A woman sits at her desk late in the evening, reading a report. Her left hand has drifted to the crown of her head, and her fingers are moving through her hair, feeling for a coarse or irregular strand. She finds one, tugs it free, and runs it between her fingers, examining the root. A small wave of relief passes through her, followed almost at once by a sinking feeling. She glances at the desk and sees a small pile of hairs that was not there an hour ago. She has no clear memory of deciding to pull, and she knows that tomorrow she will wear a scarf to hide the thinning patch above her temple, as she has done for years. She has promised herself many times that she would stop. The promise never lasts long.
In another home, a teenager stands close to the bathroom mirror, under bright light, working at a small blemish on his chin with his fingernails. He intended to spend a minute on it, and forty minutes have passed. The spot is now an open sore, and he has started on another one near his jaw. He feels both a strange satisfaction and a deep irritation with himself. He has missed breakfast with his family, and he will cover his face with a hood on the way to school. Neither of these people is careless or lacking in discipline. Both are living with conditions that are common, poorly understood, and highly treatable: trichotillomania, or hair-pulling disorder, and excoriation disorder, or skin-picking disorder.
These two conditions belong to a wider family known as body-focused repetitive behaviors, abbreviated BFRBs. The term describes repetitive, self-grooming type behaviors that involve pulling, picking, scraping, or biting at the body, which cause physical damage and which the person has repeatedly tried and failed to reduce or stop. Besides hair pulling and skin picking, the family includes nail biting, cheek and lip biting, and related habits. Studies suggest that hair-pulling disorder affects roughly one to two percent of the population, and skin-picking disorder somewhere between one and five percent, with a far larger number of people engaging in milder, subclinical forms of the behaviors. Yet people often hide these conditions for decades because of shame, and the public, families, and health professionals frequently misunderstand them.
This article offers a detailed, evidence-based account of hair-pulling and skin-picking. It explains how the conditions are defined and how they differ from ordinary habits and from self-harm. It describes the different styles of pulling and picking, the emotional and sensory functions that the behaviors serve, and what is known about their causes in the brain and in learning. It reviews the physical and psychological consequences, the conditions that commonly accompany them, and the treatments with the strongest evidence, in particular habit reversal training and the comprehensive behavioral model, along with medication options. It also offers practical strategies for reducing the behaviors and guidance for families and parents. The central message is that these behaviors are neither a sign of weakness nor deliberate self-injury, that they are driven by identifiable processes, and that most people who receive appropriate help improve.
What Body-Focused Repetitive Behaviors Are
Body-focused repetitive behaviors are repeated actions directed at the person’s own body, usually the hair, skin, or nails, that result in damage or a risk of damage, and that are performed despite attempts to stop. They are distinct from tics, from compulsions driven by obsessional fears, and from deliberate self-injury, though they overlap with each of these in some respects. Many clinicians and researchers prefer the term BFRB because it describes the behaviors without implying a single cause or a specific diagnosis.
The Place in Diagnostic Systems
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, trichotillomania and excoriation disorder are classified within the obsessive-compulsive and related disorders, together with obsessive-compulsive disorder, body dysmorphic disorder, and hoarding disorder. This grouping reflects shared features, including repetitive behaviors, difficulty resisting urges, and a degree of overlap in genetics and treatment response. Excoriation disorder was added as a distinct diagnosis in the fifth edition, in 2013, having previously been classified only under unspecified impulse control problems. Nail biting, cheek biting, and similar behaviors are recognized as other specified obsessive-compulsive and related disorders when they cause significant distress or impairment.
The Diagnostic Criteria for Hair-Pulling Disorder
According to the fifth edition, trichotillomania is diagnosed when there is recurrent pulling out of one’s hair, resulting in hair loss, accompanied by repeated attempts to decrease or stop the behavior. The hair pulling must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. It must not be attributable to another medical condition, such as a dermatological problem, and it must not be better explained by the symptoms of another mental disorder, such as the attempt to improve a perceived defect in body dysmorphic disorder. Hair may be pulled from any region, most commonly the scalp, eyebrows, and eyelashes, and less often from the pubic area, face, and other body areas.
The Diagnostic Criteria for Skin-Picking Disorder
Excoriation disorder is diagnosed when there is recurrent skin picking resulting in skin lesions, accompanied by repeated attempts to decrease or stop the behavior. As with trichotillomania, the picking must cause clinically significant distress or impairment, and it must not be attributable to the physiological effects of a substance, such as a stimulant, or to another medical condition such as scabies. It must not be better explained by symptoms of another disorder, such as delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived flaw in body dysmorphic disorder, stereotypies in a stereotypic movement disorder, or the intention to harm oneself in non-suicidal self-injury. The most common sites are the face, arms, and hands, though any area can be involved.
How Common These Conditions Are
Estimates vary with the method of study, but surveys of adults suggest a lifetime prevalence of around one to two percent for trichotillomania and about one to five percent for skin-picking disorder. Some studies of university students have found that a much larger share, up to a third or more, engage in some degree of pulling or picking, which shows that the behaviors lie on a continuum from common, mild habits to disabling disorders. Trichotillomania typically begins in early adolescence, with a peak around the ages of ten to thirteen, though a separate pattern of onset in infancy, usually transient, has been described. Skin picking often begins in adolescence, frequently linked to the onset of acne. Both conditions are reported more often in women in clinical samples, with ratios of roughly four to one for hair pulling and three to one for skin picking, although studies of children suggest that the gender difference may be smaller in younger age groups, and that men are likely to be underrepresented in treatment settings.
Normal Habits Versus a Disorder
Almost everyone engages in some grooming-type habit, such as twirling hair, biting nails, picking at a scab, or squeezing a blemish. These habits are usually brief, cause no lasting damage, and can be stopped when the person wishes. A body-focused repetitive behavior becomes a disorder when it is frequent or prolonged, causes visible damage such as hair loss or skin lesions, feels hard to control, and leads to distress, avoidance, or interference with daily life. Time is a useful marker: many people with these conditions spend from several minutes to several hours a day pulling or picking, and some lose whole evenings to it.
