How to Monitor Response to Video HRT for BFRBs
How should clinicians monitor symptom change during therapist-delivered video habit reversal training for trichotillomania or excoriation disorder?
Clinicians need a concrete way to judge whether remote HRT is helping patients with hair-pulling or skin-picking and when early improvement is emerging. This guide applies to patients receiving video HRT and focuses on the study's actual measurement schedule, severity bands, and response definition.
-
Measure baseline BFRB severity with the RBFBS
Use the Repetitive Body Focused Behavior Scale at baseline in self-report or parent-report format. The hair-pulling and skin-picking subscales each range from 0 to 12, with severity bands described as mild 1 to 3, moderate 4 to 6, severe 7 to 9, and extreme 10 to 12.
-
Repeat assessment every 3 weeks
Collect symptom assessments every 3 weeks during treatment. The study analyzed outcomes at baseline, weeks 5 to 7 to capture early response, and weeks 14 to 16 as the primary end point.
-
Look for early improvement by weeks 5 to 7
By the first follow-up window, expect that some improvement may already be detectable. In the study, mean RBFBS scores improved by 18.32% for trichotillomania and 17.51% for excoriation disorder at weeks 5 to 7, indicating that early benefit can emerge before the primary end point.
-
Judge clinically meaningful response at weeks 14 to 16
Classify treatment response as at least 35% symptom improvement from baseline. The article used this threshold as its definition of clinically meaningful response, and by weeks 14 to 16, 44.1% of trichotillomania patients and 48.7% of excoriation disorder patients met it.
-
Interpret end point scores against residual severity
Do not assume that meaningful response means remission. At weeks 14 to 16, mean scores improved to 5.27 for trichotillomania and 5.13 for excoriation disorder, which remained in the moderate range on the RBFBS despite substantial improvement from baseline.
-
Use session exposure as a treatment-engagement signal
Track cumulative session count while monitoring symptoms. Higher numbers of sessions were associated with lower symptom severity for both trichotillomania and excoriation disorder, so limited improvement should be interpreted in the context of how much treatment the patient has actually received.
-
Follow longer when patients remain engaged
Continue follow-up beyond the acute phase when possible. Among patients with follow-up data, treatment gains were maintained or improved through week 52, with mean symptom reduction reaching 45.5% for trichotillomania and 44.1% for excoriation disorder by weeks 41 to 52.
Clinical Considerations
- The 35% response threshold was borrowed from trichotillomania trial literature using another scale rather than being specifically validated for the RBFBS.
- The adult self-report RBFBS lacks comprehensive psychometric validation, which limits direct comparison with prior studies.
- Missing later assessments may reflect treatment ending for different reasons, and the authors note that this could overestimate treatment effects if early discontinuers had worse outcomes.
- All symptom outcomes were based on self-report or parent-report rather than blinded clinician ratings.
Bottom Line
Monitor video HRT with serial RBFBS assessments every 3 weeks, look for early change by weeks 5 to 7, and use a 35% reduction by weeks 14 to 16 as the study's benchmark for clinically meaningful response while recognizing that many patients still remain moderately symptomatic.
