Free from BFRB: 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, the compulsive pulling of one’s hair (trichotillomania), skin picking and lip-cheek biting 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 effective techniques such as habit reversal training and habit replacement. Further below we provide a brief overview of the most common BFRBs. In the final part, we summarize the empirical evidence on decoupling and habit replacement.
If you are interested in learning about evidence-based treatment techniques (variants of decoupling, habit reversal training, habit replacement) to reduce excessive nail biting, skin picking and/or trichotillomania (hair pulling), please register here to receive our self-help manual "Free from BFRB" at no cost. Please also visit our website www.free-from-bfrb.org
Subtypes of Body-Focused Repetitive Behaviors (BFRBs, see also www.free-from-bfrb.org)
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.
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 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!
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
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.
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, 46(4), 894–912. doi: 10.1177/01454455211010707. Link to article (full text)
Moritz, S., Penney, D., Missmann, F., Weidinger, S., & Schmotz S. (2023). Self-help habit replacement in individuals with body-focused repetitive behaviors: a proof-of-concept randomized clinical trial. JAMA Dermatology. Link to article (Abstract)
Moritz, S., Penney, D., Weidinger, S., Gabbert, T., & Schmotz, S. (2022). A randomized controlled trial on a novel behavioral treatment for individuals with skin picking and other body-focused repetitive behaviors. Journal of Dermatology. 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)