Body-focused repetitive behaviours in adolescents: a common and under-recognised source of distress and unmet need

Background: Body-focused repetitive behaviours (BFRBs), including hair pulling, skin picking and nail biting, are common but under-recognised behaviours that often emerge during adolescence. Their prevalence, associated distress, and relationship with mental health and social factors remain poorly characterised. Methods: 5,437 adolescents aged 11-18 years reported engagement in BFRBs, associated distress, and functional interference as part of the 2025 OxWell Student Survey. Participants. Problematic BFRBs were defined as at least one BFRB with moderate or high distress. Associations with gender, neurodivergence, bullying, and internalising symptoms were examined using multivariable logistic regression. Results: Overall, 58.5% of participants reported at least one BFRB. Nail biting was most common (43.6%), followed by skin picking (31.3%) and hair pulling (14.5%). Among those with BFRBs, 22.2% reported moderate-to-high distress, and 3.3% of the total sample reported the highest level of distress. Co-occurrence was common: more than half of those with BFRBs reported multiple behaviours. BFRBs were more common and more distressing in girls and trans/gender-diverse participants than in boys. Problematic BFRBs showed strong associations with internalising symptoms (6.3% in the normal range vs 34.2% in the clinical range) and bullying (9.6% with no bullying vs 27.1% with >weekly bullying). Internalising symptoms were the strongest predictor in multivariable models (OR 1.97 per 10-point increase), alongside independent contributions from gender and frequent bullying. Conclusions: BFRBs are common in adolescents, frequently co-occur, and are strongly associated with emotional distress and social adversity. Recognition of distress, rather than behaviour alone, may be important for identifying unmet need and guiding intervention.