The Behaviors in Detail
The outward behaviors may look simple, but they are performed in different ways and for different reasons, and understanding this variety is central to effective treatment.
How Hair Pulling Looks
Hair pulling can involve pulling single hairs or small clusters, using the fingers or tweezers, and may focus on hairs with particular qualities: coarse, curly, gray, short, uneven, or regrowing hairs that feel different from the rest. Some people search carefully for hairs that feel just wrong, and pulling them gives a sense of satisfaction or relief. After pulling, many examine the hair root, run the strand across their lips or face, roll it between their fingers, bite it, or swallow it. The behavior can lead to patchy hair loss, which people try to conceal with hairstyles, scarves, hats, wigs, makeup on the eyebrows, or false eyelashes. Hair loss may be extensive in severe cases.
Eating the Hair
Between a quarter and a half of people who pull their hair, in various studies, also put it in their mouth, and a smaller proportion swallow it, a behavior called trichophagia. Swallowed hair is not digested and can accumulate in the stomach, forming a hairball known as a trichobezoar. In rare cases, the mass can extend into the small intestine, a condition called Rapunzel syndrome, causing abdominal pain, nausea, vomiting, weight loss, and intestinal obstruction, and requiring surgical removal. Anyone who swallows hair and develops persistent abdominal symptoms should seek medical attention promptly.
How Skin Picking Looks
Skin picking may involve scratching, squeezing, digging, or scraping at the skin with the fingernails, or with tweezers, pins, or other tools. It often targets perceived imperfections, such as acne, scabs, bumps, ingrown hairs, or rough patches, but it can also target apparently normal skin. Picking can create new wounds, which then become new targets, producing a cycle in which the healing skin keeps being reopened. Sessions can last from a few minutes to several hours. People may pick at the face, scalp, arms, hands, chest, back, or legs, and some pick at the skin around the nails and fingers, sometimes called nail and cuticle picking. Some also bite or eat the skin they remove.
Related Behaviors
Other body-focused repetitive behaviors include nail biting, known as onychophagia, which is extremely common, cheek and lip biting, which can cause sores and chewed tissue, and, in some people, picking at the nails, biting the skin around the nails, or chewing on objects. Some people have several behaviors at once or move from one to another over time. The same principles of understanding and treatment apply to all of them.
Automatic and Focused Styles
A key distinction, first proposed by Christenson and colleagues, separates two styles of pulling and picking. In the automatic style, the person engages in the behavior with little or no awareness, often during sedentary activities such as reading, watching television, working at a computer, or driving. They may notice what they have been doing only after the behavior has finished, when they find hair or skin in their hands. In the focused style, the person is fully aware, and the behavior is a deliberate response to a particular feeling, urge, or sensation, such as tension, boredom, anxiety, or a skin irregularity that must be removed. Most people show a mixture of both styles, with proportions varying. The distinction matters because the two styles call for somewhat different strategies: awareness training is the key for automatic behavior, while managing urges and emotions is vital for focused behavior.
Rituals and Sensory Details
Many people describe a ritualized quality to the behavior. They may have favorite places, times, lighting, mirrors, tools, or positions. They may search for a particular kind of hair or lesion, test it with their fingers, and carry out the pulling or picking in a particular order. Some people feel a gratifying release when a hair comes out with a satisfying resistance, when a hair root has a particular appearance, or when a scab separates cleanly. These details reflect the strong sensory component of the behavior, which is discussed below.
Triggers and Contexts
Common triggers include stress and anxiety, boredom, tiredness, frustration, loneliness, perfectionism, and the sensation of an irregular hair or a bump on the skin. Sedentary and solitary activities carry high risk, as do bathrooms, bedrooms, and cars, which offer privacy and mirrors. Some people pull or pick more in the evening, while lying in bed, or when they are trying to concentrate. Emotions may be negative or positive: some people report urges when they are relaxed and comfortable as well as when they are tense.
What the Behaviors Do: Emotional and Sensory Functions
Pulling and picking persist because they are reinforced, and they serve functions, even though the person may not recognize them and may wish they did not exist. Understanding these functions removes some of the mystery and some of the shame.
Emotion Regulation
Research suggests that body-focused repetitive behaviors serve, in part, to regulate emotion. In studies using ecological momentary assessment, in which people record their feelings at intervals through the day, negative emotions such as tension, anxiety, and boredom tend to precede episodes of pulling and picking, while feelings of relief and satisfaction follow. The behavior thus works as negative reinforcement: it reduces unpleasant states in the short term, which makes it more likely to be repeated. Researchers such as Nancy Keuthen and Jon Grant have found that people with the conditions often have difficulty tolerating negative emotions, and that the behaviors can be used for stimulation when bored as well as for soothing when stressed. This is sometimes described as a problem of emotional regulation in both directions, in which the person is trying to bring their arousal to a more comfortable level.
Sensory Reinforcement
Sensory experiences are central. The feel of the hair or skin, the sound of the pull, the tactile sensation of the root or the scab, and the visual appearance of the result can all be rewarding. Some people find the sensation of pulling pleasant or relieving, while others experience a sensory urge: a tingling, itching, or tension in a part of the scalp or skin that is relieved by pulling or picking. Studies show that many people with trichotillomania have heightened sensitivity to tactile stimuli, and some report that the pull is satisfying in the way that scratching an itch is. Over time, the sensory feedback becomes a powerful reinforcer.
Perfectionism and Dissatisfaction With the Body
Many people who pick and pull describe a drive toward getting things just right. They may pull hairs that seem out of place or pick at skin that seems uneven, in an attempt to smooth, correct, or perfect their appearance. Studies show higher levels of perfectionism in people with these conditions, and sometimes a form of perfectionism in which the person cannot tolerate imperfection, leading them to continue until the area feels or looks right, which it never quite does. This can create a cycle in which the behavior produces damage, which is itself an imperfection that demands further attention.
