Can therapy help with hair-pulling, nail biting or skin picking? Body-Focused Repetitive Behaviors: What They Are and What Actually Helps
Understanding hair-pulling, skin-picking, nail-biting, and the shame that so often comes with them
We’ve all found ourselves pulling at our hair or biting a nail here and there. But, if you’ve noticed that you do regularly, sometimes for long periods of time without realizing it, or in a way that’s starting to cause a physical changes (bleeding fingers, bald patches, etc.) it’s possible you are experiencing body-focused repetitive behaviors BFRBs). And yes, therapy can help.
BFRBs are more common than most people realize, and significantly misunderstood. It’s important to get clear information about what BFRBs are, why they happen, and what kinds of strategies tend to actually help. And to do so without the layer of shame that so often comes with this misunderstood, but incredibly common, behavior.
What are Body-Focused Repetitive Behaviors?
Body-focused repetitive behaviors are a category of behaviors involving repetitive, compulsive actions directed at the body. The most common are:
• Trichotillomania: compulsive hair-pulling, which can involve pulling from the scalp, eyebrows, eyelashes, or other areas of the body
• Excoriation disorder (skin-picking): repetitive picking at the skin, often targeting perceived imperfections, scabs, or areas of texture
• Onychophagia: chronic nail-biting, which may also involve biting the surrounding skin or cuticles
These are classified in the DSM-5 under obsessive-compulsive and related disorders, which tells you something about their clinical profile: they share features with OCD, including the repetitive, difficult-to-control quality and the distress that typically accompanies them, but they are their own distinct category with their own treatment considerations.
BFRBs are also notably underreported. Many people who engage in these behaviors have never named them to a clinician, often because of shame, or because they assume the behavior is too minor to bring up, or because they have been managing it privately for so long it has come to feel like just a personality quirk. Research consistently suggests that BFRBs are far more prevalent than clinical samples indicate, affecting an estimated 1 in 20 people to a clinically significant degree (Grant & Chamberlain, 2016).
Is it common to not even notice you are picking or pulling? Why can’t I just tell myself to stop?
One of the most important things to understand about BFRBs is that they frequently occur outside of conscious awareness. This is an important feature of how these behaviors operate. Many people pull, pick, or bite while doing something else entirely: watching television, reading, driving, sitting in a meeting, scrolling through their phone. The behavior runs in the background, almost like a habit loop that activates automatically under certain conditions.
This automatic quality is part of why willpower-based approaches tend not to work well. Telling yourself to “just stop” is not particularly effective against a behavior that is not consistently registering as a choice in the first place. The brain has essentially routed the behavior around the part of the process where you consciously decide to do it.
BFRBs often serve a regulatory function. For many people, these behaviors provide sensory input that is calming, focusing, or stimulating in a way that helps modulate emotional or physiological states. They may increase during periods of stress, boredom, concentration, or emotional flatness. From a somatic and nervous system perspective, the body is seeking regulation, and the BFRB is the mechanism it has found. This framing does not make the behavior less worth addressing. It does make it more understandable.
Is it normal to feel ashamed about pulling, picking and other repetitive behaviors?
Shame is one of the most consistent companions to BFRBs, and it is worth addressing directly because it actively interferes with the process of change.
People who engage in BFRBs often describe hiding the behaviors from others, wearing their hair in particular ways to conceal missing patches, keeping their hands out of sight, avoiding certain lighting. The energy that goes into concealment is significant, and it operates alongside a kind of internal narrative that frames the behavior as a moral failure or evidence of weakness, lack of self-control, or something fundamentally wrong.
This narrative is not accurate, and it is not useful. Research on behavior change consistently shows that shame is a poor motivator for sustained change as it tends to produce avoidance and self-concealment rather than the kind of honest self-observation that actually supports different choices (Tangney et al., 2007). You cannot get a clear picture of a behavior you are busy feeling terrible about.
