Body-focused repetitive behaviors like trichotillomania or chronic hair pulling, as well as skin picking, nail biting and others, may affect up to one in 20 people. Yet, despite how common they are, BFRBs, as they're called, remain stigmatized, misunderstood, and underdiagnosed. Today we're going to talk with two experts about why that is and about how our understanding of BFRBs has evolved in recent years. So what are body-focused repetitive behaviors? How do they differ from ordinary habits? When and why do they start and why are they so hard to stop? How does living with trichotillomania or another BFRB affect people's lives and their mental health? What kinds of treatments and therapies can help? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills. We have two guests today. First is Dr. Suzanne Mutan Odom, a clinical assistant professor of psychology at the Baylor College of Medicine, and the founder and director of Psychology Houston, the Center for Cognitive Behavioral Treatment. She specializes in treating people with body-focused repetitive behaviors, as well as obsessive-compulsive disorder, tick disorders, and other anxiety disorders. Dr. Mutan Odom is co-chair of the board of directors and the scientific advisory board of the TLC Foundation for Body-Focused Repetitive Behaviors. She has published many scientific journal articles and has co-authored six books, including A Parent Guide to Hair Pulling Disorder and the BFRB Survival Guide, a workbook for overcoming body-focused repetitive behaviors. Our second guest is Dr. Claire McKay, a professor of neuroscience at Oxford University in the UK, where she heads the translational neuroimaging group. Most of Dr. McKay's research focuses on using neuroimaging to understand risk for diseases such as Parkinson's and Alzheimer's. In recent years, she's begun studying the neuroscience of body-focused repetitive behaviors, works spurred by her own experience dealing with trichotillomania since childhood. She's author of the forthcoming book, Keep Your Hair On, Understanding Urges to Pick, Pull, or Bite, which will be published in April, 2026. Dr. Mutan Odom, Dr. McKay, thank you both for joining me today. Thank you for having us. Thank you so much. Let's start by explaining in a little more detail body-focused repetitive behaviors. What exactly are they? How many different types are they? What is the term, encompass? That's a great question. The diagnostic and statistical manual of mental disorders describes BFRBs as hair-pulling or skin-picking. As you pointed out, trichotillomania is the technical word for hair-pulling disorder. Exchoreation disorder is the technical term for skin-picking disorder. Hair-pulling disorder can encompass any hair on the body. Eyelashes, eyebrows, pubic hair, arm hair, facial hair, leg hair, any hair. Most commonly, it's scalp, eyelashes, and eyebrows. Really, it's that you've tried to stop and you're not able to stop, and it causes some problem for you in your life. It's a pretty general definition. We used to have some other qualifications or criteria that were needing to be met. In the latest iteration, that's pretty much it. It's not accounted for by, say, allopecia or some dermatological disorder. Skin-picking disorder is pretty much the same. It involves repetitive picking of one's skin to the point where it causes a problem, and a person feels like they're not able to stop. Again, it's not accounted for by a dermatological condition or some other psychiatric diagnosis. How do these behaviors differ from what we might just consider a bad habit, like nail biting? Dr. McKay, what are your thoughts on that? Well, I don't think they're different at all from nail biting. Nail biting is another type of body-focused repetitive behavior, and it's actually the one that's kind of most socially acceptable. So, the way that I think about BFRB is that they are all of the picking and pulling and biting of hair and skin and nails. And of course, we all do these things a bit because they are normal grooming behaviors. And as Suzanne said, it's only hair-pulling and skin-picking that have made it into the DSM. But really, anybody who has BFRBs that cause them significant amounts of distress and are impacting the way that people can live their normal lives are in the same category as far as I understand it. The behaviors are not really different. I bite my nails too. I pull my hair and I bite my nails, and as far as I'm concerned, they're the same. Yeah. Is there any relationship to cutting? So, that's a great question, and it comes up a lot. You know, intentional harm to one's body. I guess one could think about these because on the surface, they kind of look like there might be self-damaging, self-harming behaviors. But really, it's quite different. We see the function of BFRB as more self-regulation, self-soothing, or serving some sort of a function to the person, the function not being self-harm. People oftentimes are even trying to fix a problem or to improve a situation by removing all of a certain type of hair or removing a bump. And so, the function is quite different than in a self-mutilation or self-harming type behavior. So, we treat them very differently and we think about them very differently. I talked in my intro about prevalence, but what does the research say about how common BFRBs are? Do we have good numbers? We don't have great numbers. We have some numbers. But unfortunately, because of the stigma around BFRBs, in many cases, the question doesn't get asked. In standard sort of screening instruments for mental health problems, the question, do you sometimes pick or pull or bite at your hair, skin, and nails? It doesn't tend to exist. So, we don't have kind of large-scale epidemiological evidence. So, the best we've got is some relatively small-scale studies and often these sorts of studies are carried out in school populations or college populations. But nevertheless, the best evidence suggests that about 5% or 1 in 20 people struggle with problematic