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Original Research Focus on Childhood and Adolescent Mental Health January 12, 2026

Therapist-Delivered Video Therapy Habit Reversal Training for Body-Focused Repetitive Behaviors: Clinical Outcomes From a Large Real-World Sample of Youth and Adults

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J Clin Psychiatry 2026;87(1):25m15834.

Abstract

Objective: To examine the effectiveness of therapist-delivered video therapy habit reversal training (HRT) in large real-world samples of children, adolescents, and adults with trichotillomania and excoriation disorder (ED).

Methods: The sample included 543 patients with trichotillomania (57 children, 75 adolescents, 411 adults) and 528 patients with ED (40 children, 46 adolescents, 442 adults). Treatment followed a protocol of weekly HRT sessions, transitioning to biweekly sessions. The Repetitive Body Focused Behavior Scale was administered at baseline, weeks 5–7, and weeks 14–16 and during maintenance periods through week 52.

Results: Mean treatment duration was 14.64±2.50 weeks (7.71±2.61 sessions) for trichotillomania and 14.54±2.69 weeks (7.73±2.68 sessions) for excoriation. At weeks 14–16, trichotillomania showed a median 33.33% severity reduction (interquartile range [IQR]=11.11%–54.55%; 44.08% achieving ≥35% reduction) with large effects (Hedges g = 1.01, 95% CI [0.88–1.14]). Excoriation showed a median 33.33% reduction (IQR=12.50%–57.14%; 48.66% achieving ≥35% reduction) with large effects (Hedges g = 1.16, 95% CI [1.02–1.30]). Improvements were maintained through week 52 (trichotillomania: g=1.51 [CI, 1.23–1.79]; excoriation: g=1.56 [1.29–1.84]). Both conditions showed improvements in depression, anxiety, and stress (g=0.22–0.29). All age groups improved, with effect sizes ranging from g=0.78–1.12 for trichotillomania and g=0.68–1.54 for excoriation.

Conclusion: This analysis shows promising evidence that therapist-delivered video therapy HRT is associated with reductions in both hair-pulling and skin-picking severity and improvements in related symptoms in a real-world setting. The large treatment effects and improvements across the lifespan for both conditions suggest this delivery format may help address barriers to accessing evidence-based care for body-focused repetitive behaviors.

J Clin Psychiatry 2026;87(1):25m15834

Author affiliations are listed at the end of this article.