This is one place where the feminist-relational framework is directly relevant. The shame people feel about BFRBs often has a gendered dimension, specifically because there are particular cultural pressures on women and female-identifying people around the appearance and maintenance of their bodies, and behaviors that visibly affect hair, skin, and nails land in that context. The distress is not just about the behavior. It is also about what the behavior means in an environment that evaluates bodies constantly and harshly.
Getting some distance from shame is not the same as not caring about the behavior. Rather, self-compassion provides the space needed to address the behavior in a meaningful way.
What kind of therapy or treatment is available for hair pulling, nail biting or skin picking?
The evidence-based treatment approach most commonly used for BFRBs is called the Comprehensive Behavioral Treatment model, or ComB, which is a descendant of Habit Reversal Training. Both approaches share a common starting point: you cannot change a behavior you cannot see.
Before implementing any replacement strategy, the first task is building awareness of when, where, and under what conditions the behavior happens. This is less about catching yourself and stopping immediately, and more about gathering honest information. Think of it as a mapping exercise rather than a test.
Some common contexts where BFRBs tend to occur:
• In the car, especially during long drives or traffic
• While watching television or scrolling through a phone
• During reading or studying, particularly when the material requires sustained concentration
• In meetings or during phone calls, when hands are otherwise unoccupied
• At a desk or computer, during periods of mental effort or mental fatigue
• At the end of the day, when the body is winding down and defenses are lower
You might notice that certain emotional states precede or accompany the behavior: boredom, anxiety, a kind of edgy restlessness, or the opposite, maybe a zoned-out, dissociated feeling. Both ends of that spectrum are common triggers. The behavior may be helping you up-regulate when you are flat, or down-regulate when you are activated.
Keeping a simple log can help. Don’t over think it, even keeping a note in your phone that says “caught it at my desk, stressed about email” or a week or two can reveal patterns that are not obvious when you are in the middle of them. At this point the most important thing is just bringing awareness and its ok if nothing else changes.
What is a replacement strategy and how does it help with BFRBs?
Once you have a clearer picture of when the behavior tends to happen, the next step is introducing competing responses, or things you can do instead that occupy the same hands, provide similar sensory input, or interrupt the habit loop before it completes.
As you begin this process, it is both scary and important to acknowledge that no replacement is going to feel exactly like the behavior it is replacing. That is expected, and it is not a failure of the strategy. The goal is not to find something that gives you the identical experience of pulling or picking or biting. And it is ok to have to grieve the loss of the relief you found in the behavior. The goal of treatment is to redirect the impulse toward something that does not cause harm to your body.
What are effective strategies for hair pulling?
Strategies that work by creating a barrier or making the behavior harder to complete without eliminating sensory input entirely:
• Hats, scarves, or headbands: covering the hair reduces access and can serve as a physical reminder when you reach up
• Gloves or finger covers: changing the tactile experience of reaching for hair can interrupt the automatic quality of the behavior
• Clenching fists: a simple competing response that occupies the hands and provides some proprioceptive input
• Stress balls or textured objects: particularly useful in the contexts where you are otherwise zoned out — something to hold while watching TV, riding in the car, or sitting in a meeting
What are strategies for Skin-Picking?
Skin-picking often involves a tactile search component — running fingers over skin looking for a texture to engage with. Strategies that provide alternative texture or create a barrier tend to be most effective:
• Fidget tools: the range of adult fidgets available now is genuinely wide. Textured rings, squishy tools, interlocking pieces, sand-filled objects — these give fingers something to do that involves similar tactile engagement. Amazon, Etsy, and specialty sensory shops have many options worth trying
• Finger bandages or finger condoms: covering the fingertips changes the sensory experience enough to interrupt the picking impulse and creates a noticeable barrier
• Gloves: particularly useful during high-risk times like evening screen time or reading, when hands tend to wander without conscious direction
What are Strategies For Nail-Biting?
