Trichotillomania is a psychiatric disorder characterized by recurrent and irresistible urges to pull out one’s own hair. It is classified as a habit and impulse control disorder in ICD-10 and as part of the Obsessive-Compulsive and Related Disorders group in DSM-5. Epidemiologically, this condition affects approximately 1.14% to 3% of the global population, with a higher prevalence among adult females, and is often accompanied by comorbidities such as anxiety disorders or depression. The etiology is multifactorial, involving a complex interaction between genetic vulnerability, abnormalities in brain structure and metabolism, and maladaptive coping mechanisms to stress. The main clinical manifestation is noticeable hair loss resulting from repetitive hair-pulling behavior, typically preceded by emotional tension and followed by a temporary sense of relief. Comprehensive management involves a multimodal approach, in which behavioral therapy—particularly Cognitive Behavioral Therapy (CBT) with Habit Reversal Training (HRT)—is considered the first-line treatment, while pharmacotherapy such as clomipramine or selective serotonin reuptake inhibitors (SSRIs) may be considered in moderate to severe cases. Prognosis varies depending on the age of onset and treatment success; however, early detection and management of comorbidities are crucial to prevent long-term psychosocial consequences and to improve patients’ quality of life.

Abstract Trichotillomania, though an impulse control disorder, is encountered in psychiatric clinical practice, with most patients being referred by dermatologists. Current literature does not recommend any single pharmacological agent showing efficacy in treatment, with add-on psychotherapy offering promising results. We present a case series based on habit reversal training for trichotillomania of three females – across of varied ages, marital status, educational status, and different comorbidities, in varied treatment settings (both – outpatient and inpatient), with varied modes of treatment (offline and online) being treated with pharmacotherapy in combination. Objective assessments were done on the Massachusetts General Hospital Hair Pulling Scale and photographic evidence, documented at baseline and at regular intervals. Over a 4 week follow-up period, the combination therapy proved to be efficacious and tolerable with satisfactory improvement in symptoms in all patients.

Sensory-integrated habit reversal intervention for hair pulling and classroom engagement in children with autism: A multiple-baseline pilot study.

<b>Conclusion:</b> This analysis shows promising evidence that therapist-delivered video therapy HRT is associated with reductions in both hair-pulling and skin-picking severity and improvements in 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.

Behavioral interventions for tic disorders.

Background: Excoriation disorder (dermatillomania) is a body-focused repetitive behavior characterized by recurrent skin picking that leads to tissue injury, emotional distress, and impaired functioning. Although formally classified in ICD-11 and DSM-5, the disorder remains underrecognized in clinical settings and often co-occurs with other psychiatric conditions. This review summarizes current evidence on the epidemiology, clinical profile, comorbidity patterns, and available treatment strategies, underscoring its clinical burden and therapeutic relevance. Methods: A narrative review of peer-reviewed clinical studies, epidemiological analyses, neurobiological investigations, and treatment trials was conducted, focusing on prevalence, risk factors, clinical outcomes, and therapeutic interventions for excoriation disorder. Results: The disorder affects approximately 3–4% of the population, predominantly females, with onset most often during adolescence and a chronic, relapsing course. Commonly affected areas include the face, arms, and hands, with episodes frequently preceded by anxiety or tension and followed by temporary relief. High rates of comorbidity, particularly with depression, anxiety, OCD, and body dysmorphic disorder, contribute to psychosocial disability, reduced quality of life, and an elevated risk of suicidal ideation. Clinical studies support behavioral therapies, especially cognitive-behavioral approaches such as habit reversal training, as first-line treatment. Pharmacological options, including serotonergic, opioid, or glutamatergic agents, as well as lamotrigine, show benefit in selected cases, although response rates remain variable. Conclusions: Excoriation disorder is a prevalent and burdensome condition with substantial psychiatric overlap and functional consequences. Early detection and integrated treatment combining behavioral interventions with targeted pharmacotherapy when appropriate are essential to improving outcomes and reducing long-term morbidity.

