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For adults and parents
Skin picking and hair pulling (BFRBs)
Excoriation disorder and trichotillomania are not habits you should be able to stop by trying harder. They are body-focused repetitive behaviours, and they respond to a specific, practical treatment.
What BFRBs are
Body-focused repetitive behaviours are recurrent, self-directed actions that damage the body and that the person has repeatedly tried to stop. The two most common are excoriation disorder (skin picking) and trichotillomania (hair pulling). Nail biting, cheek biting and skin scratching sit in the same group.
Picking typically targets the face, scalp, chest, back, shoulders, cuticles and the sides of the fingers, and usually starts from something real: a spot, a scab, an ingrown hair. Pulling most often involves the scalp, eyelashes and eyebrows, and focuses on hairs that feel coarse, wiry or out of place. Some people bite the root afterwards.
Both commonly begin around puberty, both are more prevalent than the number seeking help suggests, and both are hidden with ingenuity: hats, parting changes, make-up, false lashes, long sleeves in summer, a shaved head presented as a style choice.
How this differs from an OCD compulsion
In OCD, a compulsion has a job. You wash to remove contamination, check to prevent a fire, repeat to stop a thought coming true. There is a feared consequence.
BFRBs have none. The pull is sensory and tension-based rather than fear-based, and often pleasurable in the moment. That is why exposure and response prevention, the mainstay of OCD treatment, is the wrong tool here, and why generic CBT for these behaviours goes nowhere.
Two modes, and why it matters
Most people do both, in different proportions, and treatment addresses each separately.
Automatic
This happens outside awareness. You are reading, driving, on a video call, scrolling in bed, and your hand goes up. You notice minutes later, sometimes only when you see what you have done. Here the battle is awareness and environment: catching it earlier, making it harder.
Focused
This is deliberate, and usually follows tension, boredom or a trigger: the bathroom mirror under bright light, tweezers within reach, a spot noticed in the car mirror. There is often a ritual, and a sense of needing to make the skin or hairline right. Here the work targets the urge and what precedes it.
What treatment involves
The treatment with the best evidence is habit reversal training, usually within a broader behavioural package. I have training in habit reversal and in CBIT, the comprehensive behavioural intervention these methods come from. It is practical rather than exploratory, and most of it happens between sessions.
Awareness training
We start by finding out what is happening: when, where, in what posture, in which rooms, at what time of day, in what mood. Most people arrive believing it happens “all the time” and discover within a fortnight that it clusters in three or four situations. You learn to spot the precursor, the hand travelling upwards, the fingertips scanning the scalp, the pause at the mirror, because the behaviour can only be stopped before it starts.
Stimulus control
Then we change the conditions. This is unglamorous and effective: removing tweezers and magnifying mirrors, changing bathroom lighting, tape on the fingers used most, gloves at the worst times of day, a hat or hair tie while working, a different chair, the phone out of reach in bed. The point is not restraint but friction, enough that the automatic version cannot run unnoticed.
Competing response
When the urge arrives, you do something with your hands that is physically incompatible with picking or pulling: making a fist, sitting on your hands, gripping an object, pressing your palms together. Hold it for about a minute, or until the urge falls. The behaviour does not occur, and you learn from experience that urges subside without being obeyed. Across hundreds of instances, that breaks the cycle.
Around those three we add work on what fuels the urges: stress, sleep, boredom, the emotional states that precede focused episodes. Where the picking is bound up with appearance concerns, there is overlap with body dysmorphic disorder, and the formulation must cover both.
Shame and concealment
Almost everyone I see with a BFRB has kept it private for years, often from partners and almost always from their GP. People describe feeling disgusting, weak or childish, and the concealment generates its own problems: swimming, hairdressers, wind and intimacy avoided, hours spent covering up.
This is a recognised condition with a specific treatment, and more common than the silence around it suggests. Nothing you describe will surprise me.
Teenagers and parents
These behaviours often start in adolescence, and parents usually notice the evidence before they hear about the behaviour: lashes gone, a thinning patch, scabbing along the jawline. Inspecting, commenting, pulling hands away and expressing distress about their appearance increase shame and concealment. The more useful stance is calm and matter-of-fact, and part of my work with families is coaching that. Where anxiety drives the urges, treating the anxiety is part of the plan rather than a separate project.
Working with me
I am a clinical psychologist and have worked in psychology since 2008. I trained at the University of Washington, completed my internship at Seattle Children’s Hospital and Harborview Medical Center, and a postdoctoral fellowship at the Evidence-Based Treatment Centers of Seattle, where I was Director of Training and Education and later Assistant Director of the Child Anxiety Center. I am board certified in Behavioral and Cognitive Psychology by the American Board of Professional Psychology, HCPC-registered, and chartered with the British Psychological Society.
I see adults, teenagers and children online across the UK and in person near Ravenshead, Nottingham and Mansfield, weekdays from 9am to 9pm. Video suits this work, because we can look at the actual bathroom, chair and lighting rather than a description. I do not prescribe, but work alongside GPs, dermatologists and psychiatrists. Fees are on the fees page, and the first step is a free 30-minute call.
Common questions
Is this the same as OCD?
No, although they are related and can occur together. In OCD the compulsion prevents a feared outcome or neutralises an intrusive thought: you wash because of contamination, you check because of harm. In skin picking and hair pulling there is usually no feared consequence. The behaviour is driven by urge, tension, the sensory pull of an irregularity, or nothing conscious at all. That matters, because the treatment is not exposure and response prevention. It is habit reversal.
What is habit reversal training?
A structured behavioural treatment with three components. Awareness training builds the ability to notice the behaviour early, including the moments before your hand moves. Stimulus control changes the environment so the behaviour is harder to start: lighting, mirrors, tweezers, where you sit, what your hands do while you watch television. Competing response training gives you something incompatible to do with your hands when the urge arrives, held until it passes. It is practical, practised daily, and it works on repetition.
Why can I not just stop?
Because willpower is not the mechanism the behaviour runs on. Much of the picking and pulling happens outside full awareness, while reading, driving, on a screen or in the bathroom mirror, and by the time you notice it has been going on for several minutes. The behaviour is also genuinely reinforcing: it relieves tension and provides a satisfying sensation. Telling someone to stop asks them to defeat both automaticity and reward with intention alone. Treatment changes the conditions instead.
My teenager has bald patches and will not discuss it. What can I do?
Concealment is part of the condition, not a sign that your child does not want help. Shame is the biggest obstacle and pressure increases it. What helps is taking the alarm out of the conversation, avoiding inspection and commentary about their appearance or their hands, and offering an appointment as something practical rather than a response to a crisis. Where a young person will not attend, parent-focused work can change how the household responds, which often reduces the concealment enough for them to engage later.
Should I see a dermatologist or a GP as well?
Yes, where there is skin damage, infection, significant scarring or hair loss that is not regrowing. Picking can cause wounds that need proper treatment, and some hair loss has medical causes worth excluding. Where an underlying skin condition such as acne or eczema provides the material to pick at, treating it makes the behavioural work considerably easier. I do not prescribe, but I am happy to work alongside your GP or dermatologist.
How long does treatment take?
A typical course is 8 to 16 sessions after the assessment, weekly at first and then spaced out as you take over the work. Progress is usually visible early, but these behaviours tend to return under stress, so much of the later work is relapse planning: knowing your high-risk situations and having the competing response ready before you need it. I would rather teach you to run the method yourself than keep you in therapy indefinitely.
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