Individuals with body dysmorphic disorder engage in maladaptive behaviors such as checking mirrors, excessive grooming, asking others for reassurance, and avoiding situations due to their appearance. These counterproductive coping mechanisms, or false “safety behaviors,” serve to maintain and exacerbate symptoms rather than alleviating them. The present review provides a summary of cross-sectional, longitudinal, experimental, and treatment research to highlight the relevance of these behaviors to body dysmorphic disorder. Additionally, the article identifies current gaps in the research and future directions that will be important in further understanding the role of these behaviors.
Trichotillomania (TTM) research lacks an ecologically valid phenomenological description despite increasing research efforts. Previous studies primarily rely on retrospective cross-sectional data, emphasizing the need for longitudinal high-frequency assessments to capture the variability of hair pulling.
The objective of this study was to describe hair pulling patterns and episode characteristics by means of ecological momentary assessment (EMA), and to compare those parameters between focused and automatic episodes.
Study procedures included an online screening, a diagnostic interview via telephone, a comprehensive self-report questionnaire and a 10-day EMA-protocol (7 EMAs/day).
Data from 61 individuals who met diagnostic criteria for TTM (age: M = 29.3, SD = 7.47; 92% female) were analyzed (3948 EMAs; 1217 episodes). Participants reported a mean number of 2.00 (SD = 2.31; range: 0–4.9) episodes per day. One third did not report any days without episodes. Hair pulling showed a relatively even distribution throughout the day. Most prominent triggers were tension and visual/tactile cues. The latter were more relevant in focused episodes, whereas “habit/routine” scored higher in automatic episodes.
The results suggest that hair pulling occurs not sporadic but is rather present in daily life. Using real-time data from a clinical sample, the study enhances our comprehension of the phenomenology of TTM which may ultimately advance TTM research.
Treatment for trichotillomania is notably limited, preventing suffering individuals from having access to treatment. To address this need, researchers have developed and tested asynchronous online interventions for adults with trichotillomania. A factor that may impact the efficacy of these programs is the use of phone check-ins (or similar coaching support) to improve treatment adherence in website treatment delivery. In the current study we evaluated the role of check-ins on treatment adherence and efficacy of a website delivering acceptance and commitment therapy-enhanced behavior therapy (A-EBT). A sample of 101 adults with trichotillomania were randomly assigned to an A-EBT web-based intervention with or without phone check-in support. Adherence to the web-based program was not significantly improved by check-ins and treatment outcomes did not vary by condition (with or without check-ins). However, adherence to the program across conditions, did predict treatment outcomes. The program was found to be effective at decreasing trichotillomania symptom severity and improving trichotillomania specific psychological inflexibility over time across check-in conditions. Our findings suggest that check-ins did not improve adherence to or efficacy of the program, thus supporting recent literature suggesting that check-ins do not necessarily improve program adherence.

