How-To Guides

In this real-world sample, therapist-delivered video habit reversal training was associated with a significant reduction in trichotillomania severity. Mean RBFBS scores fell from 7.84 at baseline to 6.19 at weeks 5–7 and to 5.27 at weeks 14–16, which corresponded to a 29.90% mean reduction by weeks 14–16 (−2.56 points; Hedges g=1.01, 95% CI 0.88–1.14; n=422; F(2, 985.9)=245.58, P<.001).

For excoriation disorder, therapist-delivered video habit reversal training was associated with a significant reduction in symptom severity. Mean RBFBS scores decreased from 7.89 at baseline to 6.34 at weeks 5–7 and to 5.13 at weeks 14–16, a 32.79% mean reduction by weeks 14–16 (−2.74 points; Hedges g=1.16, 95% CI 1.02–1.30; n=409; F(2,955.75)=321.99, P<.001).

Improvement was already detectable by weeks 5–7 for both disorders. Trichotillomania scores declined by 1.65 points, or 18.32%, from baseline to weeks 5–7 (Hedges g=0.66, 95% CI 0.57–0.75; n=543), and excoriation disorder scores declined by 1.55 points, or 17.51% (Hedges g=0.66, 95% CI 0.57–0.75; n=528).

Using the study's response threshold of at least 35% symptom improvement, 44.1% of patients with trichotillomania (186/422) and 48.7% of patients with excoriation disorder (199/409) met criteria for clinically meaningful response by weeks 14–16. In both groups, 90.5% showed at least some improvement, while 9.5% had worsening symptoms over that period.

Among patients with follow-up data, symptom gains were maintained or improved through week 52. For trichotillomania, mean symptom reduction from baseline was 38.8% at weeks 17–28, 42.2% at weeks 29–40, and 45.5% at weeks 41–52 (n=122; Hedges g=1.51, 95% CI 1.23–1.79). For excoriation disorder, mean reduction was 40.9%, 42.9%, and 44.1% at weeks 41–52 (n=134; Hedges g=1.56, 95% CI 1.29–1.84).

Yes. In both disorders, a higher number of sessions was significantly associated with lower symptom severity after controlling for baseline severity and evaluation time point. For trichotillomania, session count predicted lower severity (b=−0.11, SE=0.04, t=−2.84, P=.005), and for excoriation disorder the association was similar (b=−0.12, SE=0.03, t=−3.68, P<.001).

All age groups showed meaningful improvement, although baseline severity and effect sizes differed by age. For trichotillomania, effect sizes at weeks 14–16 were g=1.12 in adults, g=0.81 in adolescents, and g=0.78 in children. For excoriation disorder, effect sizes were g=1.23 in adults, g=0.68 in adolescents, and g=1.54 in children.

The study found significant but smaller improvements in common co-occurring symptoms and functioning, not just in the BFRB itself. Across the two diagnostic groups, effect sizes were small to moderate for depression (g=0.26–0.29), anxiety (g=0.22–0.26), and stress (g=0.27–0.28), with additional improvements in quality of life (g=−0.26 to −0.25) and disability (g=0.25–0.30), all with P values <.001.

Treatment consisted of 60-minute habit reversal training sessions delivered by video over 12–17 weeks, with some patients later transitioning to 30-minute check-in sessions based on clinical progress. Core HRT elements included awareness training, competing response training, generalization training, and social supports, with stimulus control and functional analysis used at times. Patients also had optional access to in-app therapist messaging, a mobile app for tracking, and a moderated online community.

Session frequency was usually less than weekly in routine care. Through week 16, both trichotillomania and excoriation disorder patients attended a median of 7 visits (IQR 6–9), and overall treatment lasted a median of 24 weeks for trichotillomania and 23 weeks for excoriation disorder, with a median of 11 total visits for both groups. The median visit frequency was about 0.5 visits per week, which is roughly biweekly treatment.

Engagement with therapist messaging was very high. In the trichotillomania group, 542 of 543 patients (99.82%) sent at least 1 in-app message and 535 of 543 (98.53%) sent 10 or more messages; mean app opens were 81.40 and mean messages were 68.62. In the excoriation disorder group, 526 of 528 patients (99.62%) sent at least 1 message and 514 of 528 (97.35%) sent 10 or more; mean app opens were 83.93 and mean messages were 71.31.

Patients who completed satisfaction ratings reported very high satisfaction. On a 0–5 scale, mean satisfaction was 4.77 in trichotillomania (n=335, 61.7% of the sample) and 4.76 in excoriation disorder (n=333, 63.1% of the sample). The study found no significant correlation between satisfaction and symptom improvement in either group, which the authors noted may reflect a ceiling effect because ratings were consistently high.

The main limitation is that this was a retrospective observational study without randomization or a control group, so it cannot establish that the treatment caused the improvements. Other important limitations included self-report or parent-report outcome measures without blinded assessments, no formal treatment fidelity assessment, use of the RBFBS rather than more established BFRB severity scales, and missing follow-up data that could potentially overestimate treatment effects if patients who ended treatment early had different outcomes.