Ohio BFRBs
(Body-Focused Repetitive Behaviors)

Mike Miller, PhD

6133 Rockside Rd. 
Suite 207
Independence, OH 44131

30400 Detroit Rd. 
Suite 301
Westlake, OH 44145

(216) 520 - 5969


BFRB Information

Body Focused Repetitive Behaviors (BFRBs) are a group of behaviors that include such things as hair pulling, skin picking, and nail biting that results in damage to the body.  These differ from normal behaviors like squeezing a pimple or plucking a few hairs from eyebrows, in that they are excessive.  People with BFRBs have unsuccessfully tried to stop and be able to control these behaviors.  Damage may include bald spots, missing eye brows and/or eye lashes, scars, and open wounds from picking or biting.  While some of these things may sound not sound very serious, many experience a deep shame about those behaviors, which often leads to becoming socially isolated and avoidant, and experiencing increased anxiety and depression.  For skin pickers, infections sometimes happen.  I recently met a recovering skin picker who lost leg tissue to MRSSA.  One situation that partially led me to get the training in working with BFRBs was a woman who at best was late for her appointments and sometimes didn't show up at all.  It was only later that I learned that before leaving her house, she would stand in front of a mirror and pick at her badly pock marked face.  This is an example of how a BFRB not only caused lasting physical scars, but also how it interfered with her being able to work and otherwise function.

While episodes of engaging in BFRBs are sometimes deliberately initiated, it is very common that sometimes,  the person automatically begins without awareness.  However after an episode begins, people sometimes "zone out" while engaging and totally lose track of time.

BFRBS most frequently begin as people are tweeners or enter early adolescence.  An unanswered question is what role, if any, do hormones play?  Younger children have roughly the same frequency between boys and girls.  In adults, there is a greater frequency of women than men with BFRBs.  That said, I have enjoyed facilitating a men's group at several of the National TLC Conferences.  Heredity seems to have some influence.  I've met a number of children with BFRBs whose mothers also had a history of BFRB (some still active).

Research studies estimate that at least 3 % of the population lives with a BFRB.  While people are aware of what they are doing, the majority are unaware that there are treatments for those behaviors that they cannot control.  The result is way too often increased isolation and shame.

Coexisting disorders such as anxiety disorders, depression, ADHD, and alcohol/drug abuse are very common, especially when someone has engaged in a BFRB for years or even decades.


Trichotillomania is compulsive hair pulling.  While most pull from their head, pulling may occur from any part of the body.  Most use their fingers, but some use tweezers, especially to pull out hair from their legs.  A minority chew and then swallow their hair, which is dangerous.  This is called trichophagia and can results in a trichobezoar, which is a mass of hair stuck in the digestive track, often resulting in the need for surgery.


Excorciation is also known as Skin Picking and Dermatillomania, where people compulsively pick at or dig into their skin, sometimes even ripping some of their skin off.  These behaviors are frequently preceded by feeling their arms, face, legs, etc. for bumps or perceived imperfections.  Some people sometimes use tweezers, needles, and other things to assist them.  Many spend an inordinate time in front of mirrors closely looking for such "imperfections."  As previously stated, picking can leave physical scars.


Onychophagia is excessive nail biting.  This is often past the nail bed, as well as chewing on the cuticles.  Bleeding, soreness, and infection can result from this.

What Causes BFRBs?

The causes of BFRBs are not fully understood, although heredity seems to play some part.  Diagnostically, they were once considered Obsessive Compulsive Disorder (OCD).  For a time, they were thought of as an Impulse Control Disorder.  In 2013 it was labeled as an Obsessive Compulsive Spectrum Disorder.  Comparing brain scans of neural pathways involved, the pathways of BFRBs are closest to those with OCD, but not identical.

Education and Support

Sadly, BFRBs have long been under studied.  Also, there are too few providers who have been trained to treat these conditions.  If you are unfamiliar with The TLC Foundation for Body-Focused Repetitive Behaviors (www.bfrb.org), now is a great time to check their website.  TLC is THE organization that has offered support to consumers and families, provided education, provided training to providers like myself, provided advocacy, and increasingly help fund scientific research on BFRBs.  If at all possible, I strongly encourage you to attend the National Conference in April.  In 2017 it will be held in St. Louis.  The founder of TLC, Christina Pearson said many times that you will likely "meet your best friend, that you never knew you had."  It is a VERY welcoming and affirming community.  TLC also sponsors one day presentations throughout the country every year which can either jump start your recovery or deepen it.  I was part of one presentation in Cleveland in October, 2015.  If nothing else, call their office (831-457-1004) for information.  I further encourage you to strongly consider becoming a member of TLC.

                                         Copyright   2016.   Michael Miller.   All rights reserved.