Does Trauma Cause Body-Focused Repetitive Behaviors? Not Quite
What research reveals about trauma and body-focused repetitive behaviors.
Posted October 23, 2025 | Reviewed by Jessica Schrader
When the causes of body-focused repetitive behaviors (BFRBs), such as hair pulling (trichotillomania), skin picking (excoriation disorder), or nail biting, are discussed, the question often arises: Are these behaviors caused by trauma?
It’s a fair question. The assumption makes intuitive sense. Many behaviors that cause physical harm or distress are linked to emotional pain or traumatic experiences. However, the science paints a more nuanced picture.
What Research Reveals (and Doesn’t)
Empirical studies exploring trauma histories among individuals with body-focused repetitive behaviors (BFRBs) have produced mixed, but generally nonsupportive, findings regarding a causal link. Early work by Christenson and Crow (1996) found childhood trauma rates among people with trichotillomania to be similar to those observed in the general population. In contrast, Özten et al. (2015) reported somewhat higher trauma exposure among individuals with trichotillomania and skin-picking disorder compared to controls, yet trauma history was not predictive of symptom severity, suggesting correlation rather than causation. Similarly, Houghton et al. (2016) conducted a large-scale analysis and concluded that the association between trauma and trichotillomania is “tenuous at best.”
A broader review by Roberts, O’Connor, and Bélanger (2013) emphasized that habit-based and neurobehavioral mechanisms, rather than trauma pathways, best explain BFRB development and maintenance. Collectively, these findings indicate that while trauma may be present in some individuals with BFRBs, it is neither necessary nor sufficient for their emergence.
So, What Does Drive BFRBs?
BFRBs are better understood as repetitive behaviors targeting the hair, skin, or nails, that develop and persist because they temporarily regulate internal states. Neurologically, these behaviors are tied to the reward and habit circuits of the brain, particularly those involving dopamine and the basal ganglia (Fineberg et al., 2010).
In a comprehensive review, Grant and Chamberlain (2016) noted that the neurobiological and behavioral mechanisms underlying BFRBs are distinct from those of trauma-related disorders. This is consistent with growing evidence that BFRBs share features with habit and reward system dysregulation, rather than with posttraumatic symptom patterns.
Understood from a functional behavioral perspective, pulling, picking, or biting typically provides an immediate, momentary sense of relief or gratification, reinforcing the behavior. Over time, this creates a feedback loop (an antecedent urge, the behavior, and short-term relief). The more the loop repeats, the more automatic it becomes. And for many people, these behaviors can even occur outside of conscious awareness.
When Trauma and BFRBs Coexist
That said, trauma and BFRBs can co-occur and can overlap in complex ways. Trauma may influence how someone experiences antecedents and/or how they manage stress /distress. For example, someone with a trauma history may feel heightened shame , self-blame, or fear around their BFRB and may have a more difficult time managing these thoughts and feelings. Emotional sensitivity and emotional dysregulation, both of which can stem from trauma, can also exacerbate BFRB symptoms. So while trauma doesn’t cause these behaviors, it can contribute to its maintenance.
Why the Distinction Matters
When clinicians assume that a BFRB must be related to significant trauma, treatment can veer in an unhelpful direction. Individuals may spend years exploring “why” rather than learning “how” to better manage the behavior. Evidence-based behavioral therapies focus on increasing awareness, understanding antecedent triggers, and building adaptive skills and strategies for healthy self-regulation and self-care.
For some, trauma and BFRBs share space; for others, they do not. Either way, the path to living a life unfettered by one’s BFRB involves understanding one’s experiences in the context of their own internal world (thoughts, emotions, sensations/urges) and learning new ways to respond to it.
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Christenson, G. A., & Crow, S. J. (1996). The characterization and treatment of trichotillomania. Journal of Clinical Psychiatry, 57(8, Suppl), 42–49.
Fineberg, N. A., Potenza, M. N., Chamberlain, S. R., Berlin, H. A., Menzies, L., Bechara, A., Sahakian, B. J., Robbins, T. W., Bullmore, E. T., & Hollander, E. (2010). Probing compulsive and impulsive behaviors, from animal models to endophenotypes: A narrative review. Neuropsychopharmacology, 35(3), 591–604. https://doi.org/10.1038/npp.2009.185
Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania and excoriation disorder: Pathophysiology and treatment. Comprehensive Psychiatry, 66, 121–127.
Houghton, D. C., Mathew, A. S., Twohig, M. P., Saunders, S. M., Franklin, M. E., Compton, S. N., Neal-Barnett, A. M., & Woods, D. W. (2016). Trauma and trichotillomania: A tenuous relationship. Journal of Obsessive-Compulsive and Related Disorders, 11, 91–95. https://doi.org/10.1016/j.jocrd.2016.09.003
Özten, E., Sayar, G. H., Eryılmaz, G., Kağan, G., Işık, S., & Karamustafalıoğlu, O. (2015). The relationship of psychological trauma with trichotillomania and skin picking. Neuropsychiatric Disease and Treatment, 11, 1203–1210. https://doi.org/10.2147/NDT.S79554
Roberts, S., O’Connor, K., & Bélanger, C. (2013). Emotion regulation and other psychological models for body-focused repetitive behaviors. Clinical Psychology Review, 33(8), 1148–1162. https://doi.org/10.1016/j.cpr.2013.09.003
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Marla Deibler, Psy.D., ABPP , is a clinical psychologist and founder of The Center for Emotional Health of Greater Philadelphia.
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This article is part of the Bringwise Psychology Journal — daily insights on human behavior, mental health, and personal growth.