Compulsive Behaviors

🔍 Three Things You Likely Didn’t Know About Compulsive Behaviors

1. A single molecule — glutamate — appears to play a central role in driving these behaviors, and targeting it can help. Glutamate is the brain’s main excitatory neurotransmitter, and neuroimaging in patients with trichotillomania has shown that elevated glutamate levels in the anterior cingulate cortex and striatum — key structures in the brain’s habit circuits — correlate with symptom severity (Peris et al., 2020).

2. Compulsive behaviors occupy a unique space between OCD and addiction — and the distinction matters for treatment. OCD compulsions are driven by anxiety — performed to neutralize a feared outcome — while body-focused repetitive behaviors are driven by a complex mix of tension regulation, sensory seeking, and automatic habit (Stein et al., 2010). Many patients describe a building tension or “itch” temporarily relieved by pulling or picking — a cycle that more closely resembles addiction’s craving-relief loop than OCD’s fear-neutralization loop, with direct implications for which treatments are most likely to help.

3. Your brain has a grooming circuit — and in these conditions, it is stuck in the “on” position. All mammals have brain circuits that start grooming behavior, run it, and then stop it. In trichotillomania and skin picking, the start and run work fine — it is the stop signal that is broken (Chamberlain et al., 2009). This is neuroscience, not personal weakness.

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📋 Overview

Compulsive behaviors — sometimes known as body-focused repetitive behaviors (BFRBs) — encompass a range of repetitive, driven actions directed at one’s own body or involving repetitive engagement patterns that individuals feel unable to resist despite recognizing them as excessive, distressing, or harmful. The most well-characterized conditions in this category include trichotillomania (hair-pulling disorder), excoriation disorder (skin-picking disorder), and related behaviors such as nail biting (onychophagia), cheek chewing, lip biting, and nose picking when they reach clinical severity. Compulsive exercise — rigid, driven exercise that persists despite injury, illness, or significant interference with other life domains — represents another important clinical presentation.

These conditions intersect with obsessive-compulsive spectrum disorders, impulse control disorders, and behavioral addictions — reflecting the fact that they involve elements of all three: repetitive behavior, impaired inhibition, and reinforcement-driven habit loops. Clinically significant BFRBs affect 3–5% of the population — far more common than traditionally recognized. Onset typically coincides with puberty, and the conditions follow a chronic, waxing-and-waning course influenced by stress, boredom, fatigue, and emotional state.

The impact of compulsive behaviors extends well beyond the behaviors themselves. Hair loss, scarring, skin infections, dental damage, repetitive strain injuries, and other physical consequences are common.

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🔀 Subtypes and Presentations

Compulsive behaviors present across a range of specific conditions, each with distinct features:

• Trichotillomania (hair-pulling disorder) — recurrent pulling of hair from any body site, most commonly the scalp, eyebrows, and eyelashes. Pulling may be intentional or automatic. Most patients exhibit both styles. The consequences can include noticeable hair loss, bald patches, and — in some cases — trichophagia (ingesting pulled hair), which can rarely lead to gastrointestinal complications.
• Excoriation (skin-picking) disorder — recurrent picking of the skin, often targeting perceived imperfections such as bumps, scabs, or blemishes. Consequences when the condition is severe can include scarring, infection, significant skin damage, and elaborate efforts to conceal affected areas.
• Onychophagia and related oral behaviors — nail biting, cheek chewing, and lip biting that reach clinical severity, causing tissue damage and functional impairment.
• Compulsive exercise — exercise that is rigid, rule-driven, and continues despite injury, illness, or medical advice to stop. It is often (but not always) associated with eating disorders and body image disturbance. The compulsive quality is often distinguished from healthy athletic dedication by the inflexibility of the behavior.
• Other body-focused repetitive behaviors — these may present independently or alongside other BFRBs.

The clinical picture is frequently complicated by co-occurring conditions. Anxiety disorders, major depression, OCD, ADHD, and eating disorders are all overrepresented among individuals with BFRBs. In many cases, the compulsive behavior at times serves a regulatory function — managing anxiety, boredom, understimulation, or emotional overwhelm — and treatment that fails to address these underlying drivers is unlikely to lead to long-term effects.