Boredom, Stimulation, and Dissociation
Some people use the behavior to fill idle time or to manage understimulation, and describe being absorbed in it in a trance-like state in which time passes without notice. This dissociative quality is more marked in the automatic style, and it can be linked to difficulty in noticing urges and stopping. Some people also use pulling and picking to ease their way into sleep or to calm down after a stressful day.
Pain and Self-Harm: A Distinction
It is often assumed that pulling and picking are forms of self-harm. In most cases they are not. Self-harm, or non-suicidal self-injury, is typically carried out with the intention of causing physical pain or damage to cope with emotional distress, while most people with BFRBs do not want to hurt themselves and are distressed by the damage that results. Many describe the experience as painless or only mildly uncomfortable, and some find the pain a side effect. The behaviors serve a soothing, sensory, or perfecting function, not self-punishment. There are exceptions: some people do pick or pull to punish themselves, and the two conditions can coexist. The distinction matters because it shapes how family members and clinicians respond, and because treating a BFRB as self-harm may lead to inappropriate and unhelpful interventions.
What Causes Body-Focused Repetitive Behaviors
As with other conditions in this group, there is no single cause. The behaviors appear to arise from an interaction of biological vulnerability, learning, temperament, and environment.
Genetic Contributions
Twin and family studies show a genetic contribution. A twin study led by Christenson and colleagues, and others, found a heritability of around seventy to eighty percent for hair pulling in adult women, and family studies show that relatives of people with trichotillomania have elevated rates of the disorder, as well as of obsessive-compulsive disorder and other related conditions. Skin picking also seems to run in families. Research has identified a mutation in the SAPAP3 gene, which is involved in the function of the brain’s glutamate synapses in the striatum, in mice that groom themselves compulsively to the point of skin lesions, and variants in a related gene and in HOXB8, a gene linked to grooming, have been reported in some people with trichotillomania. These findings are preliminary, and no single gene is responsible, but they support a biological basis.
Brain Circuits and Neurochemistry
Brain imaging studies find differences in the circuits that connect the frontal cortex with the basal ganglia, which are involved in habit formation, the initiation and termination of repetitive behaviors, and the regulation of urges. Reduced volume in regions such as the putamen, and differences in the cerebellum and in frontal regions, have been reported in some studies of trichotillomania, though results are mixed and samples small. Differences in the way the brain monitors and inhibits repetitive actions have also been found. Several neurotransmitter systems have been implicated, including serotonin, dopamine, glutamate, and the opioid system. The involvement of glutamate has stimulated the study of drugs that modulate it, such as N-acetylcysteine, described below.
Evolutionary and Animal Parallels
Grooming is a fundamental behavior in mammals, and excessive grooming is seen in animals under stress or in captivity, where it takes the form of barbering in mice, feather plucking in birds, and overgrooming in dogs and cats. Some researchers have proposed that BFRBs may represent an overactive form of the normal grooming behaviors, which serve both hygiene and stress relief functions, a hypothesis reinforced by the genetic work in mice mentioned above. It also helps to explain why the behaviors tend to be associated with feelings of unease or a drive for completeness.
Learning and Habit Formation
Behavioral theory proposes that pulling and picking begin, in many cases, as ordinary behaviors that are reinforced. Once the behavior produces relief, pleasure, or a sense of completion, it becomes more likely to occur in the same contexts. With repetition, it shifts from a goal-directed act to a habit controlled by cues, as with other habits, so that sitting on the sofa with a book, or looking in the bathroom mirror, triggers the urge and the action automatically. This explains why the automatic style is so common, and why simply resolving to stop is insufficient.
Temperament, Stress, and Early Experience
Certain personality traits are associated with BFRBs, including perfectionism, sensitivity to emotion, and a tendency toward anxiety. Stress often precedes onset, and the behaviors frequently worsen during periods of pressure, such as exams, work stress, relationship difficulties, or bereavement. Some people report histories of trauma or adversity, though this is not universal, and the relationship is not simple. In young children, hair pulling and other grooming behaviors may arise as a self-soothing mechanism, and in most cases these early patterns resolve spontaneously, whereas onset in adolescence tends to be more persistent.
Hormones and Puberty
The common onset around puberty, and the fluctuation of symptoms with the menstrual cycle in some women, has led to speculation about hormonal influences. Some women report worsening premenstrually, and some studies have found associations with hormonal changes, though research is limited. Acne, which is common in adolescence and a frequent trigger of skin picking, may link the physical changes of puberty with the onset of the condition.
Culture and Social Environment
Body-focused repetitive behaviors are found in every culture that has been studied. Social attitudes to appearance, such as the stigma attached to visible skin blemishes or hair loss, affect how the behaviors are experienced and hidden. Access to information and treatment is uneven, and many people in many countries have never heard that their behaviors have a name.
The Cost: Physical and Emotional Consequences
Because the behaviors are often private and the damage can be concealed, their impact is easily underestimated. Studies show that quality of life is significantly reduced in people with BFRBs, and that the burden is comparable to that of other chronic mental health conditions.
Physical Consequences of Hair Pulling
The most obvious consequence is hair loss, which may be patchy or diffuse and can involve the scalp, eyebrows, and eyelashes. Repeated pulling can damage hair follicles, and in long-standing cases, regrowth may be slow or incomplete. Other consequences include skin irritation, scalp soreness, repetitive strain injuries in the hands and arms, and, for people who eat hair, the risk of trichobezoar and intestinal complications, as noted above.
Physical Consequences of Skin Picking
Skin picking can cause open sores, scabs, scars, discoloration, and permanent changes in skin texture. Wounds may become infected, and in severe cases, cellulitis, abscesses, or even sepsis can result, and some people require medical treatment, antibiotics, or in rare cases surgery or skin grafts. Chronic picking at the face can cause visible damage that is hard to conceal, and picking at the nails and surrounding skin can cause pain and infection. Some people injure underlying tissue, and rare cases of deep tissue damage have been described.
Shame, Secrecy, and Self-Criticism
Emotionally, shame is the dominant response. People with these conditions often feel that they are weak, disgusting, or crazy, and they may believe that no one else behaves in this way. Many have never told anyone, including their partners, closest friends, and doctors, and some conceal the behavior for years. Self-criticism and guilt follow each episode, and, since the behavior is often used to regulate emotion, shame can itself trigger further pulling and picking, creating a cycle.
