Obsessive compulsive disorder - OCD treatment and therapy from NOCD

OCD and BFRB: Skin Picking, Nail Biting and Hair Pulling

By NOCD Staff

Mar 24, 202310 min read minute read

Reviewed byPatrick McGrath, PhD

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Sophia*, a 27-year-old from New York, can remember the first time she pulled her hair. She was 11 years old, and she was working on her math homework. Plucking the strand gave her a sense of satisfaction and relief from the stress about her assignment. 

She carried this behavior with her in secret for the next 16 years. She knew this habit was strange, but as long as no one found out, she could pretend it didn’t matter.

There were certain hairs that gave Sophia more satisfaction to pluck. She’d find these special strands by feeling each one between her fingers. The search for the ideal strand was soothing. Sometimes, during class, she’d place her hand on the special spot of her head—the top right side. From a distance, it simply looked like she was scratching her head. 

She might forget about this habit for months at a time. But other times, like when she was studying for final exams, it became difficult to keep her pulling under control. Eventually, she found herself spending more time in front of the mirror, rearranging her hair to conceal the bald spot that was starting to become noticeable. 

Once in therapy, Sophia casually mentioned her hair-pulling habit. “I do this weird thing where I pull out my hair,” she said, just as she was leaving the session. “It’s gross.” It was the first time she’d mentioned it to anyone. Unfortunately, her therapist seemed to downplay her confession. “It’s a good thing you have a lot of hair!” she said, trying to make light of the situation. 

Finally, Sophia opened up to a friend and told her she was concerned about the bald spot becoming more visible. Her friend suggested that the hair-pulling could actually be a mental health condition called trichotillomania, which belongs to a category of conditions called body-focused repetitive behaviors, or BFRBs, along with other habits like skin-picking and nail-biting. 

BFRB meaning: What are body-focused repetitive behaviors?

BFRB is an umbrella term for conditions that cause people to engage in repetitive behaviors fixated on their body, such as hair-pulling, skin-picking, nail-biting or cheek-biting. Like Sophia, people with BFRBs struggle to control these behaviors, and often keep them secret for fear of being judged. While people may hesitate to discuss them, BFRBs are common—in fact, research shows that 1 in 20 people experience a BFRB.

People with BFRBs generally engage in these behaviors when they are stressed or bored. They may turn to picking or pulling as a way to relieve their anxiety when they are overstimulated, or because they are under-stimulated and the behavior helps stimulate their nervous system, explains April Kilduff, a licensed therapist and OCD specialist at NOCD. 

BFRBs can range in severity. For some people, their behavior will only show up during times of stress, while others engage in these behaviors more regularly, sometimes causing lasting damage to their body.

Typically, BFRBs develop in people between the ages of 11 and 15. “[The behaviors] certainly can develop at any time, but I think what’s most frequent is to see it happen in adolescence,” says Dr. Paul Greene, a psychologist who treats BFRBs as director of Manhattan Center for Cognitive-Behavioral Therapy. “But it can happen for children or more mature adults. It certainly can happen in a wide variety of ages”—even, he adds, in children as young as 2 years old.

One of the biggest and least-discussed components of BFRBs is the shame people feel around their behaviors. “[People have] also been told their whole life, ‘Oh, just stop it,’ and they feel like they should be able to stop. When they can’t, they feel defective, like there’s something wrong with them,” says Ruth Golomb, licensed therapist and author of The Hair Pulling “Habit” and You. “So there’s a great degree of emotional burden that people carry with them because of their own feelings about themselves and their behavior.”

BFRB or OCD: Are BFRBs part of obsessive-compulsive disorder?

BFRBs and OCD both involve compulsive behaviors, and they can appear similar for this reason. The DSM-5 characterizes BFRBs as unspecified obsessive-compulsive and related disorders, a distinct category from OCD. The main difference between these two conditions is the underlying reason a person engages in repetitive behavior.

“An OCD compulsion is always done in response to an unwanted thought, image or urge that provokes a high degree of distress and/or anxiety in a person. The compulsion’s function is always to relieve that anxiety and distress or to prevent something bad from happening,” Kilduff explains. “In short, a mental event triggers the compulsion.”

BFRBs, on the other hand, are not necessarily triggered by intrusive thoughts, “but rather a physical event which builds up until a person picks or pulls,” she says.

Golomb adds that with BFRBs, “there’s some sort of pleasure very often associated with some aspect of the BFRB that is typically not present for OCD.” 

“It’s usually something like, ‘I’m trying to remove that hair,’ or, ‘It feels good to get this ping when I pull my hair,’ or, ‘After I have my hair or even some skin and I rub it between my fingers, that’s really interesting and feels good,’” Golomb explains.

Dr. Greene compares BFRBs to smoking, as a helpful way to understand how people relate to their behavior: “If you’re not really trying to quit, you can end up smoking more or you can end up smoking less, if it isn’t on your mind. But if you try to quit, it’s challenging but doable. Same thing with BFRBs. The BFRBs are truly a habit, whereas OCD is more complicated than a habit. Just like with cigarettes, anxiety and stress can make BFRBs or smoking frequency worse.”

Even though the two conditions are different, they’re commonly confused. The two conditions are often comorbid, or occur simultaneously for a person, but it’s important to know the difference between OCD and BFRBs, because the treatment for each condition is different. 

Why people confuse BFRBs with OCD 

“I can’t tell you how many times I get people who call me who tell me they have OCD, because I also treat OCD. When I start asking them what their symptoms are, they actually have a BFRB,” Golomb says. 

One of the reasons for the confusion is that the behaviors of the two conditions may appear highly similar. “BFRBs are repetitive behaviors and they look compulsive, which makes people think they are the same as OCD,” she adds.

