What is the appropriate treatment approach for body‑focused repetitive behavior (BFRB) disorders such as trichotillomania, excoriation disorder, and nail‑biting?

Treatment of Body-Focused Repetitive Behavior (BFRB) Disorders

Habit reversal training (HRT) combined with stimulus control is the first-line treatment for trichotillomania, excoriation disorder, and nail-biting, regardless of severity level, with N-acetylcysteine (NAC) as the preferred pharmacologic adjunct due to its moderate efficacy and minimal side effects. 1

Initial Treatment Selection Algorithm

Step 1: Assess Behavioral Style and Awareness

• For automatic/low-awareness pulling or picking (behaviors performed while distracted, watching TV, reading, or driving), initiate HRT and stimulus control as primary interventions 1
• For emotion-driven behaviors (pulling or picking triggered by anxiety, stress, boredom, or negative emotions), add acceptance and commitment therapy (ACT) or dialectical behavior therapy (DBT) to augment HRT/stimulus control 1

Step 2: Implement Behavioral Interventions

Habit Reversal Training (HRT) components:

• Awareness training to identify triggers and early warning signs of the behavior 1
• Competing response training to substitute a physically incompatible action when urges arise 1
• Motivation enhancement and social support strategies 1

Stimulus control techniques:

• Environmental modifications to reduce access or opportunity (e.g., wearing gloves, keeping hands occupied, covering mirrors) 1
• Barrier methods specific to the body site affected 1

Cognitive Psychophysiological (CoPs) approach:

• This model addresses the tension and emotional buildup preceding the behavior rather than the habit itself, showing large effect sizes (g = 2.04 in completers) with 74% of patients achieving clinically significant improvement 2
• Particularly effective when BFRBs are conceptualized within the tic spectrum rather than the obsessive-compulsive spectrum 2

Step 3: Add Pharmacologic Treatment

N-Acetylcysteine (NAC):

• Should be considered for all severity levels and behavioral styles as the first pharmacologic intervention 1
• Functions as a glutamate modulator that reduces compulsive behaviors in BFRB disorders 3
• Offers moderate efficacy with a favorable side effect profile compared to other medications 1

Selective Serotonin Reuptake Inhibitors (SSRIs):

• Reserve for cases with significant psychiatric comorbidities (depression, generalized anxiety disorder, or OCD) 1, 4
• Consider when behavioral interventions and NAC have failed 1
• Variable efficacy in clinical trials; not first-line monotherapy 3

Critical Diagnostic Distinctions

Differentiating BFRBs from Related Disorders

BFRBs are NOT primarily motivated by appearance concerns:

• In excoriation disorder, skin picking leads to lesions but is not driven by a goal to improve appearance 4
• In trichotillomania, hair pulling is not an attempt to correct perceived appearance flaws 4
• This distinguishes BFRBs from body dysmorphic disorder (BDD), where repetitive behaviors (mirror checking, skin picking, hair pulling) are specifically aimed at correcting or concealing perceived appearance defects 5

BFRBs should not be diagnosed as OCD:

• The DSM-5 specifies that OCD should not be diagnosed when the disturbance is better explained by hair pulling or skin picking 4
• Unlike OCD, BFRBs lack diverse obsessional themes (contamination, harm, symmetry) and instead involve focused, repetitive body manipulation 6

Assessment Requirements

Use standardized measurement tools:

• The Tourette Symptom Global Scale (TSGS) can be reliably adapted to measure BFRBs, supporting their classification within the tic spectrum 2
• The Repetitive Body Focused Behavior Scale (RBFBS) demonstrates good to excellent internal consistency for screening skin-picking, hair-pulling, and nail-biting 7

Evaluate comorbidities:

• Depression and generalized anxiety disorder commonly co-occur with BFRBs 4
• Youth with BFRBs show more avoidant tendencies, anxiety sensitivity, and physical manifestations of distress 7
• Elevated BFRB severity correlates with avoidant coping, panic symptoms, and separation anxiety 7

Treatment Duration and Monitoring

Behavioral therapy timeline:

• The CoPs intervention protocol involves 14 weeks of therapy with demonstrated maintenance of gains at 6-month follow-up 2
• Improvements extend beyond symptom reduction to include mood, self-esteem, and perfectionism 2

Pharmacologic considerations:

• NAC efficacy data derives from limited clinical trials; larger studies with longer durations are needed 3
• Psychotropic medications (SSRIs, tricyclic antidepressants, anticonvulsants) show variable efficacy 3

Common Clinical Pitfalls

Avoid misclassifying BFRBs as OCD:

• BFRBs form a cohesive group more appropriately assessed as part of the Tourette/tic spectrum rather than the obsessive-compulsive spectrum 2
• This distinction affects treatment selection and conceptualization 2

Do not overlook dermatologic involvement:

• Most patients are unlikely to seek mental health treatment and instead present to dermatology for cosmetic damage 8
• A complete therapeutic plan requires dermatologic assessment of affected areas alongside psychotherapy and pharmacotherapy 8
• In trichotillomania, multiple body sites are often affected with varying patterns of alopecia 8
• In excoriation disorder, picking frequently starts with underlying dermatologic conditions (e.g., acne) but continues after dermatologic treatment, with atypical findings and distribution 8

Recognize high prevalence in youth:

• BFRBs occur in 55% of youth with anxiety or OCD, with elevated levels in 27% 7
• Skin-picking is most common (38%), followed by nail-biting (34%) and hair-pulling (4%) 7
• BFRBs are equally common but more likely to be elevated among youth with primary anxiety versus OCD diagnosis 7