBs as part of the tic spectrum, focusing on the buildup of internal tension prior to the behavior 12.

The Role of Awareness and Automaticity

Many individuals engage in BFRBs without full awareness, often while distracted. This automaticity means that behaviors can become deeply ingrained, making them harder to interrupt 5 7. Unlike non-suicidal self-injury (NSSI), which is often deliberate and serves social or emotional purposes, BFRBs are typically automatic and may be driven by boredom or attempts to "fix" appearance 5.

Treatment of Body Focused Repetitive Behavior

While challenging, BFRBs are treatable. A range of behavioral, cognitive, and self-help strategies have shown promise, though no single approach works for everyone.

Treatment	Approach	Effectiveness/Notes	Source
Habit Reversal Training (HRT)	Behavioral: awareness, competing response	Medium effect, widely used	11 13 14
Decoupling (DC, DC-is)	Behavioral: redirecting action	Effective, especially for non-skin-pickers	11 13 14
Cognitive-Behavioral Therapy (CBT)	Multicomponent (CBT, CoPs)	Effective, especially CoPs	12
Self-Help/Manuals	Guided self-application	Good acceptability, moderate efficacy	11 13 14
Pharmacological	Antidepressants	Sometimes used, less researched	12
No "Well-Established" Pediatric Treatment	Evidence gaps	Need for more research	10

Table 4: Treatment Approaches

Behavioral Interventions

Habit Reversal Training (HRT) is the cornerstone behavioral treatment for BFRBs. It focuses on increasing awareness of the behavior and teaching a competing response—an action incompatible with the BFRB—to replace it. HRT is widely used and has demonstrated moderate effectiveness, though its impact may vary by BFRB type 11 13 14.

Decoupling (DC and DC-is) techniques teach individuals to redirect the habitual movement into a harmless or neutral action. Research shows these methods can be particularly effective, with some studies suggesting DC works best for non-skin-picking BFRBs, and DC-in sensu (imaginative rehearsal) having the best completion and subjective ratings 11 13 14.

Cognitive and Psychophysiological Approaches

Cognitive-Behavioral Therapy (CBT) and the Cognitive Psychophysiological (CoPs) model address the thoughts, emotions, and physiological triggers underlying BFRBs. The CoPs approach, which focuses on the buildup of tension before the behavior, has shown significant effectiveness, with high rates of clinically significant improvement sustained over months 12.

Self-Help and Digital Tools

Guided self-help manuals and online resources are increasingly popular. Studies show that structured self-help using HRT, DC, or DC-is can provide meaningful improvements, especially when multiple techniques are combined 11 13 14. Acceptability is generally high, and self-help is a promising option for those who lack access to specialized therapy.

Pharmacological Options

Antidepressants and other medications are sometimes prescribed, particularly when BFRBs are comorbid with anxiety or depression. However, current evidence for pharmacological treatment is limited and less robust compared to behavioral therapies 12.

Pediatric Considerations

For children, individual behavior therapy has shown probable efficacy for some habits (like thumb sucking), but no treatment yet meets the highest standard of evidence for pediatric BFRBs. More research is needed to develop and validate effective interventions for young people 10.

Combining Approaches

Recent studies suggest that combining behavioral techniques—such as HRT and DC—may lead to greater improvement than any single method alone. Integrating these into accessible self-help formats could further enhance their reach and effectiveness 11 14.

Conclusion

Body Focused Repetitive Behaviors are common, often misunderstood conditions that can deeply affect those who experience them. While they share features with other disorders, BFRBs are distinct in their triggers, automaticity, and impacts. Recognition and understanding are the first steps toward effective management.

Key Takeaways:

• BFRBs are repetitive, compulsive behaviors directed at the body, leading to physical damage and emotional distress.
• The most common types are skin picking, hair pulling, nail biting, and cheek/lip biting, each with unique features but overlapping challenges.
• Causes are multifactorial, involving emotion regulation difficulties, sensory processing differences, cognitive-behavioral patterns, and possibly biological factors.
• Effective treatments include behavioral therapies (HRT, decoupling), cognitive and psychophysiological approaches (CBT, CoPs), and structured self-help—often with greater benefit when combined.
• There is a need for more research, especially in pediatric populations and on long-term outcomes.

By increasing awareness and fostering evidence-based interventions, those affected by BFRBs can find pathways to recovery and improved quality of life.