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Decoupling and Habit Reversal Training — Self-Help Treatment to Reduce Nail Biting, Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors (BFRBs; English)

Excessive nail biting, picking one's skin and the compulsive pulling of one’s hair (trichotillomania) are classified as body-focused repetitive behaviors (BFRBs). Below, you can download our treatment manual "Free from BFRB", which describes decoupling, a treatment approach developed by our group, along with other techniques. This is followed by a summary of the most common BFRBs. In the final part, we summarize the empirical evidence confirming the efficacy of decoupling.

Manual

If you are interested in learning about evidence-based treatment techniques (variants of decoupling, habit reversal training, stimulus control) to reduce excessive nail biting, skin picking and/or trichotillomania (hair pulling), please register here. After you have registered (which is free and anonymous), you will receive our self-help manual "Free from BFRB" as a PDF file.

Subtypes of Body-Focused Repetitive Behaviors (BFRBs)

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.

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.

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).

Publications

Lee, M. T., Mpavaenda, D. N., & Fineberg, N. A. (2019). Habit reversal therapy in obsessive compulsive related disorders: a systematic review of the evidence and CONSORT evaluation of randomized controlled trials. Frontiers in Behavioral Neuroscience, 13, 79. Link to article (full text)

Moritz, S. & Hauschildt, M. (2016). Handbuch: Erfolgreich gegen Zwangsstörungen (3. Aufl.). Berlin, Heidelberg: Springer.
In agreement with Springer, 100% of the author's revenue will be used for our research!

Moritz, S., Penney, D., Ahmed, K. & Schmotz, S. (2021). A head-to-head comparison of three self-help techniques to reduce body-focused repetitive behaviors. Behavior Modification. doi: 10.1177/01454455211010707. Link to article (full text)

Moritz, S. & Rufer, M. (2011). Movement decoupling: a self-help intervention for the treatment of trichotillomania. Journal of Behavior Therapy and Experimental Psychiatry, 42, 74–80. Link to article (Abstract)

Moritz, S., Rufer, M., & Schmotz, S. (2020). Recovery from pathological skin picking and dermatodaxia using a revised decoupling protocol. Journal of Cosmetic Dermatology, 19, 3038–3040. Link to article (full text)

Moritz, S., Treszl, A., & Rufer, M. (2011). A randomized controlled trial of a novel self-help technique for impulse control disorders: a study on nail-biting. Behavior Modification, 35, 468–485. Link to article (Abstract)

Weidt, S., Klaghofer, R., Kuenburg, A., Bruehl, A. B., Delsignore, A., Moritz, S., & Rufer, M. (2015). Internet-based self-help for trichotillomania: a randomized controlled study comparing decoupling and progressive muscle relaxation. Psychotherapy and Psychosomatics, 84, 359–367. Link to article (Abstract)


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