Hair pulling & skin picking

Many people feel anxiety or tension before pulling or picking, and relief afterwards. The urge can feel intense, and the behaviour may even bring a moment of pleasure or satisfaction.

Some people are fully aware while they do it. Others only notice afterwards, when they see the hair or the mark. Both are common.

After the relief, embarrassment and frustration often follow. That painful mix can then become a trigger for the next urge.

BFRBs also include nail biting, nail picking, lip and cheek biting, and nose picking. Teeth grinding, joint cracking and finger sucking can sometimes be part of the picture too.

These aren’t separate diagnoses in the main psychiatric manual, but a provider can still recognise them as a BFRB when they cause damage, distress or get in the way of life.

The TLC Foundation for BFRBs is clear that BFRBs are not self-harm. Self-harm aims to injure the body to relieve or mask emotional pain. With BFRBs, people describe the behaviour as soothing, satisfying, or a way to make things feel smooth or even. Any damage is unintended.

Primary care providers, skin doctors or dentists often spot the signs first and may suggest seeing a mental health professional. A provider looks at whether the behaviour causes damage, whether you’ve tried to cut down, and how much it is affecting your life.

Picking can also be part of other conditions, such as skin or autoimmune conditions, body dysmorphic disorder, OCD, autism or psychosis. That’s why a full check matters.

Two ways

• Automatic pulling: it happens without much thought, like while reading, watching TV, driving or scrolling
• Focused pulling: a strong urge or tension builds, and pulling brings relief, or even pleasure, for a moment

Many people do both. Knowing which kind you do helps choose the right tools: reminders and barriers for automatic pulling, and ways to handle urges and feelings for focused pulling.

Common triggers

• A hair that feels coarse, kinked or “not right”
• Being alone, or in a certain spot like bed or the bathroom mirror
• Boredom or sitting still for a long time
• Low mood or low self-esteem
• Stress, worry or frustration

Thoughts, beliefs and values can play a part too. Emotions ranging from boredom to anxiety, frustration and low mood can all affect pulling.

Many people feel deep shame and hide it with hairstyles, hats, scarves, wigs or makeup. They may avoid swimming, haircuts, sleepovers, doctor visits or dating in case someone notices. Over time, this secrecy can lead to loneliness, worry and low mood.

Some people play with, chew or swallow hair after pulling it. Swallowed hair can form a hairball in the stomach or gut. This is rare but serious, and may need surgery.

Ideas from the NHS

• Deep breathing and exercise
• Keeping your hair short for a while
• Making a fist and tightening your arm muscles until the urge passes
• Putting plasters on your fingertips, or wearing a beanie or bandana
• Squeezing a stress ball or using a fidget toy
• Taking a soothing bath
• Telling people you trust

Common triggers

• A bump, blemish or rough patch you can see or feel
• An urge or physical tension that builds up first
• Beliefs about how skin should look or feel, or “just this one” thoughts
• Guilt, shame or other hard feelings
• Skin conditions such as acne or eczema
• Stress, worry or boredom

People may pick without realising, using fingers, nails, teeth or tools like tweezers or pins.

Picking can lead to cuts, bleeding, bruises, open wounds and infections. Over time it can leave discoloured skin and scars.

Shame and embarrassment are very common. Many people cover their skin with makeup or clothing and avoid pools, gyms, beaches or medical care. Covering up can take a lot of time, and picking itself can eat into the day.

This hiding can lead to isolation and worry, and raises the chance of anxiety or low mood. Relationships with family and friends can feel strained too.

Ideas from the NHS

• Asking trusted people to gently let you know when you’re picking
• Keeping hands busy: a soft ball, fidget toy or gloves
• Keeping nails short and skin clean
• Keeping tweezers and pins out of easy reach
• Noticing when and where you usually pick, and changing that setting
• Putting moisturiser on when the urge comes
• Resisting the urge a little longer each time

Close family members of people who pull or pick have higher rates of BFRBs than expected. Brain areas linked to reward and emotion may play a part.

About 17–18% of people with a BFRB have a family member with OCD, which is higher than in the general population.

BFRBs may help manage feelings like discomfort, embarrassment, boredom or unhappiness. Most people pull or pick more when stressed, but anxiety isn’t the only cause.

Pulling or picking can act as a distraction when a person feels under-stimulated, like sitting in a long lecture, or over-stimulated, like at the end of a busy day.

Each time pulling or picking brings relief, the brain learns to reach for it again. Over time it can become a habit that is hard to break, even when the original trigger has gone.

Linked with higher risk

• A family history of BFRBs
• Being female (in adults)
• Low self-esteem
• OCD
• Past abuse or trauma
• Substance use problems

The TLC Foundation stresses that BFRBs are not caused by trauma. Many people with BFRBs have no trauma history.

BFRBs are complex habits linked to triggers, feelings and sensations. People have usually tried many times to stop. Improvement takes time and practice, often several months, with the right tools.

BFRBs are often soothing or satisfying, or about making things feel smooth or even. Self-harm aims to injure the body to cope with emotional pain. They are different, and need different kinds of help.

More women report hair pulling, but men may simply be less likely to report it. In childhood, hair pulling starts in boys and girls about equally.

Bad parenting does not cause BFRBs, and most parents of children with BFRBs are loving and supportive. BFRBs come from a mix of brain, genetic and environmental factors.