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  1. Grant JE. Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors. American Psychiatric Pub; 2012.
  2. Houghton DC, Alexander JR, Bauer CC, et al. Body-focused repetitive behaviors: more prevalent than once thought? Psychiatry Res. 2018;270:389–393. PubMed CrossRef
  3. Grant JE, Chamberlain SR. The role of compulsivity in body-focused repetitive behaviors. J Psychiatr Res. 2022;151:365–367. PubMed CrossRef
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Publishing; 2021.
  5. Stein DJ, Christenson GA, Hollander E. Trichotillomania. American Psychiatric Pub; 1999.
  6. Grant JE, Dougherty DD, Chamberlain SR. Prevalence, gender correlates, and co-morbidity of trichotillomania. Psychiatry Res. 2020;288:112948. PubMed CrossRef
  7. Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry. 1991;52(10):415–417. PubMed
  8. Thomson HA, Farhat LC, Olfson E, et al. Prevalence and gender distribution of trichotillomania: a systematic review and meta-analysis. J Psychiatr Res. 2022;153:73–81. PubMed CrossRef
  9. Bohn M, Thomsen PH, Nissen JB. Ugeskr Laeger. Trichotillomania. 2022;184(19):V11210829. PubMed
  10. Grzesiak M, Reich A, Szepietowski JC, et al. Trichotillomania among young adults: prevalence and comorbidity. Acta Derm Venereol. 2017;97(4):509–512. PubMed CrossRef
  11. Odlaug BL, Grant JE. Impulse-control disorders in a college sample: results from the self-administered Minnesota Impulse Disorders Interview (MIDI). The Prim Care Companion. 2010;12(2):PCC.09m00842.
  12. Mansueto CS, Thomas AM, Brice AL. Hair pulling and its affective correlates in an African-American university sample. J Anxiety Disord. 2007;21(4):590–599. PubMed CrossRef
  13. Szepietowski JC, Salomon J, Pacan P, et al. Frequency and treatment of trichotillomania in Poland. Acta Derm Venereol. 2009;89(3):267–270. PubMed CrossRef
  14. Cohen LJ, Stein DJ, Simeon D, et al. Clinical profile, comorbidity, and treatment history in 123 hair pullers: a survey study. J Clin Psychiatry. 1995;56(7):319–326. PubMed
  15. Lochner C, Keuthen NJ, Curley EE, et al. Comorbidity in trichotillomania (hair pulling disorder): a cluster analytical approach. Brain Behav. 2019;9(12):e01456. PubMed CrossRef
  16. Woods DW, Flessner CA, Franklin ME, et al. The Trichotillomania Impact Project (TIP): exploring phenomenology, functional impairment, and treatment utilization. J Clin Psychiatry. 2006;67(12):1877–1888. PubMed CrossRef
  17. Keuthen NJ, Koran LM, Aboujaoude E, et al. The prevalence of pathologic skin picking in US adults. Compr Psychiatry. 2010;51(2):183–186. PubMed CrossRef
  18. Hayes SL, Storch EA, Berlanga L. Skin picking behaviors: an examination of the prevalence and severity in a community sample. J Anxiety Disord. 2009;23(3):314–319. PubMed CrossRef
  19. Grant JE, Odlaug BL, Chamberlain SR, et al. Skin picking disorder. Am J Psychiatry. 2012;169(11):1143–1149. PubMed CrossRef
  20. Ricketts EJ, Snorrason Í, Kircanski K, et al. A latent profile analysis of age of onset in pathological skin picking. Compr Psychiatry. 2018;87:46–52. PubMed CrossRef
  21. Leppink EW, Lust K, Grant JE. Depression in university students: associations with impulse control disorders. Int J Psychiatry Clin Pract. 2016;20(3):146–150. PubMed CrossRef
  22. Grant JE, Chamberlain SR. Clinical correlates of symptom severity in skin picking disorder. Compr Psychiatry. 2017;78:25–30. PubMed CrossRef
  23. Flessner CA, Woods DW. Phenomenological characteristics, social problems, and the economic impact associated with chronic skin picking. Behav Modif. 2006;30(6):944–963. PubMed CrossRef
  24. Tucker BTP, Woods DW, Flessner CA, et al. The Skin Picking Impact Project: phenomenology, interference, and treatment utilization of pathological skin picking in a population-based sample. J Anxiety Disord. 2011;25(1):88–95. PubMed CrossRef