Avoidance and Social Impact
Many people avoid situations in which their hair loss or skin damage might be noticed: swimming, hairdressers, intimate relationships, social events, photographs, gyms, windy days, or even close conversation. Some avoid dating or sexual intimacy. They may wear concealing clothing, hats, makeup, or wigs, and spend considerable time and money on concealment. Studies indicate that a significant proportion of people with BFRBs report that the condition interferes with relationships, work, and education, and some have missed work or school because of appearance or because of time spent on the behavior.
Time and Productivity
The time devoted to the behavior can be substantial. Some people spend one or more hours a day picking or pulling, and others spend half the day. The time lost can affect work, study, sleep, and family life, and the effort of resisting urges can drain concentration and energy.
Effects on Self-Esteem and Mood
Poor self-esteem, depressed mood, and anxiety are common, and many people feel hopeless about changing. The frustration of repeated failed attempts to stop can lead to the belief that one lacks willpower. This belief is inaccurate, but it can sap motivation to seek help.
Impact on Children and Families
Children with BFRBs may be teased or bullied about hair loss or skin damage, and may avoid school and social activities. Parents may feel helpless, guilty, or frustrated, and conflict may arise as parents try to make the child stop. A cycle of nagging, secrecy, and shame can develop that makes the problem worse.
What Often Comes With These Conditions
Like most conditions in this group, BFRBs commonly occur with other psychological difficulties, which affect both suffering and treatment.
Anxiety and Depression
Anxiety disorders and depression are common. Studies suggest that about a quarter to a half of people with trichotillomania or excoriation disorder have a lifetime history of depression or an anxiety disorder, and many have symptoms at the time they present for treatment. Whether the emotional difficulties precede or result from the behavior varies, but they interact, and treating them is part of good care.
Obsessive-Compulsive Disorder and Related Conditions
Obsessive-compulsive disorder occurs at higher rates in people with BFRBs and in their relatives, and the conditions can co-occur. Body dysmorphic disorder is also relatively common, particularly in skin picking, where perceived flaws in the skin may drive picking. When picking is driven mainly by an appearance concern, it may be part of body dysmorphic disorder, and the treatment emphasis differs. Other BFRBs frequently co-occur: a person who pulls hair may also pick skin or bite nails.
Attention-Deficit Hyperactivity Disorder and Tic Disorders
Attention-deficit hyperactivity disorder is reported at elevated rates, and difficulty with impulse control and with managing boredom may contribute. Tic disorders, including Tourette syndrome, can co-occur, and the distinction between tics and BFRBs may be subtle: tics are typically more sudden and stereotyped, preceded by a premonitory urge but not driven by a sensory or emotional purpose in the same way. A careful assessment is needed.
Eating Disorders and Substance Use
Some studies find higher rates of eating disorders and substance use disorders, which may share features of difficulty in regulating emotion and impulses. These need attention in assessment and treatment.
Personality Factors
Perfectionism and anxious traits are frequent, and some people have a high degree of emotional sensitivity. A subset of people also show borderline personality features, in which pulling and picking may be one among several coping behaviors. Treatment is adapted accordingly.
Is It a BFRB, or Something Else?
Because the behaviors can have several causes, diagnosis requires careful assessment. The following distinctions are the most useful.
Medical and Dermatological Conditions
Hair loss can result from many medical conditions, including alopecia areata, telogen effluvium, thyroid disease, iron deficiency, and scalp infections, and skin lesions can result from eczema, scabies, acne, and other dermatological conditions. A medical or dermatological evaluation is an important part of the first assessment. A dermatologist can often distinguish hair loss due to pulling by examining the pattern, such as broken hairs of varying lengths, and may use a dermatoscope or a biopsy where needed. Skin picking can also be secondary to a medical condition causing intense itching, which should be treated.
Substance Use and Delusional Conditions
Stimulant use, such as methamphetamine and cocaine, can lead to picking at the skin, sometimes driven by the false sensation of insects crawling under the skin, called formication. In psychotic disorders, including delusional parasitosis, people may believe that their skin is infested and dig at it to remove parasites. These conditions differ from BFRBs in that the picking is driven by a fixed belief or hallucination, and they require different treatment.
Non-Suicidal Self-Injury
As described above, most BFRBs are not intended to cause harm, whereas non-suicidal self-injury is typically intended to cause pain or damage in order to cope with emotional distress. The two may coexist, and an assessment should ask about the person’s intentions and about other forms of self-harm. Anyone who is harming themselves deliberately, or who has thoughts of suicide, should seek help from a professional or an emergency service immediately.
Habits, Tics, and Stereotypies
Common habits, such as occasional nail biting or hair twirling, are not disorders unless they cause damage and distress. Tics are brief, sudden, and often preceded by an urge to move, while stereotypic movement disorder involves repetitive, seemingly driven, nonfunctional movements beginning early in development, such as head banging or hand flapping, often seen in autism or intellectual disability. A clinician considers the pattern of the behavior and the developmental context.
Obsessive-Compulsive Disorder and Body Dysmorphic Disorder
When picking or pulling is performed in response to an obsessional fear, such as contamination, it may be better explained by obsessive-compulsive disorder. When it aims to remove or improve a perceived defect in appearance, it may be part of body dysmorphic disorder. In trichotillomania and excoriation disorder, by contrast, the behavior is usually driven by sensory urges, tension, boredom, or the wish to even out hair or skin, rather than by a specific obsession or concern about appearance, although the distinction can be blurred and the conditions often overlap.
Treatment: What the Evidence Supports
Despite their persistence and the shame that surrounds them, BFRBs are treatable. The best-supported treatment is a behavioral therapy known as habit reversal training and its extensions, and several medications have been studied with more modest results. A major obstacle is that many clinicians have little training in these conditions, so finding specialized care can be difficult.
