Subtypes of Body-Focused Repetitive Behaviors (BFRBs, see also www.free-from-bfrb.org)

Nail biting

Although the direct health consequences of nail biting are rarely severe apart from an occasional infection of the nail bed, the psychological consequences can be grave. Bitten nails are easily visible and at times evoke disgust in other people. In the general population, some people equate nail biting with a nervous temperament and overall difficulty controlling impulsive behaviors. Many sufferers are ashamed to shake other people’s hands because of the appearance of their own hands. This may in turn prompt low self-esteem and social insecurity. Some patients try to hide their fingernails, which paradoxically makes the disorder even more conspicuous.

Trichotillomania

Full, thick hair is commonly associated with health, whereas bald or balding areas on the head or the lack of eyelashes and eyebrows (typical features of trichotillomania) are often mistaken for a severe somatic illness, such as cancer. People with trichotillomania are frequently ashamed of their appearance and conceal bald patches with caps, scarves, or wigs. In many cases, sufferers totally seclude themselves from their social environment, which substantially lowers their quality of life.

Skin picking

Pathological skin picking is another BFRB, and it is characterized by repetitive scratching, biting, and picking at the skin. Like the aforementioned behaviors, it is often associated with a low quality of life and can result in severe somatic problems.

To learn about other BFRBs such as joint cracking and lip-cheek biting, please visit our website www.free-from-bfrb.org. The site contains many evidence-based and effective self-help resources!

Acknowledgments

We would like to thank Jennifer Raikes, former Executive Director of the TLC Foundation for Body-Focused Repetitive Behaviors, for her helpful comments on an earlier draft of the manual on decoupling. For further information on trichotillomania, please visit the website of the TLC Foundation for Body-Focused Repetitive Behaviors at bfrb.org, which is a nonprofit organization based in the United States whose mission is to improve the quality of life of children, adolescents, and adults with trichotillomania and related body-focused repetitive behaviors such as skin picking. TLC works to raise awareness of these disorders, promote research and treatment advances, and provide information and support to sufferers and their families.

Selected media reports about decoupling

• Business Times
• All My Family Care
• Odyssey
• Curejoy
• Cedar Sinai Hospital
• Medscape
• BM Health Care

Efficacy of decoupling

Our group developed the decoupling technique in 2010. A number of treatment studies have confirmed the efficacy of the approach relative to control conditions (see Publications below). This effective and simple to learn intervention has also been recommended in meta-analyses and reviews, including a systematic review by Lee et al. in Frontiers in Behavioral Neuroscience (2019): “Throughout the review, we found evidence of benefit for ‘variants’ of HRT [habit reversal therapy], for example ‘movement decoupling’ (Moritz and Rufer, 2011)” (p. 13). Habit replacement has been investigated in one study (Moritz et al., 2023); 53% of participants using the technique reported a decrease in symptomatology compared to 20% in the control group.