Body-focused repetitive behaviours (BFRBs): hair pulling, skin picking and treatment

Almost everyone bites a nail, fiddles with hair or picks at a scab from time to time. A body-focused repetitive behaviour (BFRB) goes beyond this: it is a repeated action directed at the body that a person finds hard to stop, that can cause visible damage and that often brings shame or distress.

The two forms covered by NHS pages are trichotillomania, where someone cannot resist the urge to pull out their hair, and skin picking disorder, also called dermatillomania or excoriation disorder, where someone cannot stop picking at their skin. The NHS describes skin picking as sometimes called a body-focused repetitive behaviour and similar to hair pulling disorder. OCD-UK says trichotillomania might better be listed as a body-focused repetitive behaviour than as a form of OCD, and notes it was once considered an impulse control disorder.

Other behaviours, such as chewing the inside of the cheek or biting nails, are sometimes grouped under the same label, but the NHS pages this guide draws on cover hair pulling and skin picking, so those are the focus here.

The NHS explains that people with trichotillomania feel an intense urge to pull their hair out and experience growing tension until they do, followed by relief. Pulling may happen in response to stress or be done without really thinking about it. Most people pull from the scalp, but some pull eyebrows, eyelashes, genital hair, or beard and moustache hair. Bald patches may have an unusual shape and affect one side of the head more than the other.

For skin picking, the NHS says you may have the disorder if you cannot stop picking your skin, cause cuts, bleeding or bruising, pick moles, freckles, spots or scars to try to smooth or perfect them, do not always realise you are picking, or pick when anxious or stressed. People may use fingers, fingernails, teeth, or tools such as tweezers, pins or scissors.

Both pages describe feelings of shame and low self-esteem. OCD-UK adds that some people camouflage hair loss with hats, scarves or false eyelashes and may avoid social situations, and that some chew or swallow hair, which can cause dental and digestive problems.

The NHS advises seeing a GP if you or your child are pulling out hair, and also if there is a habit of eating hair, because this can cause hairballs to form in the stomach leading to serious illness. For skin picking, it advises seeing a GP if you cannot stop picking, you are causing serious damage such as cuts that do not heal within a few days, or picking is causing emotional distress or affecting daily life.

Signs of infection around picked skin (spreading redness, heat, pus, fever) or symptoms of a hairball such as persistent tummy pain, vomiting or a lump in the tummy need prompt medical attention. If low mood or thoughts of self-harm accompany the behaviour, speak to a GP or call NHS 111, and use 999 in an emergency.

The NHS says it is not entirely clear what causes trichotillomania. It may be a way of dealing with stress or anxiety, a chemical imbalance in the brain, changes in hormone levels during puberty, or genetic, as more than one person in a family may have it. For some, hair pulling becomes a habit that is hard to break: the more they pull, the more they want to keep doing it.

The NHS lists boredom, stress or anxiety, negative emotions such as guilt or shame, skin conditions such as acne or eczema, and blemishes that the person wants to get rid of as triggers for skin picking, and says it is related to obsessive compulsive disorder and body dysmorphic disorder. People with skin picking disorder often also have other obsessive compulsive disorders, which may need their own assessment.

For trichotillomania, the NHS says CBT is the usual referral, and that if you are under 18 it may be offered through local children and young people's mental health services. The treatment is commonly habit reversal training, which involves keeping a diary of hair pulling, working out the triggers and learning how to avoid them, replacing pulling with another action such as squeezing a stress ball, and encouragement from loved ones. The NHS says antidepressants are not usually prescribed to treat it, and OCD-UK says medication is no longer considered an effective treatment for trichotillomania itself, although it may be needed for co-existing depression.

For skin picking, the NHS says talking therapy is currently thought to be an effective treatment, usually CBT possibly with habit reversal training, offered through community mental health services. Medicines may be recommended, usually prescribed by a psychiatrist. A GP may refer to a dermatologist if the skin is badly damaged or there are underlying skin conditions.

Both NHS pages list things you can try yourself, such as keeping your hands busy with a soft ball or fidget toy, noticing when and where you tend to pick or pull, resisting for longer each time, keeping nails trimmed, putting plasters on fingertips, wearing gloves, hats or bandanas and moisturising skin when the urge arises.

The NHS notes that hiding the problem can make anxiety worse and that many people who have learned to manage trichotillomania say speaking to others led to a reduction in hair pulling. Telling a trusted friend or family member can help them notice when you are picking or pulling and support you in stopping.

Progress is often uneven, and urges can return at times of stress. Treat lapses as information about triggers rather than failure. Parents of children and teenagers can help by staying calm, avoiding punishment or nagging, and asking the GP about children and young people's mental health services.