Evidence-based Therapeutic Treatment for BFRBs

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Research into treatments for BFRBs, particularly hair pulling and skin picking disorder, has grown steadily over the past decade. Although no one treatment has been found to be effective for everyone, a number of evidence-based therapeutic treatment options have shown promise for many people.

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A psychotherapy approach called cognitive behavior therapy (CBT) is the treatment of choice for BFRBs. Existing studies suggest that CBT is superior to medication in treatment outcome. However, some individuals may need medication first or in conjunction with CBT. 

Cognitive Behavior Therapy CBT is a therapeutic approach that focuses on identifying thoughts, feelings and behaviors that are problematic and teaches individuals how to change these elements to lead to reduced stress and more productive functioning. An emphasis is placed on matching the treatment to the unique symptoms of the individual. There are a number of different treatment approaches for BFRBs that fall under the umbrella of CBT: habit reversal training (HRT) and comprehensive behavioral treatment (ComB). Acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT) are two treatment approaches that may bolster the effectiveness of other cognitive behavior therapies. 

Habit Reversal Training 

Habit Reversal Training (HRT) is an early treatment for BFRBs developed in the 1970s by Nathan Azrin and Gregory Nunn. HRT is the method that has been examined most in research studies. HRT has a varying number of components in its treatment package. The three components that are considered most critical are awareness training, competing response training and social support. 

Awareness training consists of helping the person focus on the circumstances during which pulling or picking is most likely to occur. This enables individuals to become more aware of the likelihood that the behavior will occur, and therefore provides opportunities for employing therapeutic techniques designed to discourage performance of problem behaviors. 

Competing response training teaches the individual to substitute another response for the pulling or picking behavior that is incompatible with the BFRB. For example, when an individual experiences an urge to pull or pick, he/she would ball up their hands into fists and tighten their arm muscles and “lock” their arms so as to make pulling or picking impossible at that moment. This response is to be repeated each time that individual experiences an urge to pull or pick or when faced with a situation where pulling or picking is likely to occur. 

Social support involves bringing loved ones and family members into the therapy process in order to provide positive feedback when the individual engages in competing responses. They may also cue the person to employ these strategies and provide encouragement and reminders when the individual is in a trigger situation. 

The research literature encourages using HRT for short-term improvement; however, professionals and sufferers have found that when used by itself, achieving long-term improvement in symptoms is much more difficult.

Comprehensive Behavioral Treatment 

The comprehensive behavioral (ComB) model, developed by Dr. Charles Mansueto and his colleagues, is based on the assumption that a person engages in their BFRB because it meets one or more need in the individual (e.g., helping to relax, to fall asleep, or to feel like a goal was accomplished). This model focuses on understanding why, where and how a person engages in their BFRB so that individualized interventions can be selected to help the person achieve what they want to achieve without engaging in the BFRB. The ComB model consists of four components: Assessment, Identify and Target Modalities, Identify and Choose Strategies, and Evaluation. It focuses on understanding five domains: Sensory, Cognitive, Affective, Motor, and Place (SCAMP). 

Assessment/Self Monitoring 

Using the ComB approach, the therapist and client complete a thorough assessment of the functions that the behaviors serve for the individual as well as the internal and external triggers for the BFRB. Internal triggers may be sensations, thoughts and feelings, while external triggers may be places and activities that lead to pulling or picking. Clients spend time monitoring behavior between sessions to illuminate all aspects of the behavior. 

Choosing Individualized Strategies 

The therapist helps the client explore the use of individualized strategies selected specifically to target internal and external triggers of the BFRB. For example, if itching is a trigger and scratching starts or leads to pulling, the individual might be encouraged to use a wide tooth comb as a sensory substitute, not only to provide relief for itching, but also to discourage the fingertips from making contact with the scalp. An individual who picks scabs to feel the smooth sensation on the skin might be directed to carry a smooth stone with her to manipulate when she wants to feel the smooth sensation. Another person who picks skin or pulls hair to reduce worrisome thoughts might be taught cognitive interventions for reducing worry. Each intervention is strategically designed to address unique needs that are achieved by picking or pulling. 

Internal and External Triggers for BFRBs 

Internal triggers refer to sensory experiences (sight, touch, smell, taste and sound), thoughts and feelings that can trigger a BFRB episode. Interventions are selected specifically to address needs in any of these areas. For example, if a person has a belief that “all coarse hairs must be removed,” an intervention would focus on challenging this thought and changing this rigid belief. External triggers for BFRBs refer to identifying the environment or activities that typically lead to a BFRB and finding ways to alter them in order to reduce the behavior. For example, for those individuals who engage in picking or pulling in front of a mirror, it might be recommended that the mirror be removed or covered for a period of time or that the lights in the bathroom be dimmed to reduce the ability to see. Knowing when and where the behavior is likely to happen is helpful. Techniques to raise awareness of the behavior are important because many people engage in BFRBs in a habitual or automatic way, without much awareness of their behavior. Barriers such as gloves, Band Aids, medical tape or hats are used to raise awareness so that an individual can become more conscious of their behavior and ultimately change it. 