levels of picking and pulling and biting. But the numbers of people who actually engage in the behavior at all, nail-biting, hair-pulling, skin-picking at a level that isn't problematic, is much higher. It's probably maybe half of us or maybe even all of us to a certain extent. Sure. Well, Dr. Maka, you've lived with trichotillomania since childhood, but you only began studying it and speaking about it a few years ago. Can you tell us about your experience and why you decided to start talking about it now? Yeah, thank you. The experience of living with a body-focused repetitive behavior for me was one of hiding. And the biggest problem that I experienced for 40 years of living with hair-pulling disorder was the amount of shame that I carried around about these behaviors. Unfortunately, because they're so little understood and so stigmatized, the general understanding of these behaviors is that we should be able to control them and we're just told to stop it. And that's by our families and our loved ones, but also by our doctors and the people who are there to care for us. And so when nobody has any good understanding or knowledge of these behaviors and you can't control it, unfortunately, that can set up a kind of chronic shame spiral where you just think that you're fundamentally flawed. And even though I was on the surface a successful person, I managed to do some good science around all sorts of different diseases and disorders, but it literally didn't cross my mind that I could apply some of this knowledge to the disorder that I'd been carrying around all my life because shame has such a powerful dampening effect on the way that we think. And so I got to, you know, menopause and the age of 50 were joyfully the great news is that you stop caring as much about what other people think of you. And it started to emerge for me that I could put these 30 years of neuroscience and 40 years of this disorder together and maybe do something useful with that. BFRBs used to be classified as impulse control disorders, but they're now grouped under obsessive compulsive disorders in the DSM, the diagnostic and statistical manual used by psychologists and physicians. So are these behaviors a form of OCD? How do they differ from and overlap with other disorders? I mean, are they related to things like Tourette's syndrome, for example? Sure. Great question. You know, it's tough because I wish we could have a separate category for BFRBs. It would be so nice. And we really advocated for that in the last iteration of the DSM. And unfortunately, that didn't happen. It really didn't fit in impulse control disorders. For some people it does. For some people it feels quite impulsive, but it didn't really fit with some of the other disorders that are listed in there. It doesn't 100% fit with OCD, although it is a repetitive behavior that is unwanted. They're very different. They're more like distant cousins, I think. But a lot of people assume they have OCD when they have a BFRB. And so we have to explain that they are quite different. So other than the fact that they are repetitive unwanted behaviors, and then this kind of ends the similarities, OCD people engage in repetitive behaviors because they feel like something bad will happen if they don't. This is very different from a BFRB where people... The FRBs are really more egocentonic, which means that someone wants to engage in them. I liken it more to if you have a love of chocolate. Chocolate is really good until you have too much. So it's more of an egocentonic, it's something that people want to do, whereas hand washing is something people hate doing, but they feel compelled to do it. The medications for OCD do not across the board work for BFRBs, so that's a big difference. And then another difference is the treatments. There's some overlap, but there's also some real big differences. And what we don't want is for people to feel like medication doesn't work and treatment doesn't work. And maybe I could just add that as somebody who sort of come into the field relatively recently and lived with these behaviors my whole life, what I observe is that BFRBs often get swept under the carpet of other disorders. So we've talked about OCD, we also talked a little bit about self harm, and I regularly get asked about the relationship with those two, but there also assumed to be a symptom of anxiety. And these days more and more there seem to be a symptom of neurodivergent conditions. So they seem to be more prevalent in ADHD and in autism and they're thought of differently in those disorders. So what I observe is that these behaviors, which I think of as being a kind of motor symptom of distress quite broadly defined, get swept under the carpet of other disorders that people happen to know a bit more about. And it's kind of part of the stigma that we need to reduce by thinking of them as quite distinct really from these other things so that we can find the ways to help people manage most effectively. Do BFRBs run in families? Is there, do we know whether there's any kind of a genetic component here? We have looked at twin studies and we do see that there is a higher concordance rate among twins. And we do see a higher concordance rate in families of people with BFRBs. Now, if a mother pulls her hair, it doesn't mean the child is necessarily more likely to pull hair. They might bite their nails or pick their bites or excreate their acne. But we do see that BFRBs tend to run in families. But we don't have clinical data. We have some genetics data, but not enough. You need hundreds of thousands of people in a genetic database in order to make, to really understand from an empirical standpoint, yes, there is a genetic marker that will predict this. But we do see it run in families quite often. Do we know what's happening in the brains of people when they're engaging in BFRBs? Well, there's all sorts of things happening in the brain of people while they're engaging in BFRBs. The way that I like to think about these