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🩺 Diagnosis

Compulsive behaviors are underdiagnosed. Creating a clinical environment in which patients feel safe enough to discuss these behaviors is itself a critical intervention.

• Compassionate, non-judgmental clinical interview — a detailed exploration of the behavior’s frequency, triggers, emotional context, degree of awareness, and functional impact. Many patients have never disclosed these behaviors to anyone, and the interview itself is often therapeutic — establishing that they are dealing with a recognized condition, not a personal failing.
• Standardized assessment instruments — validated scales for hair pulling and skin picking can provide severity ratings, subtype characterization, and treatment response tracking and are useful at times in combination with the thoughtful exploration of issues.
• Assessment of physical consequences — documentation of hair loss patterns, skin lesions, scarring, infection, and dental or oral tissue damage when the harm is significant. Dermatological collaboration may be appropriate.
• Differential diagnosis — BFRBs must be distinguished from OCD (where repetitive behaviors are performed to neutralize obsessional anxiety), psychotic conditions (where skin picking may be driven by delusional parasitosis), dermatological conditions (such as pruritic disorders that drive scratching), and substance-induced or medication-induced states.
• Screening for co-occurring conditions — systematic assessment for anxiety, depression, OCD, ADHD, eating disorders, and trauma is essential, as these conditions frequently co-occur and influence the treatment approach.

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💊 Treatment Approach

Psychotherapy

Habit reversal training (HRT) is the best-established psychotherapeutic intervention for body-focused repetitive behaviors. HRT involves three core components: awareness training (developing detailed, real-time awareness of the behavior and its antecedents), competing response training (substituting a physically incompatible action when the urge arises), and social support (enlisting support for practice and reinforcement). HRT has demonstrated significant efficacy for both trichotillomania and excoriation disorder in controlled trials (Woods & Twohig, 2008).

Acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT) skills are increasingly integrated into BFRB treatment. ACT helps patients develop willingness to experience urges without acting on them, while DBT distress tolerance and emotion regulation skills address the affective dysregulation that often drives the compulsive cycle.

For compulsive exercise, psychotherapy typically addresses the rigid cognitive patterns (perfectionism, conditional self-worth, exercise as moral obligation) and the anxiety that arises when exercise rules are challenged. Treatment often involves collaboration with professionals experienced in eating disorder care when these conditions co-occur.

Medication and Neuromodulation

While no medications carry FDA approval specifically for BFRBs, several medication strategies have demonstrated benefit in clinical trials and practice. Agents that modulate glutamatergic neurotransmission — targeting the cortico-striatal circuits implicated in habit formation — have shown the most novel and promising results in trichotillomania, with controlled trial data suggesting meaningful reductions in pulling urges and behavior (Grant et al., 2009).

Serotonin reuptake inhibitors, while less consistently effective for BFRBs than for OCD, may be helpful when co-occurring anxiety, depression, or obsessive features are prominent. Agents with dopaminergic and noradrenergic activity may be considered when attentional deficits or impulsivity contribute to the clinical picture. For some patients, combinations that address multiple neurochemical systems yield the best results.

Neuromodulation approaches — particularly those targeting the supplementary motor area and prefrontal cortex — are an area of active investigation. Early evidence suggests that modulating the activity of the circuits that govern motor habit initiation and inhibition may offer benefit, though this work remains preliminary.

The optimal pharmacological strategy depends on the specific behavior, the identified triggers and maintaining factors, the co-occurring conditions, and what has been tried before. There is no algorithm that replaces careful clinical judgment informed by a thorough understanding of this condition.

Integrative and Lifestyle Approaches

Targeted strategies addressing sensory modulation, stress physiology, sleep architecture, nutritional factors (including those implicated in oxidative stress and neuroinflammation), and specific supplements with evidence in the BFRB literature may serve as valuable adjuncts to behavioral and pharmacological treatment.

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🌱 Outlook

Compulsive behaviors are treatable. Habit reversal training and related behavioral interventions produce clinically meaningful improvement in the majority of patients, with response rates of 50–70% in controlled trials. When psychotherapy is combined with targeted pharmacotherapy, outcomes improve further — particularly for patients with co-occurring conditions fueling the compulsive cycle.

