Nail biting

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Nail biting
Nailbitebad.jpg
Fingernails of a nail-biter.
Specialty Pediatrics, psychiatry
Risk factors Damaged cuticles, shortened and damaged nails, hangnails, bleeding, etc.

Nail biting, also known as onychophagy or onychophagia, is an oral compulsive habit of biting one's fingernails. It is sometimes described as a parafunctional activity, the common use of the mouth for an activity other than speaking, eating, or drinking.

Contents

Nail biting is very common, especially amongst children, of which 25–35 percent bite nails. More pathological forms of nails biting are considered an impulse control disorder in the DSM-IV-R and are classified under obsessive-compulsive and related disorders in the DSM-5. The ICD-10 classifies the practice as "other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence". [1] However, not all nail biting is pathological, and the difference between harmful obsession and normal behavior is not always clear. [2] The earliest reference to nail biting as a symptom of anxiety was in the late sixteenth century in France. [3]

Signs and symptoms

Nail biting may lead to harmful effects to the fingers, like infections. These consequences are directly derived from the physical damage of biting or from the hands becoming an infection vector. Moreover, it can also have social consequences, such as withdrawal and avoiding handshakes. [2]

The ten fingernails are usually equally bitten to approximately the same degree. [4] Often, the adjacent skin is bitten off, too, which is called perionychophagia, a special case of dermatophagia. Biting nails can lead to broken skin on the cuticle. When cuticles are improperly removed, they are susceptible to microbial and viral infections such as paronychia. Saliva may then redden and infect the skin. [2] [4] In rare cases, fingernails may become severely deformed after years of nail biting due to the destruction of the nail bed. [2] [5]

Nail biting may have an association with oral problems, such as gingival injury, and malocclusion of the anterior teeth. [2] [6] It can also transfer pinworms or bacteria buried under the surface of the nail from the anus region to the mouth. [2] If the bitten-off nails are swallowed, stomach problems can occasionally develop. [6]

Nail-biting can be a source of guilt and shame feelings in the nail biter, a reduced quality of life, and increased stigmatization in the inner family circles or at a more societal level. [2] [7]

Other body-focused repetitive behaviors include onychotillomania (nail picking), excoriation disorder (skin picking), dermatophagia (skin biting), and trichotillomania (the urge to pull out hair), and all of them tend to coexist with nail biting. [2] [8] As an oral parafunctional activity, it is also associated with bruxism (tooth clenching and grinding), and other habits such as pen chewing and cheek biting. [9]

In children nail biting most typically co-occurs with attention deficit hyperactivity disorder (75% of nail biting cases in a study), [2] and other psychiatric disorders including oppositional defiant disorder (36%) and separation anxiety disorder (21%). [2] It is also more common among children and adolescents with obsessive–compulsive disorder. [2] [10] Nail biting appeared in a study to be more common in men with eating disorders than in those without them. [11]

Treatment

The most common treatment, which is cheap and widely available, is to apply a clear, bitter-tasting nail polish to the nails. Normally denatonium benzoate is used, the most bitter chemical compound known. The bitter flavor discourages the nail-biting habit. [12]

Behavioral therapy is beneficial when simpler measures are not effective. Habit reversal training (HRT), which seeks to unlearn the habit of nail biting and possibly replace it with a more constructive habit, has shown its effectiveness versus placebo in children and adults. [13] A study in children showed that results with HRT were superior to either no treatment at all or the manipulation of objects as an alternative behavior, which is another possible approach to treatment. [14] In addition to HRT, stimulus control therapy is used to both identify and then eliminate the stimulus that frequently triggers biting urges. [15] Other behavioral techniques that have been investigated with preliminary positive results are self-help techniques, such as decoupling [16] and the use of wristbands as non-removable reminders. [17] More recently, technology companies have begun producing wearable devices and smart watch applications that track the position of users' hands but no research has been published so far.[ citation needed ]

Another treatment for chronic nail biters is the usage of a dental deterrent device that prevents the front teeth from damaging the nails and the surrounding cuticles. After about two months, the device leads to a full oppression of the nail biting urge. [18]

Evidence on the efficacy of drugs is very limited, and they are not routinely used. [19] A small double-blind randomized clinical trial in children and adolescents indicated that N-acetylcysteine, a glutathione and glutamate modulator, could, in the short term only, be more effective than placebo in decreasing the nail-biting behavior. [19]

