Habit Reversal Training and Variants of Decoupling for Use in Body-Focused Repetitive Behaviors. A Randomized Controlled Trial

Abstract

Background Behavioral interventions hold promise in improving body-focused repetitive behaviors (BFRBs), such as hair pulling and skin picking. The effect of combining different treatment techniques is currently unknown. Methods In the framework of a randomized controlled crossover trial, 334 individuals with at least one BFRB were allocated either to a waitlist control or to three experimental conditions (1:1:1:1). Participants in the experimental condition received self-help manuals teaching habit reversal training (HRT), decoupling (DC) and decoupling in sensu (DC-is) during a six-week period. Treatment conditions differed only in the order of manual presentation. We examined whether applying more than one technique would lead either to add-on or interference effects. Results The three treatment conditions were significantly superior to the waitlist control group in the improvement of BFRBs according to intention-to-treat analyses at a medium effect size (all p ≤ 0.002, d = 0.52 – 0.54). The condition displaying DC first significantly reduced depressive symptoms (p = 0.003, d = 0.47) and improved quality of life (p = 0.011, d = 0.39) compared to the waitlist control. Those using more techniques concurrently showed the strongest decline in BFRB symptoms, even after controlling for days practiced. Participants rated all manuals favorably, with standard DC and HRT yielding greatest acceptability. Discussion Results tentatively suggest the concurrent application of different behavioral treatments for BFRBs leads to add-on effects. Results were superior when DC was practiced first, with positive effects extending to depressive symptoms and quality of life. Integrating the three techniques into one self-help manual or video along with other treatment procedures (e.g., stimulus control techniques) is recommended.

Self-Help Habit Replacement in Individuals With Body-Focused Repetitive Behaviors

“…While results were significant for the primary outcome, effect sizes were medium for the PP and small but significant for the ITT analyses. Accordingly, new methods should be tested to augment efficacy—for example, by means of guided in-person treatment with a therapist (for results examining the superiority of guided intervention to self-help in other psychological disorders, see Lundström et al and Karyotaki et al) or a treatment combination incorporating established treatments such as HRT or decoupling in view of some evidence that combining different self-help treatments may amplify effects …”

“…In contrast, habit replacement is a more dynamic technique that, unlike HRT, should be practiced in symptom-free intervals to reinforce a new routine in lieu of the BFRB (for HRT, a response that is not contingent on the urge to engage in the habit has been found to be ineffective). We conducted the present trial as a self-help study for various reasons: (1) few therapists specialize in the disorder, and therapists are often unaware of effective treatments, and (2) self-help is playing an increasing role in BFRB treatment to narrow the large treatment gap …”

“…2,3 Currently, therapist-guided cognitive behavioral therapy is regarded as the treatment of choice for the disorder. 4 The present study examined a new self-help treatment technique called habit replacement (for the manual, see eAppendix in Supplement 1), which, unlike other BFRB techniques such as habit reversal training (HRT) 5 or decoupling, [6][7][8] contains a strong self-soothing component. In habit replacement, the individual engages in a circling nonharmful movement when the urge to engage in the behavior emerges or the dysfunctional behavior has already been initiated.…”

“…We conducted the present trial as a self-help study for various reasons: (1) few therapists specialize in the disorder, and therapists are often unaware of effective treatments, 11,12 and (2) self-help is playing an increasing role in BFRB treatment to narrow the large treatment gap. 7 The present trial was set up as a proof-of-concept trial awaiting studies with more rigorous methodology in the event of positive results. We tested habit replacement against a waitlist control (WL) condition.…”

Updates in the Treatment of Body-Focused Repetitive Disorders

“…5 Cognitive behavioral therapy (CBT) and its related subtypes are the treatment of choice for BFRBs, particularly trichotillomania and skin picking disorder (SPD). 6,7 CBT involves identifying the situations, feelings, and thoughts that trigger an episode, systematically reducing the associated triggers, and replacing the pleasurable aspect of the unwanted behavior. 8 A 2023 randomized control trial demonstrated that a self-help manual describing habit-reversal training (HRT) and decoupling techniques led to a significant reduction in BFRBs behavior compared to a wait-listed control group (P<0.001).…”