Body-Focused Repetitive Behaviors (BFRB)


Body-focused repetitive behaviors (BFRBs) are a group of disorders currently classed as obsessive-compulsive related disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Included in BFRBs are trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder, which is often also referred to as dermatillomania. It is believed BFRBs affect two-to-five percent of the population.

BFRBs involve the repetitive grooming of one’s own body, resulting in physical damage. Despite that damage, these are not considered self-injurious behaviors since the intent of the grooming isn’t to cause harm; the harm is a consequence of the behavior. Instead, these are considered over-grooming behaviors — many people engage in occasionally pulling or plucking hair or picking at skin, for example, but when these behaviors are done to excess, they cross over into the disorder territory. Many people have more than one BFRB.

BFRBs are often described as ritualistic and people with BFRBs tend to search for specific real or perceived imperfections and don’t stop until it feels “right.” The behaviors can occur in short spurts, but numerous people spend hours engaging in them. There are two ways these behaviours manifest: focused or automatic picking, pulling, or biting. Focused means a person is aware of the behavior and actively engaging in it, and automatic means they are not aware of the behavior.

Due to the excessiveness of the behaviors and the damage caused, people with these disorders go to great lengths to hide them. The stigma and lack of information about BFRBs cause people to feel uncomfortable speaking about them and they often feel like they are the only ones with these disorders. People also face ridicule and criticism along with the misunderstanding, which further causes them to remain silent and feel shame or embarrassment. Avoiding social situations and using clothing, wigs, and other concealing methods to hide BFRBs is common.

There are repeated, often unsuccessful attempts, to curb or stop the picking, pulling, or biting. Even with professional intervention, reduction rates vary from person-to-person as there is not currently one pharmaceutical or treatment that works for the majority of people. There is no known cure for these disorders at present time.

Treatments such as cognitive behavioral therapy, dialectical behavioral therapy, habit reversal training, and acceptance and commitment therapy have shown the best results when it comes to treating BFRBs. Support and peer support groups, whether online or in-person, are also a resource people with BFRBs can use. Many with BFRBs are prescribed SSRIs although their effectiveness wildly varies from person to person; an over-the-counter amino acid called N-Acetylcysteine is yielding more positive results.

When and Why do BFRBs Occur
The average age of onset for all BFRBs is puberty, although many people experience BFRBs much younger and even older than that average.

There is no concrete answer why BFRBs exist and occur, but studies show there is a genetic link to the disorders. It is also generally agreed upon in the BFRB community and in BFRB studies that trauma does not cause the disorders; it can trigger the behaviors, but does not create them.

The DSM-5 indicates these disorders are not the result of another psychological disorder or illness, such as body dysmorphic disorder.

Kinds of BFRBs

Generally called trich or TTM for short, trichotillomania involves the repetitive pulling of one’s own hair from anywhere on the body, although the most common areas are the scalp, eyebrows, and eyelashes. Those with trich, who refer to themselves as trichsters, deal with bald spots and hair loss as a result of the disorder.

The DSM-5 criteria for trichotillomania is as follows:

  1. Recurrent pulling out of one’s hair, resulting in hair loss.
  2. Repeated attempts to decrease or stop hair pulling.
  3. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
  5. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).

Excoriation (Skin-Picking) Disorder
Skin picking disorder is referred to by many names, but the most common are dermatillomania, excoriation disorder, and chronic or compulsive skin picking. The behavior involves the repeated picking at skin anywhere on the body, although the focus is often on blemishes such as acne, bug bites, and scabs. The picking results in lesions and scarring as the person continuously opens and reopens wounds on his or her body. Other consequences of the picking include mild-to-serious infections that require medical intervention.

The DSM-5 criteria for excoriation disorder is as follows:

  1. Recurrent skin picking resulting in skin lesions.
  2. Repeated attempts to decrease or stop skin picking.
  3. The skin picking causes clinically significant distress or impairment in social, occupation, or other important areas of functioning.
  4. The skin picking is not attributable to the psychological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies).
  5. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body-dysmorphic disorder, stereotypes in stereotypic movement disorder, or intention to harm oneself in non-suicidal self-injury).

Other BFRBs
There are a number of other BFRBs that are less studied and less spoken about. At present, the BFRB community assumes these follow the same premises as the others. There is no DSM-5 criteria for these disorders.

Usually accompanying trichotillomania, trichophagia involves the ingesting of hair. In extreme cases, it can result in trichobezoars (hair balls) that need to be surgically removed from the stomach.

Not much is known about trichotemnomania, but it involves repetitive cutting of the hair.

Those with dermatophagia bite at their skin, often focused around the nails, but also including the lips and insides of the cheeks.

More commonly referred to as nail biting disorder, people with onychophagia bite their nails to the point that there is little to no nail left on the nailbed.

Rhinotillexomania is the long-form name of nose picking disorder.

Scab Eating Disorder
In many cases, people with excoriation disorder also have scab eating disorder, meaning they ingest the scabs or skin picked from their bodies.

There are many books, websites, studies, and more available with information, guidance, and support for BFRBs and those with them. The following are the only three organizations in the world geared specifically to BFRBs.

Canadian BFRB Support Network
TLC Foundation for BFRBs
Picking Me Foundation



American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Are BFRBs Self-Harm? (n.d.). Retrieved January 22, 2018, from

Browne, H. A., Gair, S. L., Scharf, J. M., & Grice, D. E. (2014). Genetics of Obsessive-Compulsive Disorder and Related Disorders. The Psychiatric Clinics of North America, 37(3), 319–335.

Canadian BFRB Support Network. (n.d.). Retrieved January 22, 2018, from

Grant, J. E., MD, JD, MPH. (n.d.). N-acetylcysteine for Trichotillomania, Skin Picking, and Nail Biting. Retrieved January 22, 2018, from

Keuthen NJ, Altenburger EM, Pauls D. 2014. A Family Study of Trichotillomania and Chronic Hair Pulling. Am J Med Genet Part B 165B:167–174.

Novak, C. E., Keuthen, N. J., Stewart, S. E. and Pauls, D. L. (2009), A twin concordance study of trichotillomania. Am. J. Med. Genet., 150B: 944–949. doi:10.1002/ajmg.b.30922

The TLC Foundation for BFRBs. (n.d.). Retrieved January 22, 2018, from

Why BFRBs Are Not Self-Harm Behaviour. (n.d.). Retrieved January 22, 2018, from

Post courtesy of the Canadian BFRB Support Network

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