  25. Azrin NH, Nunn RG. Habit-reversal: a method of eliminating nervous habits and tics. Behav Res Ther. 1973;11(4):619–628. PubMed CrossRef
  26. Bloch MH, Landeros-Weisenberger A, Dombrowski P, et al. Systematic review: pharmacological and behavioral treatment for trichotillomania. Biol Psychiatry. 2007;62(8):839–846. PubMed CrossRef
  27. Farhat LC, Olfson E, Nasir M, et al. Pharmacological and behavioral treatment for trichotillomania: an updated systematic review with meta-analysis. Depress Anxiety. 2020;37(8):715–727. PubMed CrossRef
  28. Henkel ED, Jaquez SD, Diaz LZ. Pediatric trichotillomania: review of management. Pediatr Dermatol. 2019;36(6):803–807. PubMed CrossRef
  29. Cisoń H, Kuś A, Popowicz E, et al. Trichotillomania and trichophagia: modern diagnostic and therapeutic methods. Dermatol Ther. 2018;8(3):389–398. CrossRef
  30. Everett GJ, Jafferany M, Skurya J. Recent advances in the treatment of trichotillomania (hair-pulling disorder). Dermatol Ther. 2020;33(6):e13818. PubMed CrossRef
  31. McGuire JF, Ung D, Selles RR, et al. Treating trichotillomania: a meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors. J Psychiatr Res. 2014;58:76–83. PubMed CrossRef
  32. Woods DW, Wetterneck CT, Flessner CA. A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behav Res Ther. 2006;44(5):639–656. PubMed CrossRef
  33. Keuthen NJ, Rothbaum BO, Fama J, et al. DBT-enhanced cognitive-behavioral treatment for trichotillomania: a randomized controlled trial. J Behav Addict. 2012;1(3):106–114. PubMed CrossRef
  34. Franklin ME, Edson AL, Ledley DA, et al. Behavior therapy for pediatric trichotillomania: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2011;50(8):763–771. PubMed CrossRef
  35. Rahman O, McGuire J, Storch EA, et al. Preliminary randomized controlled trial of habit reversal training for treatment of hair pulling in youth. J Child Adolesc Psychopharmacol. 2017;27(2):132–139. PubMed CrossRef
  36. Schumer MC, Bartley CA, Bloch MH. Systematic review of pharmacological and behavioral treatments for skin picking disorder. J Clin Psychopharmacol. 2016;36(2):147–152. PubMed CrossRef
  37. Selles RR, McGuire JF, Small BJ, et al. A systematic review and meta-analysis of psychiatric treatments for excoriation (skin-picking) disorder. Gen Hosp Psychiatry. 2016;41:29–37. PubMed CrossRef
  38. Falkenstein MJ, Rogers K, Malloy EJ, et al. Predictors of relapse following treatment of Trichotillomania. J Obsessive Compuls Relat Disord. 2014;3(4):345–353. PubMed CrossRef
  39. Marcks BA, Wetterneck CT, Woods DW. Investigating healthcare providers’ knowledge of trichotillomania and its treatment. Cogn Behav Ther. 2006;35(1):19–27. PubMed CrossRef
  40. Capel LK, Petersen JM, Woods DW, et al. Mental health providers’ knowledge of trichotillomania and skin picking disorder, and their treatment. Cognit Ther Res. 2024;48(1):30–38. CrossRef
  41. Sampaio DG, Grant JE. Body-focused repetitive behaviors and the dermatology patient. Clin Dermatol. 2018;36(6):723–727. PubMed CrossRef
  42. Falkenstein MJ, Mouton-Odum S, Mansueto CS, et al. Comprehensive behavioral treatment of trichotillomania: a treatment development study. Behav Modif. 2016;40(3):414–438. PubMed CrossRef
  43. Carlson EJ, Malloy EJ, Brauer L, et al. Comprehensive behavioral (ComB) treatment of trichotillomania: a randomized clinical trial. Behav Ther. 2021;52(6):1543–1557. PubMed CrossRef
  44. Mouton-Odum S, Keuthen NJ, Wagener PD, et al. StopPulling.Com: an interactive, self-help program for trichotillomania. Cogn Behav Pract. 2006;13(3):215–226. CrossRef
  45. Flessner CA, Mouton-Odum S, Stocker AJ, et al. StopPicking.com: internet-based treatment for self-injurious skin picking. Dermatol Online J. 2007;13(4):3. PubMed