behaviors from kind of first principles is that these are normal grooming behaviors. So grooming is a normal function of being a primate. Grooming evolved as a way to take care of our body surface. It's a way to keep ourselves clean and free of parasites, etc. But in many animals, these grooming type behaviors over hundreds of thousands of years of evolution acquired additional functions. And the interesting thing about primates, and of course we are primates, is that the additional function that these grooming behaviors seem to have taken on is emotion regulation. So we are more likely to touch our faces or twirl our hair or do all sorts of body-focused repetitive things when we are trying to either calm our nerves down from being in a state of over arousal, like being anxious but also being over excited. So any kind of state of over arousal increases urges to pick and pull and bite to sort of calm ourselves down. But we can also find ourselves experiencing urges when we're under stimulated. So often people with BFRBs talk about doing it when they're bored, they're not doing anything else. They're certainly not feeling particularly anxious, but it's a way of kind of giving our body some input when we're feeling under stimulated. So this sort of emotion regulation function is something that primates acquired and of course we're no different. We tend to think that we're not looking for an area of brain that's kind of gone wrong. We're needing to understand multiple systems in the brain and how they interact with each other that gives rise to these behaviors. And I think that that's, as I say, there's actually a lot known about this in the animal literature, that we haven't quite translated over into our understanding of these behaviors in humans. We're going to take a short break. When we return, we'll talk about treatments for trichotillomania and other BFRBs. Well, let's talk about treatment because I know that there are some ways of helping people who have BFRBs. So Dr. Mutin Odom, when someone comes to you for treatment, where do you start? So great question. I think it's important to think about these behaviors as very complex. And so when we approach a person, we have to think about that we can't make any assumptions just because they're pulling hair or picking skin. We don't want to assume anything. So really looking at their internal world, how they regulate their emotional system. How is their distress tolerance? How impulsive are they? Are they reward seeking? Are they more driven by positive reinforcement or negative reinforcement? Which means are they seeking a reward? Are they kind of going away from a negative? Are they perfectionistic? Are they trying to get this eyebrow to match that eyebrow? Which sometimes the cognitive has a little more of an obsessional feel to it. So we want to understand their beliefs and their assumptions and their goals. Sometimes there are goals I feel very efficient and goal directed in my behavior. And I want to achieve a certain outcome. And so we want to look at cognitive and we also want to look at the sensory system and how much is this person regulated or attempting to regulate their sensory nervous system. And so we also want to look at external things. Where is it happening? When is it happening? Are there things in the environment or in that person's external world that would make the behavior more likely to happen in a given moment? For example, if I go into the restroom but it's in the morning and the lights are low, I may be able to get in, brush my teeth, get out. But in the evening when the lights are brighter, I've had a long day. I'm emotionally dysregulated or I'm sensory overwhelmed. No one's around. I have more time. And there's a variety of external factors that also play in. So a good approach is to ask a lot of questions about what in this person's internal and external world make that behavior more or less likely to happen. And then we start to build a treatment plan based on that. It's also not about making urges disappear. If I could take away a person's urges, I would be a rich woman. But so far we don't have anything that will do that. So it's about how are we going to manage urges when they come. And not even everyone experiences urges. But whatever the precipitating environment events, internal events, external events are that make this behavior more likely to happen. When those things are at play, how am I going to manage that? We spend a lot of time in the beginning as Claire talked so brilliantly about is really undoing shame. So educating a person, helping them realize these are not strange, weird, odd behaviors. These are human behaviors. And starting that process of undoing shame, which is a constant process. It's not just a session. It is throughout the entire treatment process. And sometimes involves helping them connect with other people, which is such an important piece of treatment, is to know I am not alone. Other really amazing people engage in this behavior. That's why Claire's work is so important. Here is a very accomplished, highly intelligent, beautiful human being. And she pulls out her hair. And so what's the shame in that? So it's a process. It's a journey. We're on it together. It's collaborative. And it's sort of, I use diet and exercise a lot to as an example with the FRBs because we all have been at the point where we wanted to change our habits. We wanted to lose weight. Say I want to get healthier when I stop eating junk food, but we still do it, you know, and I can buy the tennis shoes and I can buy all the outfits. I can even join the gym, but it doesn't mean I'm going to go. It doesn't mean I'm going to engage. And so really it's about helping a person engage in the process and be ready to make those changes. And that's why we do so much training with professionals because if they don't understand that and they read an article about how to do treatment and they go in and use this and do this, it will fail. And then, you know, patients are