Nail cosmetics can help to ameliorate nail biting social effects. [20]

Independently of the method used, parental education is useful in the case of young nail biters to maximize the efficacy of the treatment programs, as some behaviors by the parents or other family members may be helping to perpetuate the problem. [2] For example, punishments have been shown not to be better than placebo, and in some cases may even increase the nail biting frequency. [2]

Epidemiology

Onychophagia Onychophagia.jpg
Onychophagia

While it is rare before the age of three, [2] about 30 percent of children between seven and 10 years of age and 45 percent of teenagers engage in nail biting. [2] [4] Finally, prevalence decreases in adults. [2] Figures may vary between studies, and could be related to geographic and cultural differences. [2] The proportion of subjects that have ever had the habit (lifetime prevalence) may be much higher than the proportion of current nail-biters (time-point prevalence). [21] Although there does not seem to be a gender correlation, results of epidemiological studies on this issue are not fully consistent. [2] It may be under-recognized since individuals tend to deny or be ignorant of its negative consequences, complicating its diagnosis. [8] Having a parent with a mental disorder is also a risk factor. [2]

Related Research Articles

<span class="mw-page-title-main">Trichotillomania</span> Compulsive hair-pulling disorder

Trichotillomania (TTM), also known as hair-pulling disorder or compulsive hair pulling, is a mental disorder characterized by a long-term urge that results in the pulling out of one's own hair. A brief positive feeling may occur as hair is removed. Efforts to stop pulling hair typically fail. Hair removal may occur anywhere; however, the head and around the eyes are most common. The hair pulling is to such a degree that it results in distress and hair loss can be seen.

<span class="mw-page-title-main">Obsessive–compulsive personality disorder</span> Personality disorder involving orderliness

Obsessive–compulsive personality disorder (OCPD) is a cluster C personality disorder marked by a spectrum of obsessions with rules, lists, schedules, and order, among other things. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations. The cause of OCPD is thought to involve a combination of genetic and environmental factors, namely problems with attachment.

Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFED, or the binge-purge subtype of anorexia nervosa.

Trichophagia is a form of disordered eating in which persons with the disorder suck on, chew, swallow, or otherwise eat hair. The term is derived from ancient Greek θρίξ, thrix ("hair") and φαγεῖν, phagein. Tricho-phagy refers only to the chewing of hair, whereas tricho-phagia is ingestion of hair, but many texts refer to both habits as just trichophagia. It is considered a chronic psychiatric disorder of impulse control. Trichophagia belongs to a subset of pica disorders and is often associated with trichotillomania, the compulsive pulling out of ones own hair. People with trichotillomania often also have trichophagia, with estimates ranging from 48-58% having an oral habit such as biting or chewing, and 4-20% actually swallowing and ingesting their hair. Extreme cases have been reported in which patients consume hair found in the surrounding environment, including other people's and animals' hair. In an even smaller subset of people with trichotillomania, their trichophagia can become so severe that they develop a hairball. Termed a trichobezoar, these masses can be benign, or cause significant health concerns and require emergency surgery to remove them. Rapunzel syndrome is a further complication whereby the hairball extends past the stomach and can cause blockages of gastrointestinal system.

Aversion therapy is a form of psychological treatment in which the patient is exposed to a stimulus while simultaneously being subjected to some form of discomfort. This conditioning is intended to cause the patient to associate the stimulus with unpleasant sensations with the intention of quelling the targeted behavior.

<span class="mw-page-title-main">Kleptomania</span> Inability to resist the urge to steal

Kleptomania is the inability to resist the urge to steal items, usually for reasons other than personal use or financial gain. First described in 1816, kleptomania is classified in psychiatry as an impulse control disorder. Some of the main characteristics of the disorder suggest that kleptomania could be an obsessive-compulsive spectrum disorder, but also share similarities with addictive and mood disorders.

Impulse-control disorder (ICD) is a class of psychiatric disorders characterized by impulsivity – failure to resist a temptation, an urge, or an impulse; or having the inability to not speak on a thought. Many psychiatric disorders feature impulsivity, including substance-related disorders, behavioral addictions, attention deficit hyperactivity disorder, autism spectrum disorder, fetal alcohol spectrum disorders, antisocial personality disorder, borderline personality disorder, conduct disorder and some mood disorders.