Nail-biting strategies often work through a combination of barrier, taste aversion, and nail maintenance:
• Gloves or finger covers: the same principle as above — a physical barrier that changes the automatic quality of reaching the nail to the mouth
• Bitter-tasting nail polish: products like Mavala Stop or similar formulas apply a taste aversion directly to the nail. For some people, the taste serves as a real-time interrupt; for others, it is less effective. Worth trying
• Regular manicures, acrylics, or gel nails: this is not vanity strategy — it is a legitimate tool. Keeping nails manicured or extending them with acrylics or gels changes the texture, the ease of biting, and for some people, the investment in their appearance creates a meaningful deterrent. It also puts nails in a state that is harder to bite without noticeable damage
Will therapy for BFRBs work right away? Are the results of BFRB therapy permanent?
Working on a BFRB is rarely linear. Most people who make progress do so through cycles: a period of increased awareness, some success with replacement strategies, a setback during a stressful period, recalibration, more progress. This pattern is expected and part of the healing process.
Setbacks tend to happen when stress goes up. This makes sense, because stress is often what was driving the behavior in the first place. When your nervous system is under more pressure, it is going to reach for what it knows. That is a completely normal physiological response and having compassion for the part of you that is struggling to let go is an essential part of the process.
What tends to make the biggest difference is staying curious about the behavior rather than reactive to it. When you notice you have been picking or pulling, the useful question is not “why can’t I stop doing this” but rather: what was happening just before? What was I feeling? What context was I in? Curiosity is a much more impactful motivator than guilt.
Do I need a specialist to help me with BFRBs?
Self-directed strategies are a reasonable starting point, and many people make meaningful progress with awareness-building and replacement tools alone. But there are also good reasons to work with a therapist, and you do not need to be in crisis or significantly impaired to do so.
Consider reaching out if:
• The behavior is causing noticeable physical harm — bald patches, open sores, infected skin, significantly damaged nails and cuticles
• The shame or distress around the behavior is affecting your quality of life, your relationships, or your willingness to be in certain situations
• You have tried self-directed strategies and found that the behavior returns consistently or feels outside your control
• The BFRB is accompanied by other anxiety symptoms, OCD-related experiences, or trauma responses that feel connected
• You simply want structured support and do not want to work through it alone
Therapists who work with BFRBs typically use the Comprehensive Behavioral Treatment (ComB) model or Habit Reversal Training (HRT), sometimes in combination with Acceptance and Commitment Therapy (ACT) to address the shame and avoidance that often accompany these behaviors. These are structured, evidence-based approaches, not just general talk therapy — and knowing what to ask for when you reach out to a provider is useful.
Wild Hope Therapy sees clients dealing with BFRBs, OCD and OCD-related conditions, anxiety, and the intersecting layers of shame that so often come with them. With in-person therapy available in Cleveland Heights and virtual counseling across Ohio, including Columbus, Cincinnati, Dayton, and beyond, we work with adults who want a space that takes these experiences seriously without pathologizing them. You do not have to minimize what you are dealing with to get through the door.
If I’ve been pulling, picking or nail biting for a long time, will therapy still work for me?
If you have been pulling your hair or picking your skin or biting your nails for years, and you have spent a fair amount of that time feeling ashamed of it, there is probably some part of you that has concluded you just cannot change this. That conclusion is understandable and it is also not the whole picture.
BFRBs respond to treatment. Not always quickly, not always completely, but meaningfully. The strategies that work are not complicated — they are just specific, and they require a degree of honest self-observation that is hard to do when shame is running the show.
The place to start is exactly where you are: noticing when it happens, getting curious instead of critical, trying one alternative, seeing how it feels, and adjusting. You already know more about your own patterns than any article can tell you. And you can build your strategies on that unique, internal knowledge.
Clinical References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania. American Journal of Psychiatry, 173(9), 868–874.
Mansueto, C. S., Thomas, A. M., & Brice, A. L. (2010). Hair pulling and its affective correlates in an African-American university sample. Journal of Anxiety Disorders, 24(7), 816–819.
Tangney, J. P., Stuewig, J., & Mashek, D. J. (2007). Moral emotions and moral behavior. Annual Review of Psychology, 58, 345–372.
Woods, D. W., & Houghton, D. C. (2014). Diagnosis, evaluation, and management of trichotillomania. Psychiatric Clinics of North America, 37(3), 301–317.