  46. Barber KE, Woolley MG, Rogers K, et al. StopPulling.Com: real-world effectiveness of a self-guided online intervention for trichotillomania. Cognit Ther Res. 2025;49:807–823. CrossRef
  47. Capel LK, Petersen JM, Becker MR, et al. The efficacy and feasibility of a fully automated, web-based acceptance-enhanced behavioral treatment for trichotillomania in adults: a randomized waitlist-controlled trial. J Obsessive Compuls Relat Disord. 2023;37:100800.
  48. Bowers EM, Capel LK, Woolley MG, et al. Efficacy and feasibility of web-based ACT-Enhanced behavioral treatment for skin picking in adults: a randomized waitlist-controlled trial. J Obsessive Compuls Relat Disord. 2024;43:100909.
  49. Gallinat C, Moessner M, Haenssle HA, et al. An internet-based self-help intervention for skin picking (SaveMySkin): pilot randomized controlled trial. J Med Internet Res. 2019;21(9):e15011. PubMed CrossRef
  50. Mehrmann LM, Antje H, Gerlach AL. Efficacy of an internet-based self-help program treating skin picking disorder with a multiple baseline design: a pilot study. J Obsessive Compuls Relat Disord. 2023;38(100811):100811. CrossRef
  51. Moritz S, Penney D, Ahmed K, et al. A head-to-head comparison of three self-help techniques to reduce body-focused repetitive behaviors. Behav Modif. 2022;46(4):894–912. PubMed CrossRef
  52. Moritz S, Hoyer L, Schmotz S. Two-year follow-up of habit reversal training and decoupling in a sample with body-focused repetitive behaviors. Cognit Ther Res. 2024;48(1):75–81. CrossRef
  53. Moritz S, Penney D, Bruhns A, et al. Habit reversal training and variants of decoupling for use in body-focused repetitive behaviors. A randomized controlled trial. Cognit Ther Res. 2023;47(1):109–122. PubMed CrossRef
  54. Schmotz S, Dilekoglu E, Hoyer L, et al. Self-help to reduce body-focused repetitive behaviors via video or website? A randomized controlled trial. Cognit Ther Res. 2024;48(1):94–106. CrossRef
  55. Moritz S, Weidinger S, Schmotz S. “Free from BFRB”: efficacy of self-help interventions for body-focused repetitive behaviors conveyed via manual or video. J Contemp Psychother. 2024;54(2):103–112. CrossRef
  56. Leibinger KW, Murray E, Aschenbrenner S, et al. Short-term intervention complemented by wearable technology improves Trichotillomania - a naturalistic single-case report. Front Psychol. 2023;14:1071532. PubMed CrossRef
  57. Asplund M, Lenhard F, Rück C, et al. Therapist-guided internet-delivered acceptance-enhanced behavior therapy for skin-picking disorder: a randomized controlled trial. Behav Ther. 2025;56(1):70–82. PubMed CrossRef
  58. Dar R, Schonbach M, Wenzler S. Efficacy of internet-based, therapist-assisted treatment programs for hair pulling and skin picking: preliminary results. Cognit Ther Res. 2024;48(1):66–74. CrossRef
  59. Lee EB, Haeger JA, Levin ME, et al. Telepsychotherapy for trichotillomania: a randomized controlled trial of ACT enhanced behavior therapy. J Obsessive Compuls Relat Disord. 2018;18:106–115. CrossRef
  60. Twohig MP, Petersen JM, Fruge J, et al. A pilot randomized controlled trial of online-delivered ACT-enhanced behavior therapy for trichotillomania in adolescents. Cogn Behav Pract. 2021;28(4):653–668. CrossRef
  61. Wiese AD, Omar Y, Swann AC, et al. Habit reversal training for excoriation disorder: differential outcomes of telehealth versus in-person treatments. Psychiatry Res Case Rep. 2023;2(1):100099. CrossRef
  62. Selles RR, La Buissonnière Ariza V, McBride NM, et al. Initial psychometrics, outcomes, and correlates of the Repetitive Body Focused Behavior Scale: examination in a sample of youth with anxiety and/or obsessive-compulsive disorder. Compr Psychiatry. 2018;81:10–17. PubMed CrossRef
  63. Tolin DF, Gilliam C, Wootton BM, et al. Psychometric properties of a structured diagnostic interview for DSM-5 anxiety, mood, and obsessive-compulsive and related disorders. Assessment. 2018;25(1):3–13. PubMed CrossRef