Introduction: Trichotillomania and skin-picking disorder are chronic body-focused repetitive behaviors that result in significant psychological distress and physical harm. Both conditions are classified under obsessive-compulsive and related disorders, sharing neurobiological mechanisms involving cortico-striatal-thalamo-cortical circuitry dysregulation. Despite advances in understanding these disorders, their underlying pathophysiology and optimal treatment strategies remain incompletely elucidated. Objective: The main objective of this review was to systematically evaluate the neurobiological correlates and treatment outcomes in patients with trichotillomania and skin-picking disorder. Secondary objectives included: (1) examining the role of functional and structural neuroimaging in elucidating neural abnormalities; (2) assessing pharmacological interventions, including glutamatergic and serotonergic agents; (3) evaluating the efficacy of cognitive-behavioral therapies and habit reversal training; (4) comparing outcomes across combined therapeutic modalities; and (5) identifying gaps in the literature to guide future research. Methods: A systematic search was performed in PubMed, Scopus, Web of Science, Cochrane Library, LILACS, ClinicalTrials.gov, and the WHO ICTRP registry for studies published between January 2015 and December 2025. Eligible studies included randomized controlled trials, cohort studies, case-control designs, and neuroimaging research involving human participants diagnosed with trichotillomania or skin-picking disorder. Animal and in vitro studies were included separately when relevant. Risk of bias was assessed using RoB 2 and ROBINS-I tools, and evidence certainty was appraised through the GRADE framework. Results and Discussion: Twenty-three studies met inclusion criteria, encompassing neuroimaging analyses, pharmacological trials, and behavioral therapy evaluations. Neurobiological findings consistently implicated hyperactivity in the anterior cingulate cortex, insula, and basal ganglia regions, while pharmacological interventions such as N-acetylcysteine and SSRIs showed variable efficacy. Cognitive-behavioral interventions, particularly habit reversal therapy, demonstrated the most consistent improvement across studies. Multimodal treatment approaches appeared to yield superior outcomes. Conclusion: Trichotillomania and skin-picking disorder exhibit shared neural dysregulation within inhibitory control circuits, supporting their conceptualization as related compulsive spectrum disorders. Behavioral therapy remains the cornerstone of treatment, though adjunctive pharmacological strategies may enhance outcomes in selected cases. Continued research integrating neuroimaging and longitudinal follow-up is essential to refine individualized, mechanism-based interventions.

Tic disorders, such as Tourette syndrome, are neurodevelopmental conditions marked by involuntary motor or vocal tics. Although these disorders have strong genetic and neurobiological bases, their expression and persistence are influenced by internal experiences and external environmental factors. Behavioral interventions have demonstrated significant efficacy in managing tic symptoms. This review examines three principal evidence-based behavioral treatments for tic disorders: habit reversal training (HRT), exposure with response prevention (ERP), and comprehensive behavioral intervention for tics (CBIT). Each intervention is analyzed based on its theoretical foundation, therapeutic components, and clinical implementation. The shared objective of these treatments is to disrupt the reinforcement mechanisms that maintain tic expression, thereby reducing symptom severity. This review synthesizes empirical evidence supporting the efficacy of HRT, ERP, and CBIT as frontline treatments for tic disorders. Drawing upon randomized controlled trials, long-term follow-up studies, and open-label trials, we examine therapeutic outcomes, methodological strengths and limitations, and the clinical generalizability of each intervention. The findings indicate robust short- and long-term efficacy for HRT and CBIT, whereas ERP shows promising short-term outcomes but a relative paucity of long-term data. Methodological variability, including session format and evaluator blinding, is addressed to inform clinical applications and guide future research.