frustrated, therapists are frustrated. Everybody walks away and says treatment doesn't work. And that is not true. Treatment does work if it's done right. Well, Dr. McKay, let me ask you, what do you do to keep your hair pulling at bay? I mean, do you have techniques? Are there triggers you try to avoid? Have you undergone therapy? How have you managed? I have. I have. I've had, when I was younger, when I was in my 30s, I had therapy which was much more behavioral. So some of those elements that Suzanne described so thinking about the situation and the awareness, etc. But it was kind of missing the thing that I now know was critical for me, which was compassion. So living with chronic shame, I should first say that I didn't even really know the extent of the shame that I was living in because it was just normal for me. And so it took a bit of therapy and that preparation work that Suzanne's talking about to get to the point where I even realized that actually the biggest problem I lived with is not pulling at my hair. It's the shame that I'm carrying around. And the antidote to shame, the thing that really works for me is compassion. Now, compassion is a word that sounds kind of fluffy and gentle and easy. We use it in common parlance. It's actually a really important skill that you need to learn and you need to practice in order to be good at it. And so learning compassion, learning self compassion is a process. I'm still in it. But for me, what that means is, is using my brain using my neuroscience brain. So the, I've just spent the last two years really trying to understand living with urges to pick and pull and bite from a number of different angles that I've gone into areas of science. I knew nothing about before and I'm learning all the time. For me, that's what compassion is. It's kind of, it's throwing away those awful, I call them dementors of shame that are swirling around your head. Otherwise, you're stupid, you're weak, you're ugly, you've got no self control, you've got no willpower. These are things that people with BFRB say to themselves all the time and learning how to dial those down so that you can ask yourself, hmm, well, I wonder why my urges are particularly tricky today and asking in a much more gentle, curious, compassionate way rather than a, oh God, I'm so stupid, I've done it again, etc. So compassion is absolutely the top of the list of things for me that made the difference. I want to ask about the influence of social media. You know, that's had an impact on a lot of disorders that people have. Is that helping or harming people with BFRBs? Do you have any opinion around that? I don't think there's any research to say one way or the other. I think we all know that social media is doing a lot of harm, especially to young women and their sense of self and their confidence. But I also imagine a lot of good. I know there's quite a few influencers and people who are utilizing social media in a positive way to establish community, to be a leader in this space where people feel alone, people feel ashamed. And as somebody who lives with the BFRB, I can tell you that as I started to think that maybe I could come out about my BFRB, social media was the first place I could come out. The first place I could take my baby steps. And actually, it's kind of now old tech, but nevertheless, Facebook support groups are fantastic for this sort of thing because you can be anonymous. You can find your community. You can find community to people who know exactly what you're going through and you can share tints and tips and things that you found. And actually, they are enormously helpful when you're, you know, when you're still not feeling able to say anything out loud to the real people in your lives. You can actually start to find community online and start to get that de-shaming process underway by just being part of a community. Yeah, so I would say that exactly as Suzanne said, it's a bit of both, but for those of us who are wanting to reach out and find people, there isn't really a safer way to do it than through the internet. Of course, I'm old enough that when I was started to struggle with my hair pulling problems, there was nowhere for me, all my parents to go for any information. It was before Trichotillomania was in the DSM. There was no Google. There was no internet. And so you are completely alone with that. So I guess coming from that generation, I see huge benefits of being able to find other people through the internet. That's so true. The only caution I would have, because I imagine there are many parents as your listeners, and oftentimes the people who post online and on Reddit and on these forums are people who are very frustrated and angry. And so I would encourage parents to go to reliable sources to get their information, because a lot of times people will come in and they will have very, very wrong information that they got on the internet. So that's just a caution to parents to be very careful where they're reading their information. So speaking of those parents who may be listening, I mean, if somebody thinks that their child is experiencing some kind of a BFRB, what should they do? Where should they go? Well, there are a lot of resources out there, the TLC Foundation for BFRBs being one of them. There are some other BFRB change makers. There are other nonprofit groups out there, the International OCD Foundation. The BFRB UK Ireland has a group that's representing Europe. Claire is very involved in Oxford and with that group. So there are communities in the world and they're growing. We're finding communities in Mexico and other parts of Europe and Asia and Canada. So I think getting good information and then possibly attending an event, whether it's an online group or an in-person event is really helpful. But it's so important to get good information from the beginning. And parents, I will have to say, need as much support as the kiddos and sometimes more. Depending on the age of the child, they might not really