Body-Focused Repetitive Behavior (BFRB) – Overview

Body-Focused Repetitive Behavior (BFRB)

The term Body-focused repetitive behavior (BFRB) refers to a group of disorders characterized by hair pulling, skin picking, and nail biting, affecting up to five percent of the population. People may engage in these behaviors as habits or tics, but they are in fact complex disorders caused by the repeated forceful contact with their hair and bodies.

The DSM-5 does not list all of these behavioral difficulties, but they all have the potential to cause great distress and functional impairment to people who face them.

It is defined as any repetitive self-grooming behavior in which one bites, pulls, picks, or scrapes one’s own skin, lips, cheeks, or nails with the goal of causing injury to one’s body, and which has been repeatedly attempted to stop or decrease.

It has been suggested that BFRBs play a role in the development of trichotillomania and excoriation disorder, but they must cause the individual significant distress or impairment in their daily functioning to be clinically significant, rather than a stereotypic movement disorder or non-suicidal self-injurious behavior.

Read: Motor Disorders

Types of body-focused repetitive behavior disorder

 BFRBs include, but are not limited to:

  • Trichotillomania: Hair pulling that results in hair loss. According to recent data, trichotillomania affects between 1% and 3% of the population.
  • Excoriation Disorder: Excessive skin picking leads to skin lesions. The U.S. adult population is estimated to be affected by pathological skin picking to the tune of 1.4% – 5.4%, 75% of whom are female.
  • Onychophagia: Nail or toenail destruction due to habitual biting. It is estimated that 28% to 45% of the population suffer from this behavior, which may result in visible damage to the skin, nails, and skin infections, as well as dental problems such as periodontal disease, malocclusion, or crowding of the teeth, or attrition of the incisors.
  • Onychotillomania: The pulling, picking, and manicuring of fingernails or toenails is typically a chronic condition. Although there are few empirical studies on this issue, it has been reported in both psychology and dermatology. It has similar complications to onychophagia. 
  • Lip Biting (Lip Bite Keratosis): A condition where one repeatedly bites the skin on one’s own lips.
  • Cheek Biting (Cheek Keratosis): Destroying one’s oral mucosa repeatedly by biting it with one’s own teeth. Most often involves the middle and inside of the cheek. An estimated 3% of American adults develop problems related to lip biting and cheek biting behavior, including ulcers, sores, and infections of the oral tissues as well as callous-like growths known as keratosis.
  • Tongue Chewing: An oral problem that is quite common is chronic chewing on the tongue, most often on the sides. There may also be keratinization, pigmentation, and hyperkeratotic changes associated with the behavior. The dental literature has mentioned this problem, although little research has been conducted on it.

Read: Tic Disorders

How soon do BFRBs usually begin?

It is usually during childhood or during the teenage years that repetitive behaviors focused on the body will begin to develop. Rarely, adults or young children may develop them. 

Symptoms and Signs of BFRB

Patients with this disorder focus on their bodies (e.g., chewing on their nails, biting their lips, and biting their cheeks).

There are some people who do these things almost automatically (ie, without being aware of it fully); others are more conscious. Behaviors are often preceded by feelings of tension or anxiety that are relieved by the actions, which can also carry with them a sense of satisfaction. Obsessions or concerns about appearance do not trigger the behaviors. Most people suffering from body-focused repetitive behaviors try to stop or reduce their behavior, but are unable to do so.

Onychotillomania (severe nail biting or nail picking) can lead to significant deformities of the nails (eg, washboard deformities, or habit-tic nails) and bleeding in the subungual area.


Typically, all of the following must be present for a patient to meet the DSM-5 criteria for body-focused repetitive behavior disorder

  • Hair pulling or skin picking are not considered body-focused repetitive behaviors
  • Refrain from repeating these behaviors
  • If the behaviors make you miserable or impair your functioning

Read: Facial Tics Disorder


Psychopathology is one of the most misunderstood aspects of BFRBs. According to recent research, these behaviors are not related to intentional self-injury, in contrast to early literature that suggested they were self-mutilative.

Although the behavior typically functions as self-soothing or aid in regulating emotions and nervous system arousal, it can also serve as a self-soothing behavior.

There are two reasons why individuals engage in this behavior: 1. They feel a physical urge to tic (similar to a premonitory urge to twitch), which is relieved by performing the behavior, or they want to change, correct, or otherwise improve some aspect of the target area (i.e., smoother appearance, quicker healing). 

Most people don’t mean to cause harm or pain to another. They make repeated attempts to minimize or stop the behavior after the damage is done to their skin, hair or nails. 

Read: How to Stop Trichotillomania

Treatment of body-focused repetitive behavior disorder

A specific cognitive-behavioral therapy (CBT), habits reversal training (HRT) is used in BFRBs such as trichotillomania and excoriation disorder.

The program includes awareness training (self-monitoring), identifying triggers, modifying the environment so picking is less likely to happen, and competing response training (finding behavior that’s not compatible with picking).

It has also been demonstrated that Acceptance and Commitment Therapy (ACT), as well as Dialectical Behavior Therapy (DBT) skills training, can be effective as adjuncts to HRT.

Is medication helpful?

The effectiveness of medication at treating BFRBs is generally regarded as less than that of behavioral treatments. The use of some drugs has shown promise for those who suffer from anxiety, depression, or OCD along with co-occurring disorders. Clomipramine, naltrexone, and olanzapine are some examples of selective serotonin reuptake inhibitors (SSRIs).

Managing BFRBs

There are several self-help strategies that can be used to manage BFRB, including:

  • Behavior blocking: The goal is to reduce injury risk or create barriers that prevent an individual from engaging in the behavior. Wearing gloves makes it more difficult to bite the nail, tying up hair makes it less likely to pull it, or wearing a mouth guard makes it more difficult to chew the cheeks.
  • Stimulation substitute: The next step would be to replace the habit with something else, like fidgeting, squeezing one of those stress toys, chewing gum, or ripping paper. Also, people can engage in hobbies that require them to use their hands.
  • triggers: You may observe that the urge to engage in the behavior arises at different times and in different situations. If a person experiences frequent triggers, keeping a journal may be helpful.
  • Mindfulness: The key to managing BFRBs over the long term is to become conscious of when the behavior occurs. Take a moment to observe how the urge feels as it arises. Find an alternative way to meet your body’s needs by asking yourself what it wants. When someone is anxious, they may hug a pillow instead of picking their skin.

The embarrassment and shame associated with BFRB can prevent individuals from speaking to a therapist or doctor. However, there is support available.

It is important to seek treatment if BFRB interferes with daily life or if it is difficult to stop the behaviors. Medical attention should also be sought if an individual has an injury in order to avoid an infection.

Managing shame and stigma

Many BFRBs are poorly understood, and media portrayals of them are sparse. It is therefore common to view these behaviors as little more than “bad habits” that can be overcome through willpower.

People with BFRBs often experience debilitating shame due to this misconception. If they cannot stop pulling their hair or picking their skin, they may beat themselves up or hide the signs, wearing wigs or makeup, or refusing to let others see what they are doing. There can be a significant disruption in relationships, intimacy, and daily functioning as a result of this intense shame.


Psychological distress can be coped with by using BFRBs. The behaviors include picking at skin, biting nails, and pulling hair.

There is nothing wrong with mild BFRBs, but when they become destructive, they can be dangerous. It can be difficult to stop them, and they may cause pain or injuries.

Support is available if you experience BFRBs due to anxiety or stress. An individual can live a happier, healthier life with treatment. It is best to consult a doctor or psychologist if a person has concerns about BFRB.

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