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Body Focused Repetitive Behaviors

Body-focused repetitive behaviors are recurrent destructive behaviors directed toward the body. They include hair pulling (trichotillomania), skin picking, and nail biting. Recommended treatment approaches for BFRBs include habit reversal therapy, acceptance and commitment therapy (ACT), and components of dialectical behavior therapy (DBT). Read more

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What Are Body Focused Repetitive Behaviors?

Signs and Symptoms of BFRBs

A diagnosis of trichotillomania is made on the basis of:

  • recurrent pulling out of one’s hair resulting in noticeable hair loss;
  • an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior;
  • pleasure, gratification, or relief when pulling out the hair.

Models and Theories of BFRBs

Behavioral approaches have frequently been used to understand BFRBs such as trichotillomania. Functional analysis is used to understand the antecedents and consequences of episodes of hair pulling (Mansueto, Golomb, Thomas, & Stemberger, 1999). Attention is paid to:

  • external cues that trigger the urge to pull (e.g., settings associated with pulling, implements associated with pulling);
  • internal cues that trigger the urge to pull (e.g., affective states such as anxiety or boredom, visual or tactile sensations, cognitive cues);
  • discriminative stimuli that facilitate pulling;
  • behaviors involved in pulling (e.g., preparation, pulling, discarding of hair);
  • consequences of pulling that maintain or terminate pulling behaviors (e.g., pleasurable sensations, attaining desired outcomes, alleviation of stress or boredom, negative evaluation).

Evidence-Based Psychological Approaches for BFRBs

Habit reversal training (HRT) is the most comprehensively studied intervention for the treatment of BFRBs. It is an evidence-based treatment for trichotillomania (Bloch et al., 2007). It is a form of cognitive behavioral therapy which includes the following components:

  • self-monitoring of the relevant behavior;
  • awareness training to increase the patient’s awareness of the relevant behavior, and of high-risk situations that frequently trigger the behavior;
  • stimulus control to decrease opportunities to engage in the target behavior, or to interfere with performance of the target behavior (e.g., wearing gloves to prevent hair pulling in high-risk situations);
  • stimulus-response intervention / competing response intervention includes the development of behaviors or habits that can be used to replace or compete with the target behavior.


  • Bloch, M. H., Landeros-Weisenberger, A., Dombrowski, P., Kelmendi, B., Wegner, R., Nudel, J., … & Coric, V. (2007). Systematic review: Pharmacological and behavioral treatment for trichotillomania. Biological Psychiatry62(8), 839–846.
  • Mansueto, C. S., Golomb, R. G., Thomas, A. M., & Stemberger, R. M. T. (1999). A comprehensive model for behavioral treatment of trichotillomania. Cognitive and Behavioral Practice, 6(1), 23–43.