What is body‑focused repetitive behavior (BFRB)?

What is Body-Focused Repetitive Behavior (BFRB)?

Body-focused repetitive behaviors (BFRBs) are a group of psychiatric disorders characterized by recurrent, compulsive actions directed at one's own body—including skin picking, hair pulling, nail biting, lip-cheek biting, and other repetitive behaviors—that result in physical damage and functional impairment. 1, 2

Core Defining Features

BFRBs involve repetitive motor activities that target body regions with the intent to eliminate or modify a body part, leading to tissue damage and impaired daily functioning. 2, 3 The behaviors are:

• Recurrent and difficult to control, despite attempts to stop or reduce them 1, 4
• Result in visible physical damage such as skin lesions, hair loss, or nail damage 3
• Associated with significant distress and functional impairment in social, occupational, or other important life areas 5, 2

Specific BFRB Disorders

The most common and clinically significant BFRBs include:

• Trichotillomania (hair-pulling disorder): Recurrent pulling out of one's hair, most commonly from the scalp, resulting in hair loss 1, 3
• Excoriation disorder (skin-picking disorder): Repetitive picking at one's skin leading to skin lesions 6, 1
• Nail biting: Chronic biting of fingernails or toenails 1
• Lip-cheek biting: Repetitive biting of the inner cheeks or lips 1, 2

Multiple BFRBs frequently co-occur in the same individual, with 73.9% of affected persons showing more than one type of BFRB. 1

Age of Onset and Clinical Course

Nail biting typically begins in childhood, while trichotillomania, skin picking, and lip-cheek biting predominantly emerge during adolescence. 1 Earlier age of onset correlates with greater overall symptom severity and higher rates of concurrent BFRBs. 1

Critical Differential Diagnosis

Distinguishing BFRBs from Body Dysmorphic Disorder (BDD)

The key distinction is motivation: In BFRBs, the repetitive behaviors are NOT driven by attempts to improve appearance or correct perceived defects. 6

• In excoriation disorder, skin picking occurs without the goal of improving appearance 6
• In trichotillomania, hair pulling is not motivated by correcting perceived appearance flaws 6
• In BDD, these same behaviors (skin picking, hair pulling) ARE performed specifically to improve the appearance of perceived defects 6

Distinguishing BFRBs from OCD

BFRBs differ from OCD in that the repetitive behaviors are not performed in response to obsessions or according to rigid rules aimed at preventing anxiety or dreaded outcomes. 6

• In OCD, compulsions are driven by contamination fears, "just right" urges, symmetry needs, or attempts to neutralize obsessive thoughts 6
• In BFRBs, the behaviors are more habit-based and focused on the body itself, not driven by cognitive obsessions 4, 2

However, trichotillomania and skin picking show higher association with OCD compared to other BFRBs, suggesting some phenomenological overlap. 1

Severity and Impairment Patterns

Trichotillomania and skin picking are associated with the greatest impairment and strongest urges to perform the behavior among all BFRBs. 1

Overall BFRB severity correlates with:

• Earlier age of onset 1
• Greater number of concurrent BFRBs 1
• More severe depression 1
• Higher suicidality 1

Clinical Presentation in Dermatology

Most patients with BFRBs are unlikely to seek mental health treatment and instead present to dermatology due to cosmetic damage. 3

• In trichotillomania, patients present with atypical patterns of alopecia, often affecting multiple body sites 3
• In excoriation disorder, picking frequently starts with an underlying dermatologic condition like acne but continues after dermatologic treatment, with the face being the most commonly affected site 3
• The dermatologic findings and distribution are atypical, helping differentiate BFRBs from primary dermatologic conditions 3

Treatment Approach

Habit reversal therapy (a form of cognitive behavioral therapy) has shown the most promise in reducing repetitive behaviors and symptoms in BFRBs. 4 There are currently no first-line curative medications for these disorders. 4

Treatment augmentation strategies include:

• Combining habit reversal therapy with mindfulness techniques 4
• Adding SSRIs when comorbid OCD is present 4
• Comprehensive dermatologic assessment and management of affected areas 3