care at this point yet, but how they are treated by their parents matters a lot. And so how parents respond is critical to the shame, the development of identity, self-esteem, confidence. And I always tell parents, you know, what we want to do is what is best for your child in the long run. And we want to focus on the things that are important about your child and their hair and their skin is not that. And so it's helping them to sort of shift the focus to what's really important. It's hard for parents, though, because their role as a parent is to help their child and they see their child doing this really scary thing that they don't understand if they did not engage in that particular BFRB. Now, oftentimes the parents will have a BFRB, but it maybe doesn't bother them as much or it's been annoying, but not to the point where it's caused bald spots. But we'll see parents who engage in nail biting or some other BFRB and helping them to develop that compassion for their child is critical for them to change their approach. I completely agree and exactly as you said, Suzanne, helping parents to understand that their feelings around their child's BFRB are big, strong, powerful feelings that need to be understood, they need to be validated, and they need to be supported separate from helping their child with their BFRB. And one more thing I would say about that is it came from an event that I did just last night with another group of Suzanne's colleagues where a parent asked the question, how can I help my child live without shame? And I was absolutely delighted to hear that question instead of the question I usually hear, which is how can I help my child stop pulling out their hair or picking at their skin? Because that's the right question. The only thing you don't want is for your child to grow up with chronic shame. And that's much more important than whether or not they've got a full head of hair and some lesions on their skin. So for both of you, what are the big questions you want to answer? What are you working on now? Dr. Mutin Odom, you want to go first? Well, I'm working on, there was a big initiative pre-COVID by the TLC Foundation. A lot of data were gathered. 250 people had lots and lots and lots of tests, genetic tests, brain scans, etc. And we're wading through those data. But I have really done a deep dive in trying to reimagine how we think about people. And we're writing up a paper that I'm super, super excited about. And I believe everyone gets a little bit siloed with BFRBs and they only see one part of the elephant, if you will. And everyone just focuses on that part. And I think we all need to step back and see the whole picture. The issue with treatment has always been everyone's trying to lump people into your this or your that or your this or your that. And sure enough, as soon as you do that, someone walks in the door and they don't fit in either of those buckets. And so we're really trying to step back and create a model that accounts for all presentations so that we can then approach that person with a path to treatment. But all of that said, we still have to do the foundational work of undoing shame and preparing the person for treatment. So coming up with a model that involves all of that is what I'm super excited about and more to come. Dr. Mackay, what about you? Yeah, so I've started quite a few new things off and I'm going to talk about one of them in particular. I've talked quite a bit about shame and we've got quite a bit of stuff going on about understanding how to conceptualize shame and how to help people with it. Actually, I'm going to talk about something a bit different, which is that I have developed a real interest in something which is regularly described as part of the phenomenology of the FRBs, which is that when we're picking and pulling and biting, we go into kind of a trance like state. This is a kind of altered state of consciousness where you're not quite aware and not quite unaware and you become hyper focused on the whatever it is that's your target, the hair, the skin, whatever your target is. And states of consciousness, of course, are things that lots of people are interested in. And this state of consciousness, which might be a kind of something that's in between awake and asleep where you're not quite awake and you're certainly not asleep, but you've kind of dissociated just somewhere else. And you still, you know, the telly's still on, you're still in the room. It's not like a trauma related dissociation. It's a different thing and trying to try to understand exactly what that phenomenon is and how that then forms part of that package that Suzanne was talking about is really critical because in that trance like state, cognitive strategies don't stand a chance. They have no way in. You're not, I don't have access to my cognitive strategies when I'm in that trance like state. So I have kind of very early ideas that actually we need to be thinking a little bit more about sensory strategies and breathing work to sort of help you snap out of that kind of that state that you get into. And so it's been described many times the state, but it's not really been explored. So that's what I'm that's one of the things I'm excited about. Wow. Well, I want to thank you both. This has been absolutely fascinating and I think it's been very helpful for our listeners to to learn and also to help destigmatize something that we know is is fairly common. So thank you. Thank you for having us. It's great to share your light on beer. You can find previous episodes of Speaking of Psychology on our website at SpeakingofPsychology.org or on Apple, YouTube, Spotify, or wherever you get your podcasts. And if you like what you've heard, please follow us and leave a review. If you have comments or ideas for future episodes, you can email us at SpeakingofPsychology.org. Speaking of Psychology is produced by Lee Weinemann. Thank you for listening for the American Psychological Association. I'm Kim Mills. Thank you.
