Effective BFRB Treatment
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 Treatment

There are no medications that have proven to be helpful, although some medications have been helpful to some people.  It is felt that when medications are helpful, it is because they are effectively treating a co-occurring condition.  However, there are two over the counter supplements that have research that have been proven to be very helpful for many.  Habit Reversal (HR) is a behavioral technique that was developed by Nathan Azrin, PhD in the 1979s and is a component of almost all of the cognitive-behavioral treatment approaches.

Cognitive Behavioral Therapy (CBT)

CBT is the approach that has been studied and shown to be effective in treating BFRBs.  An important part of CBT is an assessment of the function(s) of the BFRB.  Probably the two most common functions are dealing with stress and boredom.  Fred Penzel, PhD, one of the pioneers in understanding and treating BFRBs theorizes that when someone is overly stimulated, that the BFRB brings down that level and when they are under stimulated, the BFRB brings that level up. 

A very helpful intervention is to track the unwanted behaviors.  How long were they performed?  Where did they occur?  Was there a discernable trigger?  Sometimes just keeping track can decrease the behavior (less likely if a parent or someone else is doing the recording), as well as provide important information for treatment, as well as having a better idea of how well interventions are working.  Perhaps more importantly, tracking can help people become more aware of their behaviors and the factors involved.

Habit Reversal Training (HRT) is a technique used when you have an urge or when you find yourself pulling, picking, etc.  It involves:  Self-Awareness Training (monitoring);  Relaxation training (diaphragmatic breathing); and Competing Response.  Competing response is when you stop and do something with your hands that prevents you from engaging in the BFRB.  This may be holding your hands down in a fist, folding your hands, sitting on your hands, or something else for about one minute, away from the site of the BFRB.

A frequently used strategy, especially with kids, is to use fiddlers or fidgets.  These are small toys like stress balls and other things that keep your hands busy.  When hands are busy, those hands are unable to pull or pick.  It's good to have a supply in different places where one most often engages in the BFRB.  For kids, it can be very helpful to keep a small bag with fiddlers in the car.  A place to see a variety of fiddlers is at  http://store.trich.org/category_s/44.htm.

Charles Mansueto, PhD, another pioneer in understanding and working with people with BFRBs has added the tool of SCAMP.  This stands for Sensory, Cognitive, Affective, Motor, and Place.  These are different domains to help understand how the sensory feelings, thoughts, feelings, issues with the body, and place are involved before, during, and after the person doing the BFRB.  When the functions and specifics of the behavior are better understood, then interventions are more likely to be tailored for that individual.  An example of one woman's recovery from skin picking shows how these ideas were employed are shown at  http://bit.ly/2auMDSi.

The ongoing assessment also includes paying attention to where one engages in the BFRB.  Most do so in relative to total privacy.  The bathroom is a frequent place.  When one tends to engage in one place, then the strategy is to limit their time there, when possible.  This is referred to as Stimulus Control (SC).  When one has to be in that situation, it is critical that there be strategies developed to hopefully prevent engaging in the BFRB.

Another frequently used strategy are blocking techniques, which creates a barrier to pulling or picking.  This might be wearing hats or something else on the head, including wigs.  It also includes wearing gloves or putting something else on the fingers, such as office finger tips or band-aids or wearing long pants or leggings to protect the legs and/or long sleeves to protect the arms.

In addition to the specific techniques mentioned, people with BFRBs are first and foremost people and experience the same challenges that people without BFRBs experience.  They may have relationship issues, grown up in alcoholic homes, have ADHD, experienced trauma, have an anxiety or depressive disorder, etc.  In other words, while a person may present for treatment of a BFRB, frequently other issues are dealt with while the BFRBs are being addressed.


As previously stated, no medication has been proven to be helpful for many, although some are helpful for some.  Most widely prescribed are the SRRI's like Prozac and Zoloft.  If you have anxiety or depression in addition to the BFRB, such a medication may help with that condition.

In 2009, Jon Grant, MD published a study that showed that over half of the adult hair pullers found the over the counter supplement, N-Acetyl Cysteine (NAC) to be very helpful.  Unfortunately, a study with children and teens failed to prove it to be helpful.  A study by Dr. Grant published in 2016 also showed that NAC is also helpful in adult pickers.  Fred Penzel, PhD has this information on NAC http://bit.ly/2bcCLy2   Most adult pullers and pickers that I have worked with have found it to be helpful, even at a lesser dose than was studied.  Dr. Grant (personal communication) has said that he often has adults go up to 1800 mg twice a day.

Fred Penzel, PhD has been using a different over the counter supplement, Inositol for both BFRBs, as well as OCD for many years.  Dr. Grant has recently studied the effects of Inositol in treating adult hair pullers.  While the results are yet to be published. Dr. Penzel (personal communication) has told me that the study showed that it was helpful in decreasing hair pulling.  Dr. Penzel has this information on Inositol  http://bit.ly/2aEnohY.  He has also told me that he tends to favor Inositol over NAC, one reason that it can also be used with young people (no studies yet).

It should also be noted that the stimulant medications for ADHD, like Ritalin and Adderall often
make a BFRB worse.  If you are in this situation, consider speaking to your prescriber, possibly about trying a non-stimulant medication for ADHD.


Annette Pasternak, PhD in her Great book Skin Picking, point out that sometimes when food allergies are discovered and those foods are avoided, that the person often gets better quickly.  She also suggests trying to get off of wheat, dairy, and especially sugar (NOT at the same time). She strongly feels that when people stop sugar, they often are able to stop their BFRB.

The most important take away is that while more effective treatments are necessary, RECOVERY IS POSSIBLE!!!

                                                     Copyright   2016.   Michael Miller.   All rights reserved.