Habit Reversal Training
Habit reversal training, developed by Nathan Azrin and Gregory Nunn in 1973, is the core of behavioral treatment. It has been tested in numerous randomized trials of trichotillomania and skin picking, and meta-analyses find large effects compared with waiting-list and attention control conditions, with benefits that generally persist, though some people experience gradual return of symptoms. It has three main components.
Awareness training teaches the person to recognize when and how the behavior occurs. Using a detailed description of each step, a log of episodes, and often a mirror or video, the person learns to catch early warning signs, such as touching the hair or face, and to identify high-risk situations and urges. For people with the automatic style, this is often the most challenging and the most crucial step.
Competing response training teaches the person to perform a physically incompatible behavior as soon as they notice the urge or the beginning of the action, and to hold it for a minute or two, until the urge subsides. Examples include clenching the fists, gripping an object, folding the arms, pressing the hands flat against the thighs, or sitting on the hands. The response must be easy to perform in any situation, inconspicuous, and incompatible with pulling or picking.
Social support enlists a family member or friend to prompt the person and to praise their progress. Motivation strategies, such as reviewing the inconveniences of the behavior and the benefits of change, are also used.
The Comprehensive Behavioral Model
An important extension is the comprehensive behavioral model, known as ComB, developed by Charles Mansueto and colleagues. It starts from the recognition that BFRBs are triggered and maintained by a range of factors, and it organizes treatment around the domains of sensory, cognitive, affective, motor, and place. The therapist and patient conduct a functional analysis of each person’s behavior to identify what sensory experiences, thoughts, emotions, movements, and environmental settings are involved, and then select interventions tailored to each domain.
Sensory interventions include substituting other textures and sensations that meet the sensory need, using fidget objects, textured materials, or soft brushes, wearing gloves or bandages, or applying barriers to block access, such as hats and hair ties. Cognitive interventions address thoughts that trigger and justify the behavior, such as perfectionistic beliefs (“I must get this hair out”) and permission-giving thoughts (“Just one won’t matter”). Affective interventions teach ways to manage emotions such as tension, boredom, and frustration, with relaxation, mindfulness, and other coping skills. Motor interventions include habit reversal techniques and competing responses. Place interventions modify the environment, for instance by removing tweezers, changing the lighting in the bathroom, covering mirrors, or avoiding the places where the behavior most often occurs. The model is intuitive and flexible, and trials suggest it is effective, with growing evidence for its use.
Stimulus Control
Stimulus control is a practical component of both approaches. It involves changing the environment and routines to reduce triggers. Examples include keeping the hands busy during high-risk activities, using a fidget toy while watching television, wearing a hat or gloves in bed, limiting mirror time, using dim lighting in the bathroom, trimming nails short, covering skin lesions with bandages, removing tweezers and other tools, and sitting in places that discourage the behavior. These steps break the link between cue and action and make the behavior harder to perform automatically.
Acceptance and Commitment Therapy
Acceptance and commitment therapy has been adapted for BFRBs, and studies of acceptance-enhanced behavior therapy, led by Douglas Woods and colleagues, suggest that adding acceptance and mindfulness skills to habit reversal training improves outcomes, particularly for people who engage in the focused style. The approach teaches people to notice urges, emotions, and thoughts without struggling against them, to see that they can feel an urge and not act on it, and to take actions that align with their values. This helps to reduce the shame and avoidance that sustain the cycle, and it is an important addition because the effort to suppress urges can make them stronger.
Dialectical Behavior Therapy and Emotion Regulation
Because emotion regulation is central, dialectical behavior therapy skills, which teach distress tolerance, emotion regulation, and mindfulness, have been adapted for trichotillomania, and a trial by Keuthen and colleagues found benefit. For people with significant emotional dysregulation, these skills can be a valuable complement to habit reversal.
Cognitive Behavioral Therapy
Cognitive therapy components address thoughts and beliefs about the behavior and appearance. People with BFRBs often hold perfectionistic beliefs, permission-giving thoughts, and negative views of themselves. Cognitive restructuring can help, though trials suggest that behavioral components are the most active ingredients, and that cognitive techniques are most useful as an addition.
Technology and Online Treatments
Digital tools are being developed. Smartphone applications offer self-monitoring, reminders, and guided exercises, and wearable devices that detect hand-to-head movements and give a gentle vibration are being tested. Online programs based on habit reversal training have shown encouraging results in trials and may help people who cannot access a specialist. Some people use a simple wristband or timer to prompt awareness.
Medication
Medication is less effective than behavioral therapy for most people, but it may help some, particularly when combined with therapy or when anxiety or depression is prominent. The evidence is mixed. Selective serotonin reuptake inhibitors, the first-line drugs in obsessive-compulsive disorder, have shown inconsistent results in trichotillomania, with meta-analyses finding little benefit overall, though they may help in skin picking, with some trials of fluoxetine showing benefit, and they are often used to treat coexisting depression or anxiety. Clomipramine showed benefit in an early trial in trichotillomania, though its side effects limit use.
Among the more promising agents is N-acetylcysteine, an amino acid derivative that modulates glutamate. A trial by Jon Grant and colleagues in 2009 found that a majority of people with trichotillomania who took it experienced significant reduction in hair pulling compared with placebo, and trials in skin picking have shown benefit, though a later trial in trichotillomania in children did not show a clear advantage over placebo, and the evidence is therefore mixed. It is generally well tolerated. Olanzapine and other antipsychotics have shown some benefit in small studies but carry metabolic risks. Naltrexone, an opioid antagonist, has been tested, with some positive findings in skin picking and in trichotillomania, though results are inconsistent. Dronabinol, a cannabinoid, and other agents have been studied in small trials. Medication decisions should be made with a doctor, who can weigh the benefits and risks, and no drug should be stopped abruptly.
Treating Co-Occurring Conditions
Depression, anxiety, attention-deficit hyperactivity disorder, and other conditions should be treated in their own right, since they can reduce the effectiveness of behavioral treatment and increase the urge to pull or pick. Where skin infection or damage is present, medical or dermatological care is needed, and for people who have swallowed hair and have abdominal symptoms, gastroenterological assessment is urgent.