Recovery from compulsive behaviors is best understood as building a new relationship with the urge — not eliminating it entirely, but developing the awareness, skills, and neurobiological resilience to experience urges without automatically acting on them. For many patients, the most transformative aspect of treatment is the recognition that they are not alone, that their condition has a name and a neuroscience, and that effective help exists. The shame that has kept them silent is frequently more disabling than the behavior itself — and dissolving that shame is where recovery begins.

Flare-ups may occur during periods of stress, transition, or emotional intensity, and a strong therapeutic relationship that allows for re-engagement during difficult periods is an important part of long-term management.

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🏥 How to Get Better

At our psychiatry practice, we have extensive experience in treating compulsive behaviors and bring a thoughtful, evidence-based approach to managing them with medications and psychotherapy. We also offer adjunctive modalities including supplements, neuromodulation, stress management, movement planning, and holistic practices that can be helpful for some patients.

Ready to get started? Schedule an intake appointment — a thorough evaluation where we clarify your diagnosis, map out your treatment plan, and get everything moving: medication orders, therapy, supplements, and nutrition. Your care begins the same day, not weeks later.

Schedule Your Intake

We offer statewide telehealth services in California and Florida, with in-person appointments available in Los Angeles and Miami. We also regularly assist international patients due to our fluency in Portuguese, Spanish, and Farsi.

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📚 References

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing.
2. Grant, J. E., Odlaug, B. L., & Chamberlain, S. R. (2012). Trichotillomania and its clinical relationship to body-focused repetitive behavior disorders. In J. E. Grant, D. J. Stein, D. W. Woods, & N. J. Keuthen (Eds.), Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors. American Psychiatric Publishing.
3. Stein, D. J., Grant, J. E., Franklin, M. E., et al. (2010). Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: toward DSM-V. Depression and Anxiety, 27(6), 611–626.
4. Chamberlain, S. R., Menzies, L. A., Fineberg, N. A., et al. (2009). Grey matter abnormalities in trichotillomania: morphometric magnetic resonance imaging study. British Journal of Psychiatry, 193(3), 216–221.
5. Woods, D. W., & Twohig, M. P. (2008). Trichotillomania: An ACT-Enhanced Behavior Therapy Approach — Therapist Guide. Oxford University Press.
6. Grant, J. E., Odlaug, B. L., & Kim, S. W. (2009). N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Archives of General Psychiatry, 66(7), 756–763.
7. Snorrason, I., Belleau, E. L., & Woods, D. W. (2012). How related are hair pulling disorder (trichotillomania) and skin picking disorder? A review of evidence for comorbidity, similarities and shared etiology. Clinical Psychology Review, 32(7), 618–629.
8. Mansueto, C. S., Golomb, R. G., Thomas, A. M., & Stemberger, R. M. T. (1999). A comprehensive model for behavioral treatment of trichotillomania. Cognitive and Behavioral Practice, 6(1), 23–43.
9. Lochner, C., Grant, J. E., Odlaug, B. L., & Stein, D. J. (2012). DSM-5 field survey: hair-pulling disorder (trichotillomania). Depression and Anxiety, 29(12), 1025–1031.
10. Torales, J., Barrios, I., & Villalba, J. (2017). Alternative therapies for excoriation (skin picking) disorder: a brief update. Advances in Mind-Body Medicine, 31(1), 10–13.
11. Roberts, S., O’Connor, K., & Belanger, C. (2013). Emotion regulation and other psychological models for body-focused repetitive behaviors. Clinical Psychology Review, 33(6), 745–762.
12. Flessner, C. A., Busch, A. M., Heideman, P. W., & Woods, D. W. (2008). Acceptance-enhanced behavior therapy (AEBT) for trichotillomania and chronic skin picking: exploring the effects of component sequencing. Behavior Modification, 32(5), 579–594.
13. Peris, T. S., Piacentini, J., Vreeland, A., Salgari, G., Levitt, J. G., Alger, J. R., Posse, S., McCracken, J. T., & O’Neill, J. (2020). Neurochemical correlates of behavioral treatment of pediatric trichotillomania. Journal of Affective Disorders, 273, 552–561.