ADHD News & Research

Study: Trichotillomania, Excoriation, Other BFRBs Reduced with Habit Replacement Training

Half of the study participants with trichotillomania, excoriation, or nail-biting disorder reported that habit replacement training improved their symptoms of body-focused repetitive behavior; 80% said they would recommend the program, a new JAMA study found.

August 18, 2023

Habit replacement training significantly reduced body-focused repetitive behaviors (BFRBs) for more than half of patients with excoriation (skin picking), trichotillomania (hair pulling), nail biting, lip-cheek biting, and other BFRBs, according to a six-week proof-of-concept study published in JAMA.1

Of the study’s 268 participants, 53% of those who practiced habit replacement techniques reported improvement compared to 20% of the control group. Those who exhibited nail-biting benefited the most.

Further, 80% of those who practiced habit replacement said they would recommend it to a friend with similar problems, and 86% reported overall satisfaction with the training, which substituted the pleasurable sensation of skin picking, nail-biting, or hair pulling with another action that feels good but isn’t harmful to the body.

“BFRBs refer to recurrent and chronic behaviors inflicted upon the body (like trichotillomania and excoriation) that often result in physical damage,” said Roberto Olivardia, Ph.D., in the ADDitude webinar “Nail Biting! Skin Picking! Hair Pulling! Understanding Body-Focused Repetitive Behaviors with ADHD.”

The TLC Foundation for Body-Focused Repetitive Behaviors estimates that BFRBs affect about 3% of people worldwide. However, researchers said BFRBs often go unreported, undiagnosed, and misdiagnosed due to the shame associated with the condition. Consequently, few therapists specialize in the disorder, and many are unaware of effective treatments. 1, 2 New studies suggest a scientific link between BFRBs and ADHD, a connection confirmed by anecdotal evidence.

“BFRBs can be impulsive because individuals often mindlessly partake in them,” Olivardia said. “These behaviors can also be compulsive, wherein individuals are aware of what they’re doing and often want to stop the behavior but feel that they can’t. Those who have BFRBs report feeling pleasure and/or pain from these habits, and they often dislike the consequences of their behaviors, making it a distressing group of conditions.”

Participants in the self-help habit replacement group received a manual and video demonstrating several gentle, self-soothing techniques (i.e., circling fingertips on the palm, tapping the middle and index fingers against the thumb, crossing arms, etc.) to use whenever they felt the urge to engage in the harmful behavior. Participants in the wait-list control group received the training after the study concluded.

“The goal is to replace the BFRB with another repetitive behavior that is inconspicuous, self-soothing, and benign,” the researchers wrote.


Despite limited research on the intersection between ADHD and BFRBs, a few studies have linked the two conditions. A study from the University of Chicago, Harvard Medical School, and the University of Cambridge reported that 29% of people with trichotillomania disorder had ADHD, and 23.5% of individuals with excoriation disorder had ADHD, according to a study published in the Journal of Psychiatric Research.3, 4

“I see the presence of both [BFRBs and ADHD] all the time in clinical practice,” Olivardia said. “And while BFRBs are conceptualized within an OCD framework, I believe that some behaviors may be related to or driven by ADHD.”

Results from the proof-of-concept trial may provide relief to those struggling with BFRBs. However, the researchers acknowledged several limitations to the study, including a lack of verified diagnoses and missing follow-up data.

“Habit replacement is recommended for those with no access to direct therapeutic treatment or to bridge wait times,” they said. “It may also be adopted by those who do not respond to standard treatment. Whether administration by a therapist or combining the technique with other established interventions elevates, the effect remains to be examined.”

View Article Sources

1Moritz, S., Penney, D., Missmann, F., Weidinger, S., Schmotz, S. (2023) Self-Help Habit Replacement in Individuals With Body-Focused Repetitive Behaviors: A Proof-of-Concept Randomized Clinical Trial. JAMA Dermatol.e232167.

2Houghton, D.C., Alexander, J.R., Bauer, C.C., Woods, D.W. (2018) Body-focused Repetitive Behaviors: More Prevalent Than Once Thought? Psychiatry Res.

3Jon E. Grant, J.E., Dougherty, D.D., Chamberlain, S.R. (2020). Prevalence, Gender Correlates, and Co-Morbidity of Trichotillomania. Psychiatry Research.

4Grant, J.E., Chamberlain, S.R. (2020). Prevalence of Skin Picking (Excoriation) Disorder. J Psychiatr Res.