What to Expect From Treatment
Progress is typically gradual, and many people experience relapses, which are a normal feature of the course. A common pattern is an initial reduction over several weeks of treatment, followed by periods of fluctuation. Because BFRBs are chronic conditions for many people, ongoing management, booster sessions, and a plan for stressful periods are usually part of care. Many people achieve substantial reductions in the behavior and in the distress, even if occasional urges persist. Studies of treatment outcome show that a large proportion of people who complete habit reversal training achieve a meaningful reduction in symptoms, and that many continue to benefit in the long term, though some will need further help.
Finding Help
A challenge is finding clinicians with expertise. Many general practitioners, dermatologists, and therapists have little training in BFRBs. Organizations such as the TLC Foundation for Body-Focused Repetitive Behaviors in the United States, and similar groups in other countries, maintain directories of specialist clinicians, offer education, and provide support communities. People can ask prospective therapists whether they have experience with habit reversal training or the comprehensive behavioral model.
Practical Strategies for Reducing Pulling and Picking
Professional treatment is advisable for a disorder of this kind, and the strategies below are not a substitute for it. They are drawn from habit reversal training and the comprehensive behavioral model and may help people who are waiting for treatment, who are in therapy, or whose difficulties are milder. A person who is experiencing infection, severe injury, or abdominal symptoms after swallowing hair, or who has thoughts of ending their life, should seek medical or emergency help promptly.
Become Aware of the Pattern
The first step is to observe your behavior without judgment. For one to two weeks, keep a simple log of when, where, how long, and what you were doing and feeling before and after each episode. Note the style, whether automatic or focused, the sites involved, the tools used, and the thoughts and emotions that preceded the behavior. Many people discover patterns they had not noticed, such as a particular chair, a time of day, a mood, or a mirror. Awareness is the foundation of all other strategies.
Interrupt Early With a Competing Response
When you notice the urge, or catch your hand moving toward your hair or skin, perform a competing response for at least a minute, or until the urge fades. Clenching your fists, pressing your palms together, gripping the arms of a chair, or holding a small object are examples. Choose a response that you can do anywhere and that is physically incompatible with the behavior. Practice it in advance, when you are not under pressure, so that it becomes automatic.
Redesign Your Environment
Make the behavior harder. Remove tweezers and other tools from the bathroom, cover or reduce mirrors, use dimmer or warmer lighting, keep the nails short and filed, wear gloves, a hat, or a headband at high-risk times, apply bandages to skin lesions, and sit in places that keep your hands visible. Fidget objects, putty, or textured items can occupy the hands during sedentary activities. Position them where you tend to pull or pick, for example next to the computer or the sofa.
Meet the Sensory Need Another Way
If you enjoy the feel of the hair or skin, find substitute textures and sensations. Examples include stroking a soft fabric, using a scalp massager, rubbing a smooth stone, using a brush on the scalp, or applying lotion to the skin. If you are drawn to the visual aspect, you might try other detailed, absorbing tasks, such as drawing, knitting, or puzzles. The aim is to give the hands and senses something satisfying to do.
Manage Emotions Without the Behavior
Because pulling and picking often relieve tension or boredom, build other tools for these states. Slow breathing, with a long exhalation, brief walks, stretching, music, calling a friend, and mindfulness practices can reduce tension. Plan stimulating or absorbing activities for periods of boredom. Notice how emotions rise and fall, and practice allowing urges to pass without acting, observing them like waves. Stress management, regular exercise, and sufficient sleep reduce the baseline level of urges.
Challenge Perfectionistic and Permission-Giving Thoughts
Notice thoughts such as “I just need to get this one hair,” “This spot has to come off,” or “I will just do a little.” Recognize that these thoughts are part of the cycle. Respond with a reminder of your goals, such as “I am choosing not to, and the urge will pass.” Remind yourself that hair and skin are never perfectly even, and that the pursuit of perfection tends to cause more damage.
Care for Your Skin and Hair
Treat existing wounds gently to promote healing, keep them clean, and cover them to avoid picking. Use over-the-counter treatments for acne or dryness under advice, and see a doctor for signs of infection, such as spreading redness, warmth, pus, or fever. For hair, consider protective styles or gentle care, and allow regrowth without reaching for new hairs. A dermatologist can advise on skin and scalp care and on cosmetic options for concealing damage while it heals.
Reduce Shame and Seek Understanding
Shame fuels the cycle. Remind yourself that BFRBs are common, that they are not a sign of weakness or madness, and that they are driven by identifiable processes. Speaking with others who have the same experience, whether in a support group or online community, can be powerfully reassuring. Self-compassion is protective: speak to yourself as you would to a friend, particularly after an episode.
Reward Progress and Expect Setbacks
Celebrate reductions in time and damage, however small, and track your progress. A lapse is not a failure, and the pattern often fluctuates with stress. Treat lapses as information about triggers, and return to your strategies. If self-help has not led to improvement, seek professional treatment, which offers structure and expertise.
Supporting Someone With a Body-Focused Repetitive Behavior
Family members and friends often feel torn between worry and frustration, and the instinct to say “just stop” is strong. Understanding the nature of the behavior makes it easier to respond in a way that helps.
What Helps
Approach the person with warmth and without judgment. Acknowledge that the behavior is hard to control and that the distress is real. Ask how you can help, and agree on a gentle signal, such as a touch on the shoulder or a code word, if the person wants to be prompted when they notice the behavior. Praise efforts and progress. Learn about the condition and encourage professional help, offering to assist in finding a specialist. Provide a calm, accepting environment, and help with practical changes, such as removing tweezers or providing fidget objects.
What to Avoid
Nagging, scolding, punishment, rewards for not picking that become pressure, and public comments about the behavior or its results all tend to increase shame and secrecy, and may worsen the behavior. Do not pull the person’s hand away or remove tools without agreement, and do not comment on hair loss or skin damage. Avoid treating the behavior as an act of defiance or a bid for attention. Do not assume it is self-harm or a sign of suicidal intent unless there is evidence, but take any expression of hopelessness seriously.