Trichotillomania (TTM) is a common psychiatric disorder characterized by a recurrent, irresistible urge to pull out one's hair. This disorder has widespread adverse physical, psychological, social, and emotional effects on the lives of those affected, yet these experiences are under-documented. This study aimed to explore the lived experiences of individuals with TTM in Iran. In this phenomenological study, 12 individuals with TTM (with a mean age of 26.1 ± 6.3 and consisting of seven women and five men) were selected using purposive sampling. Data were collected through in-depth semi-structured interviews and analyzed using Colaizzi's seven-step method. Lincoln and Guba's (2004) criteria were used to ensure trustworthiness, and data management was performed using MAXQDA 2020 software. The experiences of individuals with TTM were categorized into six main themes and 23 sub-themes. The main themes included The Compulsion Loop - Trapped in Repetitive Urges, Emotional Struggles, Identity and Socio-Cultural Pressures, The Body as Battlefield - Physical and Psychological Consequences, Journey Towards Recovery and Barriers to the path of recovery. Individuals with TTM experience intense internal conflict with wide-ranging psychological and social consequences. They are trapped in this destructive behavior due to the immediate gratification derived from hair pulling and tend to conceal the disorder due to social stigma. While some individuals improve through self-regulation and coping strategies such as cognitive behavioral therapy and habit reversal training, others become trapped in a cycle of failure through self-sabotaging defense mechanisms. Increased public awareness, psychosocial support, and the provision of effective therapeutic interventions, such as cognitive behavioral therapy and habit reversal training, are recommended to facilitate the recovery process for these individuals.

Trichotillomania (TTM) is a condition characterized by recurrent hair pulling, often resulting in hair loss and functional impairment. The disorder remains underreported in the pediatric population, despite high rates of psychiatric comorbidities. Moreover, diagnosing and treating TTM among children remains challenging due to a lack of standardized guidelines. Hence, this systematic review aims to evaluate the current treatment approaches for pediatric TTM. A comprehensive search was conducted of five databases, using the search concepts of trichotillomania, pediatric populations, and treatments/interventions. Studies were included if they (1) directly addressed the topic, (2) were of an appropriate study type (e.g., clinical trials, case-control studies, cohort studies, cross-sectional studies, or interview studies), (3) were published within the past 10 years, and (4) appeared in peer-reviewed journals published in English. Ultimately, 10 studies met our inclusion criteria, from which data were extracted and synthesized following formal quality assessment. Our results indicate that behavioral interventions, particularly habit reversal training, consistently demonstrated the greatest therapeutic benefit. Pharmacological treatments, including selective serotonin reuptake inhibitors, have been explored in various case series. Although some individuals have shown improvement, overall evidence remains insufficient to support pharmacotherapy as first-line. Alternative therapies, such as N-acetylcysteine, have also been studied, though findings are variable and require further investigation in pediatric cohorts. Our review underscores the importance of early behavioral intervention and the need for larger, controlled studies to inform standardized treatment protocols. Given the functional and psychosocial burden of TTM in youth, comprehensive management strategies are essential.

This case study demonstrates the use of Habit Reversal Training (HRT) combined with Relaxation Training (RT) in addressing trichotillomania. The subject, a 28-year-old woman, reported experiencing stress and frequent lateness to work. Her hair-pulling behavior, triggered by the early appearance of grey hair, led her to spend 30 to 60 minutes each morning pulling her hair, which contributed to her tardiness. Over the course of 14 weekly therapy sessions, interventions included self-monitoring, psychoeducation, identification and modification of visual triggers, stimulus-response strategies, and restructuring daily routines. The treatment resulted in reduced stress and effective control of hair-pulling behaviors. The case suggests that incorporating a hair care regimen into therapy may further enhance positive outcomes. It also highlights the importance of considering both psychological and societal influences in the development and treatment of trichotillomania.

Background Habit reversal training (HRT) is an efficacious intervention for individuals with tic disorders that can be delivered both in-person and via telehealth. Despite noted effectiveness, no known studies have directly compared provider perceptions of these modalities of HRT delivery. Methods Professionals providing HRT for individuals with tic disorders ( n = 136) completed an online survey to assess perceptions of telehealth-delivered HRT compared to in-person services. Results Providers reported lower feasibility of telehealth relative to in-person HRT for patients younger than 8 years old but greater feasibility of telehealth for patients 13-17 years old and 18-65 years old. Telehealth HRT was perceived to be more feasible for patients with less severe tic presentations. Providers reported greater feasibility in an in-person environment compared to telehealth for addressing therapeutic factors, individual patient differences, and characteristics of the patients’ tics. Lastly, providers reported that all aspects of HRT are more feasible to implement in-person compared to telehealth settings. Conclusion Findings suggest there are a variety of clinical factors that providers believe could impact HRT treatment, which should be considered when determining whether an in-person or telehealth treatment model is best fit for individuals with tic disorders.

