Getting a Handle on: Body-Focused Repetitive Behaviors (BFRBs)

When "just stop" doesn't work

Do you — or your child — pick at skin, pull hair, bite nails, or chew the inside of your cheeks, and want to stop but can't?

It's easy to write these off as bad habits or nervous tics. But for a lot of people, they fall under a real, well-studied category: Body-Focused Repetitive Behaviors (BFRBs). They show up at every age, and they're more complicated than they look.

What counts as a BFRB?

BFRBs are repetitive behaviors aimed at the body that can cause physical harm and feel hard to stop. The most common ones:

• Hair pulling (trichotillomania) — from the scalp, eyebrows, or eyelashes

• Skin picking (excoriation disorder) — at scabs, blemishes, or "imperfections"

• Nail biting (onychophagia)

• Lip or cheek biting

• Hair eating or other repetitive grooming behaviors

Some picking or biting is normal, at any age. It becomes a concern when it's frequent, hard to control, causing injury, or getting in the way of daily life.

Why does this happen?

There's no single cause — and contrary to popular belief, it's not just anxiety.

Some people pick or pull when stressed. Others do it when bored, deep in focus, or half-watching TV. A few common drivers:

• Sensory triggers — an uneven nail or rough patch of skin creates an urge to "fix" it

• Emotion regulation — the behavior shifts how you're feeling, even briefly

• Under- or over-stimulation — boredom on one end, overwhelm on the other

• Deep focus — it happens on autopilot while your attention is elsewhere

• Perfectionism — a need for things to feel even, smooth, or "right"

• Reinforcement — once it feels good or relieving, the brain repeats it

Genetics play a role too. BFRBs tend to run in families, though no single gene explains it.

Automatic vs. focused

Automatic BFRBs happen with almost no awareness — you might look up from the TV and realize you've been picking for twenty minutes without noticing.

Focused BFRBs come with more awareness and a specific target: I just need to get this one spot.

Most people do some of both.

Not the same as self-harm

BFRBs can cause real damage — bleeding, scarring, hair loss — but they're not usually about wanting to hurt oneself. They're driven by urges, sensations, and habit, not intent to injure.

"I know I'm doing it — so why can't I stop?"

Because awareness and control aren't the same thing. BFRBs are learned patterns that bring some kind of immediate relief, even when the long-term cost is obvious. For kids and teens especially, being told to "just stop," or getting called out every time, rarely works — and can add shame that makes things worse.

What treatment looks like

Good treatment starts by figuring out what's actually driving the behavior for that person — not assuming anxiety is the root cause. That means asking when it happens, what triggers it, how aware they are, and what they get out of it.

From there, treatment often draws on CBT, Habit Reversal Training, and the Comprehensive Behavioral (ComB) model — building awareness, spotting triggers, and developing alternative responses. This approach works across ages, though the specifics look a bit different for a seven-year-old than for an adult who's been picking for twenty years.

For parents of kids and teens

Swap shame for curiosity:

• Instead of "Stop picking," try "I noticed your hands are busy — what's going on?"

• Instead of "You have to stop," try "Let's figure out when this happens."

Your kid isn't doing this to frustrate you, and you haven't failed by not fixing it yet.

For teens and adults

If you've been managing a BFRB on your own for years — maybe with makeup, concealment, or sheer willpower — you're not alone, and it's not a character flaw. Many adults with BFRBs were never told as kids that what they were doing had a name. It's not too late to understand what's driving it and get support that actually targets the function of the behavior, not just the behavior itself.

When to get help

Reach out to a professional if the behavior:

• causes wounds, bleeding, or hair loss

• is getting more frequent or harder to control

• causes real shame or distress

• interferes with school, work, sleep, or relationships

• has survived repeated attempts to quit

You don't need to know the "why" before you ask for help — that's often what treatment is for.

At Green Door Clinic, we work with kids, teens, adults, and families on BFRBs using individualized, evidence-informed care focused on why the behavior is happening — not just stopping it. Reach out if you're not sure whether what you're seeing (or experiencing) is a BFRB.