For Parents of Children and Teenagers
Young children frequently engage in hair twirling, nail biting, or skin picking, and many of these behaviors resolve without intervention. If the behavior causes damage, persists, or distresses the child, seek an assessment from a pediatrician or a child mental health professional. Keep a calm, matter-of-fact tone, avoid punishing or shaming, and respond with encouragement. Help the child become aware of the behavior with gentle reminders agreed in advance, offer alternatives such as fidget toys, and support stress management. Habit reversal training and the comprehensive behavioral model have been adapted for children and adolescents, with parent involvement, and trials suggest good effects. Address teasing or bullying at school, and work with teachers to avoid singling out the child.
Partners and Intimacy
Partners may feel confused about how to respond, particularly if the person hides hair loss or skin damage. Reassure the person that you care for them as they are, avoid comments that focus on appearance, and respect their choices about concealment while encouraging openness. Intimate relationships may be affected by shame, and open, kind communication helps.
Looking After Yourself
Supporting a person with a BFRB can be frustrating, and it is natural to feel worried. Seek information and support for yourself, and keep in mind that you are not responsible for the person’s behavior or for curing it.
Common Myths About Hair-Pulling and Skin-Picking
Several beliefs add to the burden of these conditions. The first is that they are simply bad habits that could be stopped with willpower. They are driven by sensory, emotional, and neurobiological processes, and willpower alone is rarely enough, though effective strategies exist. The second is that they are forms of self-harm. Most people with BFRBs do not intend to hurt themselves and find the damage distressing. The third is that they are rare or a sign of severe mental illness. They are common and occur in people of all backgrounds and levels of functioning.
A fourth myth is that people who pull and pick do so to get attention. In fact, most hide the behavior and its results with considerable effort. A fifth is that they are caused by poor parenting or trauma. Genetics, temperament, and learning play major roles, and while stress and adversity can contribute, many people with these conditions have no such history. A sixth is that nothing can be done. Behavioral treatment helps most people, and medication can help some. A seventh is that children will always grow out of it. Many early childhood behaviors resolve, but onset in adolescence often persists without treatment. An eighth is that only women are affected. Men and boys also have BFRBs, though they may be less likely to seek help.
A Realistic and Hopeful Outlook
The course of BFRBs varies. Some people experience a period of pulling or picking that resolves, others have a chronic pattern that fluctuates over decades, often worsening under stress. Without treatment, the behaviors tend to persist, particularly when they begin in adolescence or adulthood. With treatment, the outlook is encouraging: studies of habit reversal training and the comprehensive behavioral model show that many people achieve substantial reductions in the behavior and in the distress and impairment it causes, and many maintain those gains over time, particularly if they continue to use their skills and seek booster support when needed.
Recovery rarely means the complete and permanent disappearance of all urges. Many people find that the urges lessen but may return in periods of stress, and that they have learned how to respond. They regain time, confidence, and freedom from concealment, and hair and skin often heal. Many describe a sense of relief on learning that their condition has a name, that others share it, and that it can be managed. Support communities have played a major role in reducing isolation, and the growth of public awareness is helping to reduce stigma.
When to Seek Help
It is time to seek professional help when pulling or picking causes visible damage, takes up significant time, causes distress or shame, interferes with work, school, relationships, or leisure, leads you to avoid situations, or when you have tried to stop and cannot. Seek medical attention for signs of infection, deep wounds, or abdominal symptoms after swallowing hair. A good first step is to see a general practitioner or dermatologist to rule out medical causes, followed by a mental health professional experienced in BFRBs. If you are feeling hopeless or have thoughts of self-harm, contact a doctor, a crisis line, or emergency services without delay. Early treatment tends to be more effective, and there is no need to wait until the damage is severe.
Conclusion
Hair-pulling and skin-picking are body-focused repetitive behaviors that are far more common than most people realize and far less well understood. They are not habits of weakness or acts of self-punishment, but behaviors driven by sensory urges, emotional regulation, perfectionism, and the learning of habits, with a basis in genetics and brain circuits that govern repetitive grooming. They exist in automatic and focused forms, they provide short-term relief and satisfaction, and they leave behind damage, shame, and secrecy that feed the cycle.
Understanding the conditions in this way opens a path to help. Habit reversal training teaches awareness, competing responses, and support, the comprehensive behavioral model tailors strategies to the sensory, cognitive, affective, motor, and place factors in each person’s behavior, acceptance-based approaches reduce the struggle against urges and the shame that accompanies them, and medication such as N-acetylcysteine and treatment of co-occurring conditions can help some people. Families can contribute by replacing nagging and shame with warmth and practical support. Anyone who recognizes themselves in this description is encouraged to speak with a doctor or a mental health professional, ideally one who knows BFRBs, and to seek urgent care for infection, injury, or crisis. The urge to pull and pick is real and powerful, but it is not beyond influence, and with the right understanding and help, most people can reclaim control of their hands, their time, and their lives.
FAQ About Hair-Pulling and Skin-Picking
What is the difference between trichotillomania and skin-picking disorder?
Trichotillomania, or hair-pulling disorder, involves recurrent pulling out of one’s own hair, resulting in hair loss, while excoriation disorder, or skin-picking disorder, involves recurrent picking at the skin, resulting in skin lesions. Both are classified among the obsessive-compulsive and related disorders, and both require repeated attempts to stop and significant distress or impairment. They share features, such as sensory and emotional triggers, automatic and focused styles, and responsiveness to habit reversal training, and they often occur in the same person. The principal differences are the body site and the type of damage, and some medications may differ in effect between the two.
Is hair pulling or skin picking a form of self-harm?
In most cases, no. Self-harm is typically carried out with the intention of causing pain or injury as a way of coping with emotional distress, while most people with hair-pulling or skin-picking disorder do not want to hurt themselves and are upset by the damage. The behaviors usually serve sensory, soothing, or perfecting functions, and many people describe them as painless or only mildly uncomfortable. The two can sometimes coexist, and some people pick or pull to punish themselves, so a clinician will ask about the person’s intentions. Treating a BFRB as self-harm can lead to inappropriate responses, though any deliberate self-injury or thoughts of suicide should be taken seriously.
