Virtual Therapy Habit Reversal Training for Body-Focused Repetitive Behaviors: Clinical Outcomes from a Large Real-World Sample of Youth and Adults

Abstract Objective To examine the effectiveness of virtual therapy-delivered habit reversal training (HRT) in large real-world samples of children, adolescents, and adults with trichotillomania and excoriation disorder. Methods The sample included 543 patients with trichotillomania (57 children, 75 adolescents, 408 adults) and 528 patients with excoriation disorder (40 children, 46 adolescents, 442 adults). Treatment followed a protocol of twice-weekly HRT sessions, transitioning to weekly sessions. The Repetitive Body Focused Behavior Scale (RBFBS) was administered at baseline, weeks 5-7, weeks 14-16, and during maintenance periods through week 52. Results At weeks 14-16, trichotillomania showed a median 33.33% severity reduction (IQR=11.11%-54.55%; 44.08% achieving ≥35% reduction) with large effects (Hedges’ g=1.01, 95% CI [0.88, 1.14]). Excoriation showed a median 33.33% reduction (IQR=12.50%-57.14%; 48.66% achieving 35% reduction; g=1.16 [1.02-1.30]). Improvements were maintained through week 52 (trichotillomania: g=1.51 [CI: 1.23 to 1.79]; excoriation: g=1.56 [1.29-1.84]). Both conditions showed improvements in depression, anxiety, and stress (g=0.22-0.29). Mean treatment duration was 14.64±2.50 weeks (7.71±2.61 sessions) for trichotillomania and 14.54±2.69 weeks (7.73±2.68 sessions) for excoriation. All age groups improved, with effect sizes ranging from g=0.78-1.11 for trichotillomania and g=0.68-1.54 for excoriation. Conclusion This analysis demonstrates that virtual therapy-delivered HRT can effectively reduce both hair-pulling and skin-picking severity and improve related symptoms in a real-world setting. The large treatment effects and improvements across the lifespan for both conditions suggest this delivery format may help address barriers to accessing evidence-based care for body-focused repetitive behaviors.