Dissemination Trial of Provider Training of ACT-Enhanced Behavior Therapy for Trichotillomania: A Waitlist Controlled Study.

IntroductionGilles de la Tourette Syndrome (GTS) is characterised by tics which appear as sudden, rapid, purposeless motor movements and vocalisations. In contrast to other movement disorders, temporary and purposeful suppressibility for a few minutes at a time can be achievable. However, this is ineffective over time. Apart from the physical consequences incurred, tics and their associated neuropsychiatric symptoms can diminish individual quality of life.ObjectivesTo present an adult single case study of the implementation of Habit Reversal Training (HbRT) for the treatment of a motor tic and to determine the clinical efficacy of the intervention over time (i.e., post-intervention and at a one-, three- and six-month follow-up).MethodsA twenty-six-year-old male patient with a well-established diagnosis of GTS was referred to a tertiary-care neuropsychiatry outpatient clinic. Prior to the HbRT intervention, the patient had well-tolerated a continuous tetrabenazine prescription (25mg twice a day). His tic consisted of twitching of his nostrils and sudden and repeated head nods. The tic was reported to being experienced throughout the day and almost always being preceeded by a premonitory sensation. The patient’s history was unremarkable with respect to pre, peri-, and postnatal development. There was no family history of tics nor any other movement disorders. Formal measures revealed the following: Clinical Outcomes in Routine Evaluation-Outcome Measure (11), Frost Multidimensional Perfectionism Scale (117), Autism-Spectrum Quotient (2), Adult Attention Deficit Hyperactivity Disorder Scale (1), and Yale-Brown Obsessive Compulsive Scale (15).ResultsBy the end of a five-week fifty-minute one-to-one intervention window and at a one-, three-, and six-month follow-up appointment, the following main results are reported: [i] at post-intervention, a self-reported tic improvement score (measuring effectiveness of competing response on tic management since the first appointment) of eighty percent was achieved, [ii] self-reported tic improvement scores carried over to all three follow-up appointments, and [iii] week-to-week monitoring revealed that tic management improved by fifty percent by the third week of the intervention.ConclusionsThis study has accomplished its objectives of offering additional support for the implementation of HbRT for the treatment of a motor tic and to establish the clinical efficacy of the intervention over time. With these objectives in mind, TD and GTS continues to provide clinicians, clinician-scientists, and researchers with an abundance of possibilities for future research. For instance, on a clinical level, it is essential to further characterize variations in motor tic phenotype so that the factors that modify tic behaviour can be clarified. It would also be fascinating to longitudinally study and explore changes in tic frequency and intensity over time following a behavioural intervention such as HbRT.Disclosure of InterestNone Declared

The Effectiveness of Habit Reversal Training in Tic Disorders in Children and Adolescents

<h3>Introduction</h3> Skin-picking disorder (SPD), also known as excoriation disorder or dermatillomania, is characterized by compulsive skin picking, resulting in tissue damage. SPD affects 3.5% of the US population and is more common in females. Patients find their picking difficult to stop and tend to suffer from social impairments and emotional distress. Herein, we explore risk factors, comorbidities, and treatment options associated with SPD. <h3>Methods</h3> One thousand thirty-three unique articles were retrieved from PubMed. We conducted title, abstract, and full-text screenings to identify articles describing psychiatric comorbidities of SPD and current treatments. <h3>Findings</h3> Fifty-five articles met inclusion criteria, offering epidemiological data regarding SPD and common psychiatric conditions, including attention-deficit/hyperactivity disorder, posttraumatic stress disorder, trichotillomania, and depressive and anxiety disorders. Clinical data on behavioral therapies (cognitive behavioral therapy, habit-reversal training, and acceptance and commitment therapy), as well as pharmacotherapy, were also included. <h3>Conclusion</h3> While no official treatment guidelines exist for SPD, this review sought to characterize pertinent risk factors and promising emerging therapies. Cognitive behavioral therapy, habit-reversal training, and glutamate-modulating agents (eg, N-acetylcysteine and memantine) were observed to be the most efficacious. Larger studies are required to validate these treatments and understand their long-term outcomes.