<span class="mw-page-title-main">Excoriation disorder</span> Medical condition

Excoriation disorder, more commonly known as dermatillomania, is a mental disorder on the obsessive–compulsive spectrum that is characterized by the repeated urge or impulse to pick at one's own skin, to the extent that either psychological or physical damage is caused.

Stereotypic movement disorder (SMD) is a motor disorder with onset in childhood involving restrictive and/or repetitive, nonfunctional motor behavior, that markedly interferes with normal activities or results in bodily injury. To be classified as SMD, the behavior in question must not be due to the direct effects of a substance, autism, or another medical condition. The cause of this disorder is not known.

Autophagia is the practice of biting/consuming one's body. It is a sub category of self-injurious behavior (SIB). Commonly, it manifests in humans as nail biting and hair pulling. In rarer circumstances, it manifests as serious self mutilative behavior such as biting off one's fingers. Autophagia affects both humans and non humans. Human autophagia typically occurs in parts of the body that are sensitive to pain, such as fingers. Human autophagia is not motivated by suicidal intent, but may be related to the desire to seek pain.

Habit reversal training (HRT) is a "multicomponent behavioral treatment package originally developed to address a wide variety of repetitive behavior disorders".

The obsessive–compulsive spectrum is a model of medical classification where various psychiatric, neurological and/or medical conditions are described as existing on a spectrum of conditions related to obsessive–compulsive disorder (OCD). "The disorders are thought to lie on a spectrum from impulsive to compulsive where impulsivity is said to persist due to deficits in the ability to inhibit repetitive behavior with known negative consequences, while compulsivity persists as a consequence of deficits in recognizing completion of tasks." OCD is a mental disorder characterized by obsessions and/or compulsions. An obsession is defined as "a recurring thought, image, or urge that the individual cannot control". Compulsion can be described as a "ritualistic behavior that the person feels compelled to perform". The model suggests that many conditions overlap with OCD in symptomatic profile, demographics, family history, neurobiology, comorbidity, clinical course and response to various pharmacotherapies. Conditions described as being on the spectrum are sometimes referred to as obsessive–compulsive spectrum disorders.

<span class="mw-page-title-main">Compulsive behavior</span> Habit and impulse disorder

Compulsive behavior is defined as performing an action persistently and repetitively. Compulsive behaviors could be an attempt to make obsessions go away. Compulsive behaviors are a need to reduce apprehension caused by internal feelings a person wants to abstain from or control. A major cause of compulsive behavior is said to be obsessive–compulsive disorder (OCD). "Compulsive behavior is when someone keeps doing the same action because they feel like they have to, even though they know these actions do not align with their goals." There are many different types of compulsive behaviors including shopping, hoarding, eating, gambling, trichotillomania and picking skin, itching, checking, counting, washing, sex, and more. Also, there are cultural examples of compulsive behavior.

<span class="mw-page-title-main">Dermatophagia</span> Compulsion towards biting ones own skin

Dermatophagia or dermatodaxia is a compulsion disorder of gnawing or biting one's own skin, most commonly at the fingers. This action can either be conscious or unconscious and it is considered to be a type of pica. Those affected with dermatophagia typically bite the skin around the nails, leading to bleeding and discoloration over time. Some people also bite on their skin on their finger knuckles which can lead to pain and bleeding just by moving their fingers.

<span class="mw-page-title-main">Obsessive–compulsive disorder</span> Mental and behavioral disorder

Obsessive–compulsive disorder (OCD) is a mental and behavioral disorder in which an individual has intrusive thoughts and feels the need to perform certain routines (compulsions) repeatedly to relieve the distress caused by the obsession, to the extent where it impairs general function.

Onychotillomania is a compulsive behavior in which a person picks constantly at the nails or tries to tear them off. It is not the same as onychophagia, where the nails are bitten or chewed, or dermatillomania, where skin is bitten or scratched. Onychotillomania can be categorized as a body-focused repetitive behavior in the DSM-5 and is a form of skin picking, also known as excoriation disorder.

<span class="mw-page-title-main">Body-focused repetitive behavior</span> All compulsions toward damaging ones own body in some way

Body-focused repetitive behavior (BFRB) is an umbrella name for impulse control behaviors involving compulsively damaging one's physical appearance or causing physical injury.

