Decoupling – A Self-Help Treatment to Reduce Nail Biting, Hair Pulling (Trichotillomania), Skin Picking, and Other Body-Focused Repetitive Behaviors (English version)


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Body-focused repetitive behaviors

Excessive nail biting (biting one’s fingernails and/or the adjacent skin) and the compulsive pulling of one’s hair (trichotillomania) are impulse control disorders that are classified as body-focused repetitive behaviors.

Although the direct health consequences of nail biting are rarely severe apart from an occasional infection of the nail bed, the psychological consequences are often grave. Bitten nails are easily visible and often evoke disgust in other people. In the general population, nail biting is often equated with a nervous temperament and 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.

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.

Pathological skin picking is another body‐focused repetitive behavior, 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.

If you are interested to learn about two evidence-based treatment manuals (variants of decoupling, habit reversal training) designed to help you reduce excessive nail biting, skin picking and/or hair pulling, please register here at no cost:

After the registration (free and anonymous) you will receive the manuals as pdf-files.

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Preliminary research results on decoupling

A number of treatment studies have confirmed the efficacy of decoupling (see the literature listed below). This simple to learn and effective intervention has recently been recommended in several 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).


Moritz, S., Rufer, M. & Schmotz, S. (in press). Recovery from pathological skin picking and dermatodaxia using a revised decoupling protocol. Journal of Cosmetic Dermatology.

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.

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.

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.

Moritz, S. & Rufer, M. (2011). Movement decoupling: A self-help intervention for the treatment of trichotillomania. Journal of Behavior Therapy & Experimental Psychiatry, 42, 74-80.

Further information

For further information on trichotillomania, please visit the website of the TLC Foundation for Body-Focused Repetitive Behaviors at, 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.


We would like to thank Jennifer Raikes, Executive Director of the TLC Foundation for Body-Focused Repetitive Behaviors, for her helpful comments on an earlier draft of the manual on decoupling.