A retrospective study was conducted on the clinical data of 122 children diagnosed with chronic tic disorders admitted to Hebei Children's Hospital Affiliated to Hebei Medical University from January 2021 to January 2024. According to different treatment methods, patients were separated into the HRT group (n = 55), who received routine HRT, and the music therapy group (n = 67), who received music therapy combined with HRT. The baseline data before treatment and the clinical efficacy after 8 weeks of treatment of the two groups were compared. Before and after the 8-week treatment, the Yale Global Tic Severity Scale (YGTSS) scores, serum neurotransmitter levels, Child Behavior Checklist (CBCL), and Pediatric Quality of Life Inventory (PedsQL) were compared between the two groups. After an 8-week treatment, the Global Severity Score and Total Tic Score of YGTSS significantly decreased in both groups, with the music therapy group showing lower scores than the HRT group (P < 0.05). The total effective rate in the music therapy group was higher than that in the HRT group (92.54% vs. 80.00%, P < 0.05). Serum dopamine and serotonin levels significantly decreased after treatment in both groups, with the music therapy group showing lower levels than the HRT group (P < 0.05). Conversely, serum γ-aminobutyric acid levels significantly increased after treatment in both groups, with the music therapy group showing higher levels than the HRT group (P < 0.05). The CBCL and PedsQL scores significantly improved after treatment in both groups, with the music therapy group showing a significant decrease in CBCL scores and a significant increase in PedsQL scores compared with the HRT group (P < 0.05). Music therapy combined with HRT significantly enhanced treatment efficacy for children with tic disorders. It reduced tic severity, improved behavioral outcomes, and modulated neurotransmitter levels. The study demonstrated the potential clinical value of music therapy as a nonpharmacological treatment for tic disorders.

Treatment strategies for skin picking disorder: Efficacy of pharmacological and nonpharmacological approaches—A systematic review and evidence mapping

This case study explores the application of Cognitive Behavioral Therapy (CBT) in treating Trichotillomania (Hair-Pulling Disorder) in a 12-year-old adolescent female. She presented with recurrent hair-pulling behaviours resulting in significant hair loss and emotional distress, including feelings of guilt, shame, and social withdrawal. Using a comprehensive assessment approach, including the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS) and Impairment Scale (NIMH-TIS), her condition was initially evaluated as severe. The therapeutic intervention employed a structured CBT approach incorporating psychoeducation, Habit Reversal Training (HRT), stimulus control, and cognitive strategies to address the cognitive-behavioural cycle contributing to her hair-pulling behaviours. Following 10 therapy sessions, she demonstrated a significant improvement, with reductions in hair-pulling behavior. Post-treatment assessments revealed a marked decrease in severity, as evidenced by a reduction in NIMH-TSS and NIMH-TIS scores, as well as noticeable hair regrowth. This case highlights the efficacy of CBT, especially when combined with behavioural strategies, in treating trichotillomania and underscores the importance of family involvement and relapse prevention techniques in ensuring long-term recovery.

Psychosomatic diseases of the oral cavity present complex challenges involving physical symptoms with psychological factors.Traditional medical treatments often fall short, necessitating a holistic approach that addresses both the mind and body to achieve harmony in health.This paper explores a multifaceted management strategy for these disorders, integrating pharmacological treatments, behavioural therapies, and supportive care.Pharmacological interventions remain essential, with antidepressants, anticonvulsants, and anxiolytics providing symptom relief.However, these are complemented by behavioural therapies such as Habit Reversal Training (HRT), which targets the elimination of harmful oral habits through awareness and competing response strategies.Cognitivebehavioural therapy (CBT) and mindfulness-based stress reduction (MBSR) also play crucial roles in addressing the psychological aspects of these disorders, promoting mental well-being and reducing symptom exacerbation.Biofeedback is a therapeutic technique that has been employed in the management of various psychosomatic disorders, including those that manifest in the oral region This holistic approach not only alleviates physical symptoms but also addresses emotional and psychological distress, leading to comprehensive care and improved quality of life for patients with psychosomatic oral diseases.By harmonizing physical and mental health strategies, this method shows a balanced and effective model for managing complex oral health disorders.