The ComB model provides a useful framework for pullers and pickers to evaluate the triggers and consequences to their behavior. This model also suggests tools to  increase behavioral awareness and multiple and varied interventions for early prevention as well as all throughout the behavior chain that leads to picking and pulling. This treatment has had limited empirical evaluation to date though studies are currently being conducted. 

Acceptance and Commitment Therapy 

A promising treatment approach that may serve to add strength to other cognitive behavior therapies is called acceptance and commitment therapy (ACT), developed by Steven Hayes. This approach differs from others in that it promotes an increased acceptance of, and tolerance for, urges to pick or pull, without acting to reduce or eliminate them. Thus, individuals are asked to experience negative emotions that come before or after pulling as events to be observed without judgment rather than as events that must be acted upon. Understanding, feeling and experiencing that one does not have to respond to an urge or emotion can be quite freeing. 

Understanding a Patient’s Values 

A key part of ACT is to understand what is meaningful and important to the individual. What do they want to be remembered for? The rest of treatment is set in this context. Patients ask themselves throughout treatment if what they are doing in the BFRB process is moving them in a way that is consistent or inconsistent with their stated values.

Understanding How Patients Relate to Urges and Negative Experiences 

Part of the therapy process involves discussing how the patient uses pulling/ picking and other methods to reduce or eliminate urges, anxiety, or sensations that they experience as unpleasant.  Through this process, it is often the case that patients have not found an effective and healthy strategy to control these experiences that does not also prevent them from doing things that they value. 

Seeing Internal Experiences for What They Are 

A large part of ACT involves teaching patients what private experiences like urges, thoughts and emotions are, and what they are not.  Often, people treat their private experiences as if they must cause pulling to occur or must cause people to react. However, through various exercises, patients are taught to understand what urges, thoughts and emotions are—events that a patient can choose to react to or not react to—and that these events are temporary. Often, people have a tendency to try to eliminate unpleasant experiences. In ACT, mindfulness-based strategies are used to teach patients to openly accept (not necessarily enjoy or like) any internal experience they have without trying to reduce, modify, or eliminate them. 

Commitment to the Process 

The individual will need to commit to working on their difficulties by experiencing and tolerating these thoughts and emotions instead of attempting to avoid them. 

ACT-Enhanced Behavior Therapy 

Dr. Douglas Woods and his colleagues developed an ACT-enhanced behavior therapy that combines principles of ACT with other strategies typically used to treat BFRBs, including HRT and stimulus control. These latter strategies are employed only to make the pulling or picking more difficult for the individual (not to eliminate urges) so the individual can engage in more value-driven activity. 

Early research has documented that the use of ACT-enhanced habit reversal treatment is more effective than a control condition in reducing pulling symptoms. Importantly, short-term treatment benefits were also maintained several months after treatment termination. Additional research is needed to confirm these findings. A large-scale randomized, controlled trial of ACTenhanced behavior therapy is underway. 

Dialectical Behavior Therapy 

Dialectical Behavior Therapy (DBT), a treatment developed by Marsha Linehan, is another treatment approach that may add to the effectiveness of other learning-based therapies.  DBT was researched by Dr. Nancy Keuthen in conjunction with more traditional habit reversal and stimulus control approaches.  A pilot and a randomized controlled study demonstrated the superiority of DBT-enhanced behavior therapy to a minimal attention control condition for TTM. Maintenance of treatment benefit months after treatment termination was demonstrated. As with all other approaches discussed earlier, additional research is needed to confirm treatment efficacy and to understand the mechanisms by which they reduce symptoms. This approach has not yet been utilized to treat BFRBs other than hair pulling. 

DBT has four modules including mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance. In DBT-enhanced behavior therapy, all of the modules were utilized except for interpersonal effectiveness. These modules are discussed below. 


This module borrows from Buddhism in its focus on living in the moment and experiencing feelings and senses fully with a nonjudgmental perspective. Mindfulness can help the individual to be more aware of BFRB triggers and early motor movements that precede the BFRB, reduce worry by being present focused and accept and tolerate powerful emotions without acting on them. 

Emotion Regulation 

This module instructs individuals in how to better manage their emotions using the follow techniques: 

  • Identify and label emotions 
  • Identify obstacles to changing emotions 
  • Reduce vulnerability to emotions 
  • Increase positive emotional events
  • Increase mindfulness to current emotions
  • Take opposite action 
  • Experience uncomfortable emotions without acting on them 

Given that emotions often trigger picking and pulling behavior, the goal is to instruct the individual in more functional methods of emotion regulation that can preclude the need for engagement in the BFRB. 

Distress Tolerance 

This module is designed to instruct the individual in different ways to tolerate or get through a crisis situation in the short-term without making it worse. These techniques can be employed to tolerate uncomfortable urges to pull or pick without acting on them. 

Note: The types of cognitive behavior therapy described above are not mutually exclusive. Elements derived from several approaches may be helpful for an individual striving to manage a BFRB.

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