There can be hereditary overlaps, though. Golomb explains that someone with a BFRB is slightly more likely than others to have someone in the extended family with OCD. “They are related in that way a little bit,” she says. 

In some cases, a person may experience a BFRB triggered by OCD, but this is uncommon, according to Golomb. She shares an example of how a person might experience both conditions. “You might see this with someone who’s got contamination OCD: They’ve touched something and they can’t wash their hands thoroughly enough. They get really anxious, and they’re sitting down, and then they start pulling their hair,” she says. 

Treatment for BFRBs vs. OCD

The treatment for BFRBs and OCD is different. Habit-reversal training or a type of cognitive behavior therapy called comprehensive behavioral (or ComB) therapy is the recommended form of treatment for BFRBs. Exposure and response prevention therapy, or ERP, is the gold standard of treatment for OCD. 

HRT involves tracking specific details about when you’re most likely to engage in a habit, so that you can gather as much information about when it occurs. 

The first step to HRT is behavioral monitoring, Dr. Greene explains. “We have people keep track of when they’re pulling hair or picking skin, whatever it may be,” he says. “And this process in and of itself really helps people become much more aware of when it’s happening, as well as why and how long it goes on. And what they often find is that by developing additional awareness, they’re sometimes able to reduce the frequency of the behavior itself.” 

HRT looks at the different circumstances in a person’s life that could contribute to the pulling episodes. HRT is short-term, typically occurring over 12 therapy sessions or fewer, and it’s highly effective if you’re able to follow the directions given to you by your therapist, according to Dr. Greene. 

He adds that when considering treatment, it’s helpful to keep in mind that HRT is “different than just trying to use willpower, which everyone has already tried, and it really doesn’t work as well as people would like.”

ComB additionally involves taking account of the larger circumstances a person is facing that could play a role in these behaviors. “We look at all of the things that contribute to the pulling: sensory cognitions, feelings, motor movements and certain environments. We look at all of that and then we try to address those things very specifically, so that we can really capture the whole picture and help the person most effectively manage their behavior,” Golomb explains. 

When should people seek HRT?

Dr. Greene recommends seeking treatment when your BFRB starts to impede your ability to live the life you’d like. “For example, if you start to become concerned that you’re missing patches of hair, and it’s making you feel self conscious about your appearance, it’s a good time to get treatment,” he says. Or if someone finds their behavior concerning and they have a desire to stop, even if it doesn’t visibly affect their appearance or health, Dr. Greene recommends seeking treatment as well. 

Golomb elaborates on the emotional toll BFRBs can take. Seeking treatment is “really dependent upon how distressing it is for the individual,” she says. “Even if someone doesn’t pull or pick their skin that much, too many people feel so disheartened because they feel that they’re not in control of their behavior. Or they feel the result of the picking or pulling—even if it’s a small scab or a small bald spot, they know it’s there—and they feel so distressed by it because they feel responsible that they’ve done this to themselves. So even if the result is small, the distress can be high, and therefore living with it becomes a huge burden.”

On the other hand, not everyone with a BFRB may need or want treatment. “If you pull hairs or pick skin and it doesn’t cause you infections or bald patches and it doesn’t really bother you that much, then there’s not really any treatment necessary,” Dr. Greene adds. As Dr. Greene points out, BFRB can function like smoking—it’s a habit meant to cope with stress. If that’s the case, it may be worth addressing the anxiety that drives the habit, or find healthier options to explore, like a stress ball. This, of course, depends on the individual and how much distress their BFRB is causing them. 

What is ERP therapy for OCD? 

ERP involves specifically targeting the source of a person’s obsessions by directly exposing them to situations that trigger them, then guiding them in resisting compulsions as a response. Let’s say that every time Taylor eats at a restaurant, he gets anxious and feels like his hands can’t be cleaned well enough. In order to relieve his anxiety, he feels a strong urge to wash them for at least 10 minutes. During therapy, Taylor will expose himself to the source of his obsession, such as eating at a restaurant, but he will refrain from his compulsive hand-washing routine, perhaps setting a 45-second limit on his hand-washing as a first step. 

The idea of ERP is that by confronting your obsessive thoughts without engaging in compulsions, you can learn that your feared outcome won’t occur, that you can manage the outcome if it does occur, and that you can tolerate the anxiety or distress that arises as a result of your obsessions. In some cases, people find that ERP helps their anxiety subside to the point where they no longer experience fears related to their thoughts on a regular basis. 

Regardless of the condition or treatment, Golomb encourages people to stay optimistic. “People have been able to successfully manage these behaviors and lead a full and happy life,” she says. “I think the most important thing to mention is that there’s hope.” 

After Sophia discovered there was a name for the hair-pulling behavior she’d kept secret for 16 years, she felt relieved to know she wasn’t alone. She wrote an email to her therapist explaining what she’d discovered, and began researching treatment options. She feels better knowing there is specific treatment available for her particular condition. Sophia still occasionally pulls during times of stress, but because she’s aware of what is happening—that she has a treatable condition, rather than something irreparably wrong with her—the behavior is no longer accompanied by the same oppressive sense of shame.

If you’re looking for more information about BFRBs, Golomb recommends the TLC Foundation for BFRBs, an organization with helpful information and support groups. 

If you or someone you know is struggling with OCD, you can schedule a free call today with the NOCD Care Team to learn more about how a licensed therapist can help. At NOCD, all therapists specialize in OCD and receive ERP-specific training. ERP is most effective when the therapist conducting the treatment has experience with OCD and training in ERP. Many NOCD Therapists also specialize in treating BFRBs, and have experience treating people for both OCD and BFRBs.

* Names have been changed to allow people to speak freely about personal matters.

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