Body-Focused Repetitive Behaviors: Effective Therapy for Hair Pulling and Skin Picking

You have been doing it for years. Pulling at your eyelashes while you read. Picking at the skin on your fingers during a meeting. Scanning your scalp for a hair that feels different from the others. Sometimes you do not notice until it is already done. Sometimes you watch yourself do it and cannot stop. Afterward, there is often a moment of shame, a quick check in the mirror, a private resolution that you will not do it again.

And then you do.

If this sounds familiar, there is a name for what you are experiencing, and there is effective treatment for it. You have not been doing it because you are weak or broken. You have been doing it because you have a Body-Focused Repetitive Behavior, and the approach that actually helps is probably not what you have tried before.

What Are Body-Focused Repetitive Behaviors?

Body-Focused Repetitive Behaviors, commonly referred to as BFRBs, are a group of repetitive self-grooming behaviors directed at the body that can become difficult to control. The most common BFRBs include trichotillomania, the repetitive pulling of hair from the scalp, eyebrows, eyelashes, or other areas of the body, and excoriation disorder, also called skin picking or dermatillomania, which involves repetitively picking at skin, scabs, cuticles, or blemishes.

Other BFRBs include nail biting, cheek biting, and lip picking, though hair pulling and skin picking often tend to cause the most visible consequences and the greatest distress.

BFRBs are more common than most people realize. Trichotillomania affects approximately 1 - 2% of the population. Excoriation disorder appears similarly common, although recent studies suggest prevalence may be somewhat higher, approaching 3% in some samples. Many people with BFRBs have never told anyone about them.

BFRBs often occur alongside anxiety, OCD-spectrum symptoms, ADHD, or sensory sensitivity, though they can also occur independently.

Why Body-Focused Repetitive Behaviors Persist Even When You Want to Stop

One of the most persistent and damaging misconceptions about BFRBs is that they are simply bad habits that a sufficiently motivated person could stop if they really wanted to. This framing causes a great deal of harm. It leads people to try willpower-based approaches that do not work, to feel ashamed when they fail, and to conclude that something is fundamentally wrong with them rather than recognizing that they are dealing with a condition that requires a specific kind of help.

BFRBs are not habits in the ordinary sense of the word. They are complex behavioral cycles that serve a function: regulating emotion, reducing tension, providing stimulation, or producing a satisfying sensory experience. The behavior works in the short term, which is why it persists. Telling someone to simply stop a BFRB without addressing the function it serves is like telling someone to stop using their phone without giving them another way to manage boredom and connection. The underlying need does not disappear just because the behavior is being suppressed.

What BFRBs Feel Like Internally: Urges, Relief, and Shame

For adults with BFRBs, the experience often has several layers.

There is the behavior itself, which may happen automatically and outside of awareness, or may involve a deliberate search for a particular hair or patch of skin that meets some internal criterion. There is frequently a feeling of tension or discomfort before the behavior and a sense of relief or satisfaction during or after it. And then there is often shame: about the visible consequences, about the inability to stop, about having something that feels so strange and so private that it has never been mentioned to a doctor, a partner, or a friend.

Many adults with BFRBs have developed elaborate systems for managing the visibility of their behavior. Eyebrow pencil to fill in sparse patches. Hairstyles chosen to conceal bald spots. Long sleeves. Strategic positioning in conversations so that a particular side of the face is not visible. The effort that goes into concealment is significant, and the fear of being discovered can shape daily decisions in ways that are exhausting over time.

A Note for Parents: When Your Child Is Hair Pulling or Skin Picking

If your child is pulling out their eyelashes, picking at their skin until it bleeds, or has developed a bald patch on their scalp, your reaction as a parent is understandable. You want it to stop. You are worried about what it means. You may be concerned about infections, scarring, or what other people will think when they notice your child has no eyebrows or a visible bald spot. You may have tried asking them to stop, reminding them, pointing it out when it happens, or taking away access to mirrors. And it has probably not worked, or has worked briefly before the behavior returned.

The frustration parents feel in this situation is real. The approaches that often feel most natural to parents can backfire.

When a child is called out for a BFRB in the moment, or reminded repeatedly to stop, it often increases shame and self-consciousness without meaningfully reducing the behavior. In some cases it can increase the behavior, because shame and anxiety are among the emotional states that BFRBs help regulate. A child who feels watched, embarrassed, or criticized is a child whose nervous system is more activated, not less, and the behavior that helps them manage that activation may become more compelling.

This is not a willpower problem in your child. It is not defiance. It is not attention-seeking. It is a behavioral pattern that serves a function, and the most effective path forward involves understanding that function and working with it rather than against it.

Getting support for your child does not mean giving up or accepting the behavior permanently. It means getting the right kind of help, which often looks very different from what most families have tried on their own.

What Effective BFRB Treatment Looks Like: ComB and Habit Reversal Training

The most evidence-based behavioral treatments for BFRBs include Habit Reversal Training (HRT) and the Comprehensive Behavioral (ComB) model. ComB is an individualized approach that begins with a careful assessment of the specific contexts, sensory experiences, emotions, thoughts, and motor patterns involved in a person's particular BFRB. Because BFRBs vary significantly from person to person in their triggers, functions, and maintaining factors, effective treatment needs to be tailored to the individual rather than applied as a one-size-fits-all protocol.

Based on this assessment, a ComB-trained therapist works with the client to develop strategies that address the specific functions the behavior is serving. This might include sensory substitutes that provide a similar tactile experience, awareness training to help the person recognize when the behavior is beginning, environmental modifications that reduce access or change the context in which the behavior typically occurs, and emotion regulation strategies that address the underlying states the behavior is helping manage.

ComB does not ask people to simply stop the behavior through force of will. It works with the behavior’s function, gradually replacing it with alternatives that meet the same needs without the same consequences. This is one reason it often succeeds when willpower-based approaches have not.

Treatment for children follows the same principles but often involves parents directly. Parents learn how to respond to the behavior in ways that are supportive rather than inadvertently increasing shame, and how to create an environment at home that supports rather than undermines progress.

When to Seek Help for Hair Pulling, Skin Picking, or Other BFRBs

It is worth reaching out for a professional evaluation when the BFRB is causing visible physical consequences such as hair loss, skin damage, infections, or scarring; when it is causing significant distress or shame; when it is taking up meaningful time or mental energy; or when repeated attempts to stop on your own have not been successful.

For children, it is worth seeking help when the behavior is increasing rather than resolving, when it is affecting self-esteem or social confidence, or when the dynamic around the behavior at home has become tense or conflicted.

Many people with BFRBs wait years before seeking help, often because they do not know treatment exists or because shame makes disclosure difficult. If you have been managing this alone for a long time, that is not a reason to keep waiting. It is a reason to reach out sooner.

BFRB Therapy in Austin and Round Rock for Hair Pulling and Skin Picking

At Austin Anxiety and OCD Specialists, we provide individualized treatment for hair pulling, skin picking, and other body-focused repetitive behaviors using the Comprehensive Behavioral Treatment model. We work with children, adolescents, and adults, and we offer both individual therapy and an Intensive Outpatient Program for those who need more structured support.

If you recognize yourself or your child in what you have read, we would be glad to help. Reach out to schedule an appointment, and we will help you figure out the right next step.