  64. Crosby JM, Twohig MP. Habit reversal. In: Encyclopedia of Child Behavior and Development. Springer US;2011:719–721.
  65. Woods DW, Piacentini J, Chang S, et al. Managing Tourette Syndrome: A Behavioral Intervention, Adult Workbook, Treatments That Work. Oxford University Press; 2008.
  66. Mansueto CS, Golomb RG, Thomas AM, et al. A comprehensive model for behavioral treatment of trichotillomania. Cogn Behav Pract. 1999;6(1):23–43. CrossRef
  67. Snorrason I, Ricketts EJ, Flessner CA, et al. Skin picking disorder is associated with other body-focused repetitive behaviors: findings from an internet study. Ann Clin Psychiatry. 2012;24(4):292–299. PubMed CrossRef
  68. Keuthen NJ, O’Sullivan RL, Ricciardi JN, et al. The Massachusetts General Hospital (MGH) Hairpulling Scale: 1. development and factor analyses. Psychother Psychosom. 1995;64(3–4):141–145. PubMed CrossRef
  69. Moritz S, Gallinat C, Weidinger S, et al. The Generic BFRB Scale-8 (GBS-8): a transdiagnostic scale to measure the severity of body-focused repetitive behaviours. Behav Cogn Psychother. 2022;50(6):620–628. PubMed CrossRef
  70. Henry JD, Crawford JR. The short-form version of the Depression Anxiety Stress Scales (DASS-21): construct validity and normative data in a large non-clinical sample. Br J Clin Psychol. 2005;44(Pt 2):227–239. PubMed CrossRef
  71. Endicott J, Nee J, Harrison W, et al. Quality of Life Enjoyment and Satisfaction Questionnaire: a new measure. Psychopharmacol Bull. 1993;29(2):321–326. PubMed
  72. Ustün TB, Chatterji S, Kostanjsek N, et al. Developing the World Health Organization Disability Assessment Schedule 2.0. Bull World Health Organ. 2010;88(11):815–823. PubMed
  73. Farhat LC, Olfson E, Li F, et al. Identifying standardized definitions of treatment response in trichotillomania: a meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry. 2019;89:446–455. PubMed CrossRef
  74. Grant JE, Chamberlain SR. Characteristics of 262 adults with skin picking disorder. Compr Psychiatry. 2022;117:152338. PubMed CrossRef
  75. Kwon C, Sutaria N, Khanna R, et al. Epidemiology and comorbidities of excoriation disorder: a retrospective case-control study. J Clin Med. 2020;9(9):2703. PubMed CrossRef
  76. Slikboer R, Nedeljkovic M, Bowe SJ, et al. A systematic review and meta-analysis of behaviourally based psychological interventions and pharmacological interventions for trichotillomania. Clin Psychol. 2017;21(1):20–32. CrossRef
  77. Rautio D, Andrén P, Bjureberg L, et al. Body-focused repetitive behavior disorders in children and adolescents: clinical characteristics and treatment outcomes in a naturalistic setting. Behav Ther. 2024;55(2):376–390. PubMed CrossRef
  78. Keuthen NJ, Rothbaum BO, Falkenstein MJ, et al. DBT-enhanced habit reversal treatment for trichotillomania: 3-and 6-month follow-up results. Depress Anxiety. 2011;28(4):310–313. PubMed CrossRef
  79. Shareh H. A preliminary investigation of metacognitive therapy and habit reversal as a treatment for trichotillomania. Behav Cogn Psychother. 2018;46(1):1–20. PubMed CrossRef
  80. Moritz S, Penney D, Weidinger S, et al. A randomized controlled trial on a novel behavioral treatment for individuals with skin picking and other body-focused repetitive behaviors. J Dermatol. 2022;49(9):933–934. PubMed CrossRef
  81. Moritz S, Penney D, Missmann F, et al. Self-help habit replacement in individuals with body-focused repetitive behaviors: a proof-of-concept randomized clinical trial. JAMA Dermatol. 2023;159(9):992–995. PubMed CrossRef
  82. Grant JE, Valle S, Aslan IH, et al. Clinical presentation of body-focused repetitive behaviors in minority ethnic groups. Compr Psychiatry. 2021;111:152272.

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