Note: This writing was pre-written to keep things active on my blog. I’m still recovering from my surgery. Thank you for being here while I rest.
BFRBs: Stimming, Relief & What Real Recovery Looks Like
People enjoy talking about mental health when it is cute, tidy and marketable. There is an entire side that rarely gets spoken about because it does not look soft or pretty. Not everything is mindfulness, calm breathing apps or “you’ve got this” quotes. Some of us have nervous systems that learned to survive by repeating the same regulating action again and again because it calms things down for a few seconds even though it leaves marks, shame and a cycle that is hard to step out of. Those are body-focused repetitive behaviours (BFRBs) (Okumuş, 2022).
What Counts as a BFRB
BFRBs are repetitive, self-grooming-type behaviours such as hair pulling, skin picking, nail biting, lip or cheek biting, tongue chewing and similar behaviours that can cause tissue damage, emotional distress or interference with daily life (Okumuş, 2022). It is normal for people to groom themselves now and then. It becomes a problem when the behaviour starts happening very often, when it begins to injure the skin, hair, nails or mouth, and when the person has tried to stop more than once and simply cannot. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), trichotillomania (hair-pulling disorder) and excoriation (skin-picking disorder) are both officially listed and placed under the obsessive–compulsive and related disorders section (American Psychiatric Association, 2013). Nail biting, lip biting and cheek chewing are usually placed under “Other Specified Obsessive–Compulsive and Related Disorders” once they become clinically significant (Okumuş, 2022). This matches the guidance that came when DSM-5 moved these problems closer to OCD in federal reporting tools as well (Substance Abuse and Mental Health Services Administration, 2016).
When researchers actually looked at the prevalence, they found that BFRBs are not rare at all. A large population study reported that almost a quarter of people had at least one BFRB that left visible consequences. Nail biting was the most common, followed by skin biting, skin picking and lip or cheek biting which shows that many people do this even if they do not talk about it openly (Moritz, Scheunemann, Jelinek, Penney, Schmotz, Hoyer, Grudzień & Aleksandrowicz, 2024). The silence around it is not because it is unusual. It is because it is embarrassing.
Why BFRBs Happen
All of these behaviours move through roughly the same loop. There is an urge. The behaviour happens. There is a wave of relief. Afterwards comes shame, frustration or the familiar, “Why did I do that again?” Studies show that tension or negative affect rises just before the behaviour, drops during the behaviour and is then followed by guilt or self-criticism (Snorrason, Smári & Ólafsson, 2010). Seen this way, the body is not being “irrational”, however, it is regulating itself in the fastest and most accessible way it knows even if that way is not good for the person long term.
There are several ways to look at what is going on. Neurobiological perspectives point to difficulties with inhibiting movements, differences in cortico-striato-thalamo-cortical circuits and sensory processing differences (Okumuş, 2022). Behavioural perspectives describe habit loops where the brain starts to link a place, a time or a feeling with the behaviour. Mirrors, long study sessions, scrolling in bed, boredom, doing make-up or even good lighting can all become paired with picking, pulling or biting. Trauma tends to make everything more complicated. People with trauma histories often have both automatic BFRBs (the behaviour happens before they even notice) and focused BFRBs (the behaviour is used on purpose to calm down or to “repair” the body). Dissociation seems to help keep the loop going which is why trauma survivors can get pulled into these patterns quickly and find it hard to exit them (Okumuş, 2022). All of this means it is not just a “bad habit”. It is the nervous system regulating with the tools it currently has.
How BFRBs Look Day to Day
In daily life, BFRBs can look very small from the outside. Skin picking might be a quick “scan and snag” during a show or it might be twenty minutes in front of a mirror trying to fix a tiny bump. Hair pulling is often about removing hairs that feel “wrong” or have a different texture. Nail biting can begin with one rough edge that needs smoothing. Lip or cheek biting often begins when the mouth is dry or there is a part that feels uneven. Stress, tiredness, task-switching, sensory or cognitive overload and being alone with too much time are very common triggers. Environmental factors keep it going too, such as bright lighting that shows every pore, magnifying mirrors on the counter or leaving tweezers where they can be seen (Okumuş, 2022; Moritz, Scheunemann, Jelinek, Penney, Schmotz, Hoyer, Grudzień & Aleksandrowicz, 2024). The mix of internal tension plus easy access makes relapse almost inevitable.
Oral BFRBs
Oral BFRBs follow the exact same urge, behaviour and relief sequence, however, they come with extra risks. Lip biting, cheek chewing (morsicatio buccarum), tongue chewing and jaw clenching can cause ulcers, keratosis-like thickened white patches, infections and even worn-down teeth. There are case reports of dentists using soft mouthguards or cheek shields to protect the tissues while the person worked on the behaviour in therapy (Bhatia, Goyal, Kapur & Bansal, 2013; Rana, Srivastava, Kaushik & Panthri, 2016). These devices lower harm and give the mouth a chance to heal. They do not usually remove the urge which is why the behavioural work is still needed.
Treatments
Habit Reversal Training (HRT)
HRT is the approach with the strongest evidence base for BFRBs. It usually involves raising awareness of the behaviour, changing the environment so the behaviour is harder to do and training a competing response that physically blocks or interrupts the BFRB. Awareness training means learning exactly what you do which hand you use, where you are, what you were feeling and what triggered it. Stimulus control means making small environmental changes, like putting away mirrors, keeping nails smooth, or covering areas that are usually picked. Competing responses are movements that make it hard to do the BFRB, such as pressing palms together, holding a smooth object, keeping both hands busy with a fidget or gently holding the lips together if the behaviour is oral. Early work showed that HRT can help with chronic skin picking (Teng, Woods & Twohig, 2006). Later, a randomised controlled trial showed that HRT and related decoupling methods led to real reductions across several BFRBs and that many people kept their gains over time (Moritz, Penney, Bruhns & Jelinek, 2022).
