Understanding and Managing Body‑Focused Repetitive Behaviours (BFRBs)
Body‑Focused Repetitive Behaviours (BFRBs), such as trichotillomania (hair pulling) and dermatillomania (skin picking), are estimated to affect between 1–3% of the population. They are recognised in the Diagnostic and Statistical manual of mental disorders (DSM-5) under "Obsessive‑Compulsive and Related Disorders", and are more likely to occur in people with OCD than those without.
BFRBs tend to arise from a mix of biological/genetic, emotional, environmental, and sensory factors. People may feel an urge—driven by anxiety, boredom, tension, or sensory discomfort—and experience relief upon acting on it. BFRBs often serve to soothe or provide stimulation, and not as acts of deliberate self-harm. Though unintentional physical harm, such as skin lesions, infections or hair loss often occur, leading to further emotional distress, shame and social isolation.
The good news is that BFRBs are treatable, and tend to have a good prognosis with evidence-based psychological intervention.
Treatment Options: Psychological Interventions at the Forefront
All evidence-based treatments for BFRBs fall under the umbrella of cognitive behavioural therapy (CBT). These include habit reversal therapy (HRT), acceptance and commitment therapy (ACT) and Dialectical Behaviour Therapy (DBT) with added behavioural components.
Habit Reversal Training (HRT)
The components of HRT include psychoeducation, functional analysis, awareness training, stimulus control, and competing response training. Ultimately, patients focus on engaging in behaviours that prevent them from performing the BFRB.
An example of this in a case of trichotilimania might involve learning to bring awareness to your emotions, triggers, and behaviours; initially wearing your hair up to limit access and reduce temptation to pull; developing a set of competing responses*, such as clasping your hands; and practising relaxation techniques.
*There is also some research showing that ‘Decoupling’, which involves replacing the compulsive behaviour with a similar, inert movement that interrupts the cycle, may be an effective tool in the treatment of BFRBs.
Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) as adjunct psychological interventions
Two additional treatments that research has shown help bolster the above treatments, are acceptance and commitment therapy (ACT) and dialectical behavioural therapy (DBT). Some studies have even shown ACT to have some efficacy as a stand-alone treatment for BFRBs. ACT helps people to identify their values and then act in accordance with those values, rather than the disorder. Whereas DBT utilises mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills to address emotion-driven behaviours in the recovery of BFRBs.
Medications and Alternative Adjunct Therapies
Limited but promising support exists for the use of SSRIs or clomipramine, particularly in cases with co-morbidities, and/or when behavioral treatments alone are insufficient. Outside of this, N‑acetylcysteine (NAC) is an alternative supplement that has demonstrated mild symptom reduction in both hair pulling and skin picking, with a relatively favourable side‑effect profile. However, as with any medication, these options should only be considered when recommended and used under the supervision of a medical professional.
Practical Strategies & Takeaways
Here’s a quick-action guide for those affected by BFRBs:
Start with self-monitoring: noting when and why the behavior occurs.
Utilise HRT techniques: awareness + competing behaviours (eg clasping hands, using fidget toys or stress balls)
Engage in therapy: with a clinician experienced in working with BFRBs and HRT.
Consider techniques from ACT or DBT to help manage emotion‑driven urges.
If needed, explore supplemental support like SSRIs or NAC under the guidance of a medical professional.
Build emotional and social support: compassion, partner/family education, and peer groups make a real difference.