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Skin Picking and Hair Pulling (BFRBs)

While nearly every single person pops a pimple, picks a scab, or bites off a broken nail, there is a chance that these behaviors can develop into chronic disorders that can cause significant stress and interfere with life. 

What are body-focused repetitive behaviors (BFRBs)?

Body-focused repetitive behaviors (BRFBs) are a set of disorders categorized by repetitive self-grooming routines, which include biting, picking, pulling, or scraping one’s hair, skin, nails, cheeks, or lips. 

This woman is suffering from a hair pulling condition.

Common BFRB disorders


Individuals with trichotillomania, commonly called hair pulling disorder, pull out hair on their head, eyebrows, eyelashes, or other areas. While there is no official cause of trichotillomania, experts believe it may be attributed to stress, anxiety, sensory issues, or habit. Despite trying to stop, individuals have an irresistible urge to pull out their hair and can experience shame and distress as they go to great lengths to disguise the loss of hair. 


Dermatillomania, sometimes called excoriation disorder, is a disorder related to OCD. It’s characterized by repetitive picking at one’s skin. Skin picking is a BFRB that can result in swollen or broken skin, causing significant disruption in one’s life. Typically, dermatillomania begins in adolescence but can occur in children or adults. 


Onychophagia, also known as nail-biting, is considered an uncontrollable, chronic nail-biting that is destructive to fingernails, cuticles, and surrounding skin. While it can be temporary and non-destructive, it can develop into a long-term issue. 

Other Notable BFRBs

  • Morsicatio Buccarum – mouth-biting
  • Morsicatio Labiorum – lip-chewing
  • Morsicatio Linguarum – tongue-chewing
  • Dermatophagia – scab-eating
  • Rhinotillexomania – nose-picking 
  • Trichophagia – hair-eating
  • Trichodaganomania – hair-biting
  • Trichotomnomania – hair-cutting

What causes BFRBs?

Research shows that BFRBs are likely inherited, indicating that immediate family members share a higher predisposition than the general population. However, genetics isn’t the only factor that contributes to developing BFRBs. BFRBs arise from a multitude of factors, not just a single one. 

Other factors include: 

  • Individual temperament and personality 
  • Environmental factors
  • Beliefs about one’s image
  • Need for sensory input
  • Emotion management
  • Lack of family support

It’s important to remember that if you are experiencing any of these issues, it is not your fault and you’re not alone: about 1 in 20 people have a BFRB. 

How We Assess BFRB at CBT Baltimore

At CBT Baltimore, we are mindful of the shame and distress of experiencing a BFRB. As we learn more and more about these disorders, we’ve tailored our assessments to understand the mechanics behind the impulses and help individuals feel understood and less isolated. 

We use a therapy approach called Comprehensive Behavioral (ComB) treatment developed by Charles Mansueto and his colleagues at the Behavior Center of Greater Washington. It’s an approach introduced in 1990 and has been extensively researched and used to treat individuals with BFRBs effectively.  

ComB helps therapists understand the complexities of BFRBs, the wide range of variables that contribute to the cause and persistence of these disorders, and the mix of different factors that underlie each client’s BFRB. 

The Effectiveness of ComB Treatment on BFRBs

At ComB’s core, it’s a collaborative effort between therapist and client and it begins by identifying the function of the target behavior (e.g., hair-pulling, skin-picking, nail-biting) and creating a targeted replacement for it. Five functional domains associated with the promotion of BFRBs are assessed in the ComB model: sensory, cognitive, affective, motor, and place. 

The acronym used for them is SCAMP: 

  • Sensory: The first domain focuses on any sensory experience that occurs before, during, or after the BFRB behavior can promote engagement in the BFRB. Once sensory factors have been identified, the goal is to figure out a way to prevent the sensory triggering from happening. 
  • Cognitive: The second domain aims to discover the thoughts that cue and promote BFRBs (e.g., thoughts that could heighten the appeal to engage in the BFRB, thoughts that reward behavior engagement). 
  • Affective: Emotions and feelings are the focus of the third domain and to build awareness around which feelings bring about the need to engage and how BFRBs can help a person regulate their emotions. 
  • Motor: The third domain is all about capturing one’s awareness of and ease of engaging in BFRBs. Awareness is one of the biggest components to address and is the first step in keeping hands busy or using a tool that makes engaging in the BFRB difficult. 
  • Place: The fifth domain focuses on time of day, location, and the environment that might be promoting the BFRB. 

ComB is uniquely creative and tailored to each client, providing a framework that helps therapists design and implement a unique treatment plan.

At CBT Baltimore, we specialize in BFRB treatment.

Therapy for BFRBs

Contact us to learn more about therapy for BFRBs, or feel free to request a session