Stress is a common trigger, but boredom, frustration, the feel of a hair or bump, thoughts and simple habit all matter too. Good help looks at your own mix.

People with BFRBs are often very distressed by the damage. The behaviour isn’t about vanity, even when it’s aimed at a “flaw” like a bump or an uneven hair.

The International OCD Foundation reports that about 22–29% of people with hair pulling and 10–15% of people with skin picking also have OCD. And 10–30% of people with OCD have a BFRB.

Anxiety and depression often come with hair pulling and skin picking. The isolation and shame can feed low mood, and low mood can make urges stronger.

Skin picking is linked to body dysmorphic disorder, where a person gets stuck on a flaw in their appearance that others barely notice. If that sounds familiar, mention it to your provider, because the help is a little different.

Habit reversal training is a type of CBT that helps you notice when and why you pull or pick, and swap in a harmless action instead.

How habit reversal training works

1. Awareness: keep a diary of when, where and how you pull or pick, and what you were feeling
2. Spot your triggers: certain places, times, moods or sensations
3. Competing response: when the urge comes, do something with your hands that makes pulling or picking impossible, like making a fist or squeezing a ball
4. Support: let a trusted person cheer you on and gently point out when it’s happening

The Comprehensive Behavioural (ComB) approach builds on HRT. It looks at five areas that keep the behaviour going, and creates a plan that fits you.

The five ComB areas, with examples

• Feelings: calm breathing, relaxation and skills for boredom, worry or frustration
• Movement: noticing hand-to-face habits, and keeping hands busy (like both hands on the steering wheel)
• Place: changing the setting, like studying in a shared room or putting tweezers away
• Sensory: fidget toys or textured objects to give your fingers the feeling they’re looking for; soothing lotion for skin
• Thoughts: noticing beliefs like “this bump has to go” and talking back to them kindly

Acceptance and commitment therapy (ACT) and dialectical behaviour therapy (DBT) can also help with the urges and feelings behind pulling and picking.

ACT helps you notice an urge without obeying it, and keep moving toward what matters. DBT teaches skills for getting through intense moments.

Because BFRBs are less well known, it helps to find a therapist who has treated them before. The TLC Foundation and the International OCD Foundation both have directories of providers who treat BFRBs.

Questions you could ask

• Do you use habit reversal or the ComB approach?
• How do we track progress?
• How many sessions might I need?
• How often have you worked with hair pulling or skin picking?

Improvement usually takes time and practice, often several months. Symptoms are managed over time rather than stopped overnight, so it helps to keep up your plan even after you feel better.

Slip-ups are a normal part of the journey. Each one is information about a trigger you can plan for next time.

You might notice

• Hair on the floor, pillows or desk
• Hands often near the head or face
• Hats or other coverings to hide bald spots
• Low self-esteem, or shame about how they look
• Lots of mirror checking
• Sores, scabs or bitten nails that don’t get a chance to heal
• Sudden heavy hair loss, or uneven, one-sided patches

Some children pull while zoning out, like watching TV. Others know they’re doing it, say it feels good or relieving, and wait until they are alone.

If your child pulls out or eats hair, see your child’s doctor. They will usually check for scalp infections or other medical reasons for hair loss first, then may suggest a therapist.

CBT is the usual treatment. It helps children notice the feelings and situations that trigger pulling, then teaches skills to stop or replace it.

Ideas therapists may suggest

• Carrying a small object, like an eraser or a smooth stone, to fiddle with instead
• Making pulling harder, like plasters on the fingers
• Simple awareness tricks, like tying hair back or wearing a jangly bracelet
• Working on the stress and hard feelings that set it off

What helps

• Agree together on a gentle, private cue, instead of pointing it out in front of others
• Learn about BFRBs, so you can see it as a habit to work on, not naughtiness
• Praise effort and small wins
• Talk about the feelings and moments behind it

What to avoid

• Asking “Why are you doing that?”
• Commenting on bald patches, scabs or nails
• Punishing or shaming
• Watching them all the time

Do

• Encourage professional help, like CBT or habit reversal, and offer to help find a therapist
• Learn about BFRBs: they are not a lack of willpower
• Listen without trying to fix, and validate their feelings first
• Respect boundaries: let them decide how much to share

Slip-ups are common in long-term recovery. Patience over months matters more than any one day.

Don’t

• Ask “Why are you doing that?”, which can increase shame
• Call it “just a little habit”: that can leave them feeling more helpless
• Comment on their skin, hair or nails, which can feel like shaming
• Monitor them closely: it can feel invasive and raise anxiety

The TLC Foundation for BFRBs works to end the isolation and shame around hair pulling, skin picking, nail biting and cheek biting. It runs online support groups on Zoom for adults (18+), for teens aged 13–18, and for parents of children with BFRBs, plus a Spanish-language group.

You register for each session you want to join. TLC also lists peer-led groups and therapists with BFRB experience.

The International OCD Foundation lists support and treatment groups for skin picking and hair pulling in its Resource Directory, and hosts an online BFRB community.

Support groups are not a replacement for therapy, but they can lead to it, add to it, and help prevent setbacks.

BFRBs can strain relationships, and family members may need professional help to cope too. Looking after yourself makes it easier to stay calm and kind.