Why can’t I just stop pulling or picking?
The behaviors are reinforced by relief from tension or boredom, by sensory satisfaction, and by the sense of getting things just right, and with repetition they become habits triggered automatically by cues, often without awareness. The brain circuits involved in habit formation and in the control of repetitive grooming appear to function differently, and genetic factors contribute. Because many episodes are automatic, resolving to stop is insufficient: you cannot resist a behavior that you do not notice. Effective treatment builds awareness, introduces competing responses, changes the environment, meets sensory needs in other ways, and teaches emotion regulation. Difficulty stopping reflects the nature of the condition and not a lack of willpower.
What is the best treatment for trichotillomania and skin picking?
Behavioral therapy has the strongest evidence. Habit reversal training, which includes awareness training, competing response training, and social support, produces large improvements in trials, and the comprehensive behavioral model, which tailors strategies to sensory, cognitive, affective, motor, and place factors, extends it. Adding acceptance and mindfulness skills can help, particularly for focused pulling and picking. Medication has a smaller role, with N-acetylcysteine, naltrexone, and certain antidepressants or antipsychotics showing benefit in some people, though results are mixed. Co-occurring conditions such as depression and anxiety should be treated. Finding a clinician with experience in BFRBs improves the chances of a good outcome.
Does swallowing hair cause health problems?
It can. A proportion of people who pull their hair put it in their mouth, and some swallow it, a behavior called trichophagia. Hair is not digested and can collect in the stomach to form a hairball called a trichobezoar, which in rare cases extends into the intestine and causes obstruction, a condition known as Rapunzel syndrome. Symptoms include abdominal pain, nausea, vomiting, loss of appetite, and weight loss. Anyone who swallows hair and develops persistent abdominal symptoms should seek medical attention promptly, since surgical removal may be needed. Treating the underlying behavior reduces the risk.
Are hair pulling and skin picking related to OCD?
They are classified in the same group of disorders and share features, including repetitive behaviors, difficulty resisting urges, family history, and some overlap in brain circuits. They differ in important ways: in OCD, repetitive behaviors are typically driven by obsessions, such as fears of contamination or harm, and aim to reduce anxiety or prevent a feared event, whereas in BFRBs the behaviors are more often driven by sensory urges, tension, boredom, or the wish to even out hair or skin. Treatments differ, as habit reversal training is more effective for BFRBs than the exposure and response prevention used for OCD. The conditions can co-occur, and a clinician can help to assess which are present.
Can children grow out of hair pulling or skin picking?
Some do. Hair pulling and similar habits that begin in infancy and early childhood often resolve on their own, and many children who twirl hair or bite nails stop as they grow. Onset in late childhood or adolescence tends to be more persistent and is more likely to continue into adulthood without treatment. If the behavior causes damage, distress, or interference with daily life, or persists for several months, it is sensible to seek an assessment from a pediatrician or child mental health professional. Habit reversal training and the comprehensive behavioral model have been adapted for young people, with parent involvement, and early treatment improves outcomes.
How can I help my child who pulls hair or picks skin?
Respond calmly and with warmth; avoid punishing, scolding, or shaming, and do not draw attention to hair loss or skin damage in front of others. Help the child to become aware of the behavior through gentle prompts agreed in advance, offer alternatives such as fidget toys and textured objects, reduce triggers such as boredom during long sedentary activities, and help the child manage stress and emotions. Seek a medical check to rule out skin or hair conditions, and a consultation with a mental health professional who knows BFRBs, since behavioral treatment adapted for children is effective. Address teasing or bullying, and remember that the behavior is not a sign of defiance or of poor parenting.
Is there a medication that stops hair pulling or skin picking?
No medication is approved specifically for these conditions in most countries, and no drug works for everyone. N-acetylcysteine, which modulates glutamate, has shown benefit in some trials of trichotillomania and skin picking, though evidence is mixed. Naltrexone, olanzapine, and some antidepressants, such as fluoxetine for skin picking, have been studied with variable results. Antidepressants are often used to treat coexisting depression or anxiety. Behavioral therapy generally produces larger and more lasting benefits than medication, and the two can be combined. A doctor can discuss options, and medication should not be stopped abruptly.
How common are body-focused repetitive behaviors, and am I alone?
You are far from alone. Hair-pulling disorder affects roughly one to two percent of people, and skin-picking disorder about one to five percent, which means that millions of people live with these conditions, and a much larger number engage in milder forms of pulling and picking. They occur across all backgrounds, ages, and cultures. Many people hide the behaviors and never tell anyone, so the apparent rarity reflects secrecy and not true rarity. Organizations and online communities offer education and support, and many people find that meeting others with the same experience reduces shame and helps them to seek treatment.
Recommended Books on Body-Focused Repetitive Behaviors
- The Hair Pulling Problem: A Complete Guide to Trichotillomania by Fred Penzel
- Overcoming Body-Focused Repetitive Behaviors: A Comprehensive Behavioral Model Treatment Guide by Charles Mansueto and colleagues
- The Trichotillomania Workbook: A Step-by-Step Guide to Overcoming Hair Pulling by Suzanne Mouton-Odum and Ruth Golomb
- Stop Picking Your Skin: A Workbook for Overcoming Compulsive Skin Picking by Katharine A. Phillips and Dan Stein
- Overcoming Compulsive Hair Pulling: Your Step-by-Step Guide to Ending Trichotillomania by Fred Penzel and colleagues
- Treating Trichotillomania: Cognitive-Behavioral Therapy for Hairpulling and Related Problems by Nancy J. Keuthen, Dan J. Stein, and Gary A. Christenson
- Pulling Out the Pain: Overcoming Trichotillomania by Jenny Brown
- Help for Hair Pullers: Understanding and Coping With Trichotillomania by Nancy J. Keuthen, Dan J. Stein, and Gary A. Christenson
- Self-Compassion: The Proven Power of Being Kind to Yourself by Kristin Neff
- The Gifts of Imperfection: Let Go of Who You Think You’re Supposed to Be and Embrace Who You Are by Brene Brown
