Ten FAQs About Body-Focused Repetitive Behaviors

By Charles S. Mansueto, PhD, Sherrie Mansfield Vavrichek, LCSW-C, and Ruth Goldfinger Golomb, LCPC, coauthors of Overcoming Body-Focused Repetitive Behaviors

1. What are Body Focused Repetitive Behaviors?

The term “Body Focused Repetitive Behaviors (BFRBs)” is an umbrella term for chronic problems in which people engage in pulling out their hair (trichotillomania or hair pulling disorder) or picking or otherwise damaging their skin on their face or body (excoriation disorder or skin picking disorder). They may also damage other areas of the body such as arms, legs, fingernails, toenails, tongue, lips, or the insides of the cheeks. The resulting visible problems and the medical damage, as well as the time spent engaging in these behaviors, can affect a person’s self-esteem and their ability to function socially, at work, or at school.

2. Why do people do these things to themselves?

There are many different reasons and combinations of reasons that may explain why some people engage in BFRBs. These may include biological factors such as genetic/neurological predispositions or hormonal effects, in addition topsychological factors such as relief from stress or boredom, or to gain pleasure or satisfaction from the activity. Because it can be hard to tolerate elements of healing (such as “stubby” new hairs or scabs) people often pick or pull even more, thereby creating a vicious BFRB cycle. BFRBs are not thought to be a product of trauma or other “deep-seated” psychological problems.

3. Why don’t I know of anyone else with these problems?

People with BFRBs often live lives of secrecy and deceit. Not because they are inherently dishonest, but because there is usually a heavy dose of shame that they feel about their BFRB. It is common for these individuals to spend much time, energy, and expense in efforts to conceal the damage to their hair or skin. Furthermore, problems of depression, anxiety, decreased self-esteem, and relationship problems can develop as secondary effects of having a BFRB.

4. Will my hair ever grow back? / Will my skin ever heal?

Your skin and hair have the capacity to heal as long as you effectively manage your behavior. However, the degree of damage does make a difference. Most often hair will grow back. Sometimes, the hair follicle (below the skin) needs time to mend so that hair can grow again. Less commonly, there is some scarring or other tissue damage that prevents healthy hair growth. Similarly, severe damage to the matrix of the skin may have permanent effects. In some cases, medical consultation is recommended. Remember that we live in a time of rapidly developing medical procedures with new medications and hair and skin care products that can help, so there is a lot of hope! Most often we are pleasantly surprised at the degree to which hair and skin recovers, even after years of picking or pulling.

5. Are any treatment approaches been shown to be effective for these problems?

At this time, clinical research points to learning-based approaches to treatment, broadly called cognitive behavior therapy (CBT) as offering the most effective treatment for BFRBs. Traditional forms of psychotherapy are not considered by BFRB experts to be effective for these problems. Likewise, psychoactive medications have not fared well in research studies examining their targeted effects for alleviating BFRBs, though they may be helpful for associated conditions like depression and anxiety.   

6. How do I start the recovery process?

Your recovery begins by learning the facts about your condition: First, by recognizing that having a BFRB is not a character flaw, a sign of severe mental illness, or on the other hand, an easy-to-break habit. Second, today there is much more hope and help than in years past because of the work of the TLC Foundation’s leadership and members, as well as contributions by dedicated clinicians. Third, shame is one of the worst things about having a BFRB. So, it is important to be aware that there are millions of smart, talented, kind, accomplished people out there just like you, who deserve to get the help they need.

7. Why can’t people just stop these destructive behaviors?

BFRBs are more complicated than they first appear, and they are typically well-practiced habits. Most people who engage in these behaviors have generally good willpower but they have found that willpower alone has not been sufficient for them to effectively manage these behaviors. It is also true that there is remarkable variation in what factors encourage the continuation of these problem behaviors from one person to another. Whatever their unique combination of factors, most find that they do not have the necessary tools to effectively manage their BFRB. It is for these reasons that comprehensive behavioral (ComB) therapy was developed years ago, and has helped thousands of sufferers to gain control over these problems.

8. I have tried to stop before and it didn’t work. Why try again?

You may be in a better frame of mind, in a different stage of life, or simply feel more ready this time. We often need to work on change a number of times before we are successful: working on your BFRB is no different. Try again. The ComB approach, based on decades of clinical research and experience, can guide you through the process of developing an action plan that is powerful enough to overpower your BFRB.

9. I have been doing this to myself for decades. Is there any point in getting my hopes up?

Absolutely! There is always a next time to start anew. You can learn to change your behaviors if you are willing to make the commitment to do some work. The ComB approach guides you in using creative techniques to help change your behavior. Are you ready to try something new? Are you willing to work through the ups and downs of making important changes? If the answer is yes, it does not matter how long you have picked at your skin or pulled out your hair. What matters is committing to a program that leads you through the process of change.

10. Where can I get more information? The TLC Foundation for BFRBs is a nonprofit organization—a community of sufferers, family members, volunteers, clinicians, researchers, and other professionals. It is a resource where you can find up-to-date and accurate information, and support from people who care. There is no reason for you to be alone in your struggle, for the TLC community is there for you, just as it has been there for thousands of others. Their website is www.bfrb.org. Contact TLC today. If you are so inclined, you may also want to check out our new self-help book, Overcoming Body-Focused Repetitive Behaviors. Let the healing begin!

Charles S. Mansueto, PhD, is founder and director of the Behavior Therapy Center of Greater Washington, a leading center for the treatment of obsessive-compulsive and related disorders.

Sherrie Mansfield Vavrichek, LCSW-C, specializes in cognitive behavioral therapy (CBT) for body-focused repetitive behavior (BFRB) and a wide range of clinical problems. She is author of The Guide to Compassionate Assertiveness.

Ruth Goldfinger Golomb, LCPC, is a senior clinician with the Behavior Therapy Center of Greater Washington. She is coauthor of The Hair Pulling “Habit” and You.