Scientists estimate that about 5% of people worldwide are afflicted with body-focused repetitive behaviours – like compulsively pulling or picking at their hair or skin, or biting their nails – but an approach called habit replacement might help reduce this, they say.
Trying to contain these behaviours, which in the case of pulling at hair or skin can sometimes cause scabs, scars and bald spots – is not easy, according to the TLC Foundation for Body-Focused Repetitive Behaviors, an advocacy group for people with the conditions.
The latest research, published in JAMA Dermatology, found that the habit replacement technique helped 53% of people in the study, compared with about 20% in the control group, reports NBC News.
The treatment involves gently rubbing the fingertips, palm or back of the arm at least twice a day.
“The rule is just to touch your body lightly,” said lead study author Steffen Moritz, head of the clinical neuropsychology working group at University Medical Centre Hamburg-Eppendorf, in Germany. “If you’re under stress, you might perform the movements faster, but not with more self-applied pressure.”
The study was considered “proof-of-concept” research – early research that needs further confirmation. Still, experts said the results were encouraging.
In the six-week study, Moritz and colleagues looked at 268 people who had trichotillomania (a condition in which people pluck out hair in response to stress or to self-soothe) or repeatedly bit their nails or the inside of their cheek.
The researchers randomly assigned the volunteers into two groups. One group was given a manual and video that showed them how to form the new, less harmful habit by gently rubbing their fingertips, palm, or arm any time they felt the urge to bite their nails or engage in the harmful behaviour.
They were also instructed to practise the new habit when they weren’t feeling the urge to pull, pick or bite.
People in the control group were told they had been put on a waiting list for treatment, and only got the habit replacement training after the study was concluded.
Overall, nearly 80% of the people in the treatment group said they were satisfied with the training and 86% said they would recommend it to a friend.
People who bit their nails seemed to benefit the most from the habit replacement technique.
How can rubbing your arm stop you from biting your nails?
The new approach is a variation of other behavioural techniques for body-focused repetitive behaviours, which include habit reversal training and something called decoupling.
While some medications, including antidepressants, are prescribed off-label to people with these behaviours, there are no FDA-approved drugs specifically for the condition. Cognitive behavioural therapy is thought to be the most effective approach.
In habit reversal training, people are taught “competing responses”, said Natasha Bailen, a clinical psychologist at the Centre for OCD and Related Disorders at Massachusetts General Hospital and Harvard Medical School.
“So they might involve, for example, clenching your fists really tightly when you have an urge to pull your hair or pick your skin. It might be sitting on your hands,” she said.
The aim is to use a group of muscles so that you can’t physically perform the harmful behaviour.
In decoupling, a habit is unlearned by performing a similar movement but switching it up at the last minute. For example, if you bite your nails, you might put your hand to your face but touch an earlobe instead of your mouth.
Moritz said that the study’s habit replacement training differs in that it aims to replace the sometimes pleasurable sensation of picking and pulling with something that also feels good but won’t be harmful: gentle touch.
In fact, the training manual in the study recommends that people avoid touching their bodies in ways that are rough or apply too much pressure, like scrubbing their skin in the shower or brushing their teeth too hard.
“I would say one-third to half of the patients with BFRB (body-focused repetitive behaviour) benefit from decoupling, but the rest do not,” Moritz said. “And so the idea was to find another technique that is perhaps more suitable for these non-responders.”
The training also recommends that people treat themselves to things like a massage, a warm bath, or applying lotion “both consciously and, ideally, lovingly”.
More research needed
John Piacentini, president of the board of directors of the TLC Foundation for Body-Focused Repetitive Behaviours, said: “This study will raise awareness of BFRBs because they’re really poorly understood, often misdiagnosed or missed completely.”
However, he noted some of the study’s limitations, including that the control group wasn’t undergoing some type of alternative treatment; that the study was relatively short at only six weeks; and it wasn’t clear if the intervention were affected by other conditions like anxiety or depression, or helped reduce impairment.
“In this population, we’re really looking for treatments that are going to have an impact on or really reduce the severity of these specific symptoms,” he said.
The study authors also listed several limitations, including that the participants were recruited from social media, lacked diversity (most were white women in their 30s), and did not have their diagnoses confirmed.
Study details
Self-Help Habit Replacement in Individuals With Body-Focused Repetitive BehaviorsA Proof-of-Concept Randomized Clinical Trial
Steffen Moritz, Danielle Penney, Franziska Missmann, et al.
Published in JAMA Dermatology on 19 July 2023
Key Points
Question Is self-help habit replacement effective against a control group for the treatment of body-focused repetitive behaviours (BFRBs), such as skin picking?
Findings In this randomised clinical trial including 268 individuals with BFRBs, habit replacement significantly reduced BFRBs relative to controls.
Meaning Habit replacement may be adopted for those with no access to direct therapeutic treatment or to bridge wait times.
Abstract
Importance
Body-focused repetitive behaviours (BFRBs; eg, skin picking) encompass a set of conditions at the interface of dermatology and psychiatry/psychology. The disorder is prevalent but currently underdiagnosed and undertreated.
Objective
To compare a new self-help intervention, habit replacement, against a wait-list control condition for the treatment of BFRBs.
Design, Setting, and Participants
This randomised clinical trial was conducted online in 2022. Participants were a population-based nonclinical sample with BFRBs and were recruited via social media. Initially, 481 individuals entered the assessment; 213 were excluded blind to results. A final sample of 268 participants were randomised. The intervention period was 6 weeks.
Interventions
Participants were randomised to a self-help intervention, habit replacement, or a wait-list control condition (each n = 134).
Main Outcomes and Measures
The Generic BFRB Scale-45 (GBS-45, self-report) represented the primary outcome.
Results
Individuals in the 2 conditions (n = 268; 241 [89.9%] women; mean [SD] age, 36.8 [11.1] years; skin picking, 68.3%; trichotillomania, 28.4%; nail biting, 36.6%; lip-cheek biting, 26.1%; other, 20.1%) did not differ on any baseline characteristics. The experimental group significantly improved on the primary outcome (GBS-45) for both the per-protocol (technique was used at least once weekly, ηp2 = 0.068, P = .001) and the intention-to-treat analyses relative to the wait-list control group (expectation–maximisation algorithm; ηp2 = 0.019, P = .02). The interaction of group and time yielded statistical trends in favour of the experimental condition only on the Patient Health Questionnaire-9 and quality of life. For the Clinical Global Impressions scale, more individuals in the habit replacement group reported improvement (52.8% vs 19.6%; P < .001). User satisfaction in the habit replacement group was high. Moderation analyses that included all baseline variables showed that those who exhibited nail biting particularly benefited from the new technique.
Conclusions and Relevance
The present proof-of-concept randomised clinical trial tentatively demonstrates that habit replacement is a feasible and effective self-help strategy against BFRBs, especially for nail biting. Study limitations include the lack of external assessment and verified diagnoses. In addition, the study is missing follow-up data. Self-help habit replacement shows promise in reducing BFRBs but not concomitant symptoms.
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