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Hair Pulling! Skin Picking! Nail Biting! Oh, My!

Body-focused repetitive behaviors upset and mystify many of us. Here, learn about causes, the ADHD-link, and treatment options.

Most of us know that depression, anxiety, and oppositional defiant disorder frequently come along with a diagnosis of ADHD. Not many realize that something called body-focused repetitive behaviors (BFRBs) do as well. Jane^ is concerned about her son Kevin, who pulls his hair while watching television and plucks out his eyelashes in the bathroom. Serena, a 40-year-old mother with ADHD, has a shameful secret. She picks at her skin nightly, often to the point of bleeding. When Matthew has trouble focusing, he bites his nails and chews on them.

BFRBs are related to self-grooming, anxiety management, or sensory stimulation. The most common BFRBs are trichotillomania (hair pulling), dermatillomania (skin picking), onychophagia (nail biting), dermatophagia (skin biting), rhinotillexomania (nose picking), as well as cheek biting and joint cracking. These behaviors tend to be chronic, and those who have them report feeling pleasure and/or pain from these habits. Although many people with BFRBs want to stop these behaviors, they are compelled to perform the behavior. Many sufferers are not aware of them.

Causes of BFRBs

These repetitive behaviors often begin with a desire to remove an unwanted stimulus. After checking himself in the mirror, Franco wants to rid himself of the blackheads on his face. Juliet is bothered by the asymmetry in her fingernails, while 10-year-old Alan cannot leave the scab on his knee alone. Clients report stroking their hair before pulling it, or feeling the contours of a pimple before squeezing it. Marci pulls at the hair on a certain spot on her head, and then rolls it between her thumb and index finger. Ricky likes to chew the nail he has just bitten off.

People with BFRBs spend minutes or hours doing these behaviors. Sufferers often do physical damage to their body -- leading to bald spots, skin scarring, blood loss, acne, damaged nails, and cuts in the mouth (from chewing on nails or cheek chewing). Gastrointestinal problems develop in hair pullers or nail biters who eat the hair or nails. These physical consequences bring more self-disgust and frustration, which leads to social isolation and depression. One patient reported, "I feel like a freak. I feel alone, as if I have a dirty little secret."

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