Self-help & Decoupling
Not everyone has access to a psychologist who understands BFRBs. Due to this, researchers have tested self-help versions of HRT and decoupling. These self-guided programmes still produced medium-sized improvements compared with people who were just on a waitlist, which makes them a practical first step when in-person therapy is not available or is too costly (Moritz, Penney, Bruhns & Jelinek, 2022).
Harm Reduction & Safer Alternatives
Therapy is useful for the overall plan, however, daily life requires tools you can reach for immediately. Harm-reduction swaps work best when they are matched to the specific sensation your nervous system keeps chasing.
For skin picking:
Hydrocolloid patches can cover the area and still give the satisfaction of removing something later. Barrier creams or thick balms can smooth out the skin so nothing catches the eye or the fingers. Palm-to-palm pressure, stress balls and putty are good for people who like the pressure sensation. Cold resets like an ice cube wrapped in cloth can interrupt the urge. Textured rings, smooth stones and other sensory fidgets can keep the hands busy.
For hair pulling:
Weighted fidgets, spinner rings and putty can occupy the hands when watching TV or scrolling. Cotton gloves or finger covers can make it harder to grasp individual hairs. Braids, scarves or hats reduce access to the pulling spots. If there is also an oral component, chewable jewellery or chewy pencil toppers can be added. Decoupling techniques can help retrain the automatic movement and send the hand somewhere else.
For nail biting:
Chewable tubes, silicone jewellery and safe chew sticks give oral input without damage. Sugar-free gum or lozenges keep the mouth busy. Cuticle oils and nail balms can remove the roughness that often starts the whole cycle. Keeping nails short and smooth lowers temptation. Stress putty or fidget cubes can help with finger tension. Light mouth-awareness exercises such as gently pressing the lips together for a brief period, restore control.
For lip biting, cheek chewing and tongue chewing:
Medical-grade chew tubes or silicone chews provide the chewing sensation without hurting tissues. Soft mouthguards or cheek shields can protect the areas that keep getting injured (Bhatia, Goyal, Kapur & Bansal, 2013; Rana, Srivastava, Kaushik & Panthri, 2016). Sugar-free gum or chewy sweets can be used as replacements. Lip balms or gels remove dryness which is a common trigger. Cold water or ice chips can reset the mouth when the urge is strong. Jaw stretches and gentle massage can help when clenching is part of the pattern.
For skin biting (dermatophagia):
Chewable jewellery or silicone sticks offer resistance without harm. Fabric or leather tabs can give a similar “bite and pull” sensation. Bitter-tasting barrier creams can make biting less rewarding. Stress toys and tactile fidgets can redirect the hand-to-mouth pathway. Every single time the person gives the nervous system the right input in a safe way, the old loop gets slightly weaker and the new loop gets slightly stronger.
When to Get Extra Help
Harm reduction is good but it is not always enough. Extra support is important when the skin or mouth does not heal, when there is infection or scarring, when there is dental damage, when the behaviour is taking over time and relationships or when there are other things happening at the same time such as trauma, OCD, anxiety or dissociation. Psychologists who understand BFRBs can offer HRT or the Comprehensive Behavioral (ComB) model. Dermatologists and dentists can help protect the tissues and manage complications. The best outcomes tend to happen when behavioural therapy, harm-reduction strategies and medical or dental care are all combined (Okumuş, 2022; Moritz, Penney, Bruhns & Jelinek, 2022).
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Bhatia, S. K., Goyal, A., Kapur, A., & Bansal, M. (2013). Habitual biting of oral mucosa: A conservative treatment approach. Contemporary Clinical Dentistry, 4(3), 386–388. https://doi.org/10.4103/0976-237X.118379
Moritz, S., Penney, D., Bruhns, A., & Jelinek, L. (2022). Habit reversal training and variants of decoupling for use in body-focused repetitive behaviours: A randomised controlled trial. Cognitive Therapy and Research, 47(1), 1–14. https://doi.org/10.1007/s10608-022-10334-9
Moritz, S., Scheunemann, J., Jelinek, L., Penney, D., Schmotz, S., Hoyer, L., Grudzień, D., & Aleksandrowicz, A. (2024). Prevalence of body-focused repetitive behaviours in a diverse population sample: Rates across age, gender, race and education. Psychological Medicine, 54(8), 1552–1558. https://doi.org/10.1017/S0033291723003392
Okumuş, H. G. (2022). Body focused repetitive behaviour disorders. Archives of Neuropsychiatry, 59(Suppl. 1), S1–S6. https://doi.org/10.5152/npa.2022.21712
Rana, V., Srivastava, N., Kaushik, N., & Panthri, P. (2016). Cheek plumper: An innovative anti-cheek biting appliance. International Journal of Clinical Pediatric Dentistry, 9(2), 146–148. https://doi.org/10.5005/jp-journals-10005-1355
Substance Abuse and Mental Health Services Administration. (2016). Impact of the DSM-IV to DSM-5 changes on the National Survey on Drug Use and Health (Tables 3.27 & 3.28). Rockville, MD: Author.
Snorrason, I., Smári, J., & Ólafsson, R. P. (2010). Emotion regulation in pathological skin picking: Findings from a non-treatment-seeking sample. Journal of Behavior Therapy and Experimental Psychiatry, 41(3), 238–245. https://doi.org/10.1016/j.jbtep.2010.01.009
Teng, E. J., Woods, D. W., & Twohig, M. P. (2006). Habit reversal as a treatment for chronic skin picking: A pilot investigation. Behavior Modification, 30(4), 411–422. https://doi.org/10.1177/0145445504265707
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