Body-focused repetitive behaviors like trichotillomania or excoriation disorder impact up to 5% of people—and usually start when they're kids. Here's what parents need to know.
Medically reviewed by Emily Edlynn, PhD
When I was 9 years old, I went to summer camp. The best parts of camp were the friendship bracelets and hand-clapping games and s’mores. The worst part was the mosquito bites. I scratched at the bites until I broke the skin. Once they scabbed over, I would pick off the scabs. I did this again and again.
When summer ended and there were no more mosquitoes, I started picking off the skin around my fingernails. When I got a few years older and developed acne, I picked that off, too. I knew that this behavior was gross and weird. My classmates would ask why my cuticles were bleeding. My parents and teachers told me to stop. And I wanted to stop. But I didn’t know how.
It would be another 25 years before I’d come to understand what was going on. The narrative I’d believed since I was nine—that I did these gross and weird things because I was gross and weird—wasn’t true. In fact, I have what’s called a body-focused repetitive behavior disorder, or BFRB.
What Is a Body-Focused Repetitive Behavior?
BFRBs include hair-pulling (trichotillomania) and skin-picking (excoriation disorder or dermatillomania), as well as compulsive nail biting and lip biting. While the Diagnostic and Statistical Manual of Mental Disorders initially classified BFRBs as a type of impulse control disorders, it’s now categorized under the umbrella of obsessive-compulsive disorders. It’s estimated that 3 to 5% of people may have BFRBs, the majority of them girls and women, with first onset of symptoms generally occurring in early adolescence.
For people with BFRBs, picking and pulling are “coping mechanisms,” says Stacy Nakell, LCSW, author of Treatment for Body-Focused Repetitive Behaviors. BFRBs can help people like me tolerate challenging emotional states, like boredom, anxiety, or frustration.
Diagnosing a Body-Focused Repetitive Behavior
When it finally occurred to me that my inability to quit picking might be due to a clinical issue, not just poor self-discipline, I went to a psychologist who confirmed a BFRB diagnosis.
Nakell says that patients or their parents usually seek her out once they realize they are struggling with skin-picking or hair-pulling. Because there is a stigma around BFRBs, she says, “teens often pretend they don’t know why they have bald spots and sometimes go to doctors at their parents’ request.”
Fortunately, she adds that in those situations, “there are ways to determine whether damage is through hairpulling or something else, like alopecia, through trichoscopy (study of the hair).” Once diagnosed, a person’s treatment process—often cognitive behavioral therapy or psychodynamic treatment, Nakell says—can begin.
Getting a diagnosis hasn’t magically caused me to stop picking, as much as I wish it would. Unfortunately, there’s not yet a medicine with a great track record of treating the disorder.
Preliminary research indicates that the dietary supplement N-acetylcysteine can help lessen the desire to pick, though I personally haven’t yet benefited from it. When I started seeing a therapist who specializes in BFRBs, she commented that it’s easier to quit cigarettes than it is to quit skin-picking. I’ve never been a smoker, but given that I’ve been trying to stop picking for thirty years now, I’m inclined to believe her.
Although getting a diagnosis hasn’t cured me, it has radically changed my self-perception. I spent years believing there was something uniquely wrong with me, and now I know that’s not true.
BFRBs and Mental Health
Unfortunately, you can’t magically undo the effects of decades of shame and self-blame. I wish I had learned about the existence of BFRBs a long time ago, rather than spending so long mad at myself for continually doing something that I knew was “bad.” It makes me hopeful for the next generation to see that today there is such a greater understanding of neurodiversity and the differences in kids’ (and people of all ages!) sensory needs, and I want to help spread that awareness.
My newest middle-grade novel, The Museum of Lost and Found, stars Vanessa, an eleven-year-old with an undiagnosed BFRB. Vanessa hates how her skin-picking habit makes her dad upset and disappointed with her. She’s mortified when classmates or teachers ask what she’s doing. But when she discovers that BFRBs are a genuine mental health disorder, she’s finally able to stop blaming herself.
My hope is that this book will help some kids feel less alone. If they read The Museum of Lost and Found and see themselves in Vanessa, then maybe they can understand that they too are dealing with a diagnosable condition.
Maybe some readers will share the book with their parents, if they’re too ashamed to outright state what they’re grappling with, as shame often goes hand in hand with BFRBs. I hope this book will help kids realize, while they’re still young, that they’re not weird, or gross, or broken. As Vanessa comes to realize: “This wasn’t a bad choice that she made and kept making. It was just a part of her. There was no one to blame.”
How to Manage Body-Focused Repetitive Behaviors in Children
Plenty of people will pluck out an errant hair or tear off a hangnail, and that’s usually not cause for concern. But if you notice that your child engages in these behaviors frequently and to their own detriment, despite repeated attempts to stop, then they might have a BFRB.
If that’s the case, Nakell says that parents “have to be collaborative with their children. If they notice hair pulling or skin picking, they can check with their child to see if it bothers them," she says. "How can the parent model regulating emotions? Breathe together when upset? Go to couples’ counseling if you need to work on how you handle conflict. Remember that your kids can’t be perfect and they will rebel in adolescence.”
Treatment options for BFRBs can include psychotherapy, habit reversal training, and comprehensive behavioral treatment, as well as several other types of behavioral therapies.
On a practical level, something that I’ve found incredibly helpful is behavioral replacement. This means fidgets! Telling a child with BFRBs to “stop picking” is unlikely to work. It might make them hide the behavior from you, or feel ashamed of it, but it won’t make them stop.
If they’re picking to meet emotional or sensory needs—such as, Nakell says, “frustration, boredom, feeling trapped, and being isolated”—then they still need something to help get those needs met. Try offering them fidgets to take that place. The TLC Foundation for Body-Focused Repetitive Behaviors is another great resource for helping manage BFRBs.
I really wish this were a condition with a slam-dunk treatment. Maybe someday it will be. In the meantime, I think the most helpful thing we can do for kids with BFRBs is spread awareness, through books and essays and stories, so that they feel less isolated. In my experience, picking and pulling might sometimes result in scars—but it’s the invisible scars of shame that are so much harder to heal.
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