Morsicatio buccarum is a condition characterized by chronic irritation or injury to the buccal mucosa, caused by repetitive chewing, biting, or nibbling.

Decoupling is a behavioral self-help intervention for body-focused and related behaviors (DSM-5) such as trichotillomania, onychophagia, skin picking and lip-cheek biting. The user is instructed to modify the original dysfunctional behavioral path by performing a counter-movement shortly before completing the self-injurious behavior. This is intended to trigger an irritation, which enables the person to detect and stop the compulsive behavior at an early stage. A systematic review from 2012 suggested some efficacy of decoupling, which was corroborated by Lee et al. in 2019. Whether or not the technique is superior to other behavioral interventions such as habit reversal training awaits to be tested. Decoupling is a variant of habit reversal training.

<span class="mw-page-title-main">Habit-tic deformity</span> Condition of the nail caused by external trauma to the nail matrix

Habit-tic deformity is a condition of the nail caused by external trauma to the nail matrix. The condition is characterized by ridges which run horizontally across the entire nail, most often occurring on the thumbs, as well as marked damage to or absence of cuticles.

References

  1. ↑ "Impulse control disorder". SteadyHealth. 30 December 2010. Retrieved 28 April 2012.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Ghanizadeh, A (Jun 2011). "Nail biting; etiology, consequences and management". Iranian Journal of Medical Sciences. 36 (2): 73–9. PMC   3556753 . PMID   23358880.
  3. ↑ Aboujaoude, Elias; Koran, Lorrin M., eds. (2009). Impulse Control Disorders. doi:10.1017/cbo9780511711930. ISBN   9780511711930.
  4. 1 2 3 Leung AK, Robson WL (1990). "Nailbiting". Clin Pediatr (Phila). 29 (12): 690–2. doi:10.1177/000992289002901201. PMID   2276242. S2CID   208874278.
  5. ↑ Jabr FI (September 2005). "Severe nail deformity. Nail biting may cause multiple adverse conditions". Postgrad Med. 118 (3): 37–8, 42. doi:10.3810/pgm.2005.09.1712. PMID   16201307. S2CID   71984361.
  6. 1 2 Tanaka OM, Vitral RW, Tanaka GY, Guerrero AP, Camargo ES (August 2008). "Nailbiting, or onychophagia: a special habit". Am J Orthod Dentofacial Orthop. 134 (2): 305–8. doi:10.1016/j.ajodo.2006.06.023. PMID   18675214.
  7. ↑ Pacan, P; Reich, A; Grzesiak, M; Szepietowski, JC (Feb 17, 2014). "Onychophagia is Associated with Impairment of Quality of Life". Acta Dermato-Venereologica. 94 (6): 703–6. doi: 10.2340/00015555-1817 . PMID   24535041.
  8. 1 2 Bohne A, Keuthen N, Wilhelm S (2005). "Pathologic hairpulling, skin picking, and nail biting". Ann Clin Psychiatry. 17 (4): 227–32. doi:10.1080/10401230500295354. PMID   16402755.
  9. ↑ Cawson RA, Odell EW, Porter S (2002). Cawson's essentials of oral pathology and oral medicine (7th ed.). Edinburgh: Churchill Livingstone. p.  66. ISBN   0443071063.
  10. ↑ Grant JE, Mancebo MC, Eisen JL, Rasmussen SA (January 2010). "Impulse-control disorders in children and adolescents with obsessive–compulsive disorder". Psychiatry Res. 175 (1–2): 109–13. doi:10.1016/j.psychres.2009.04.006. PMC   2815218 . PMID   20004481.
  11. ↑ Mangweth-Matzek B, Rupp CI, Hausmann A, Gusmerotti S, Kemmler G, Biebl W (2010). "Eating disorders in men: current features and childhood factors". Eat Weight Disord. 15 (1–2): e15–22. doi:10.1007/BF03325276. PMID   20571316. S2CID   46664252.
  12. ↑ Allen KW (March 1996). "Chronic nailbiting: a controlled comparison of competing response and mild aversion treatments". Behav Res Ther. 34 (3): 269–72. doi:10.1016/0005-7967(95)00078-X. PMID   8881096.
  13. ↑ Bate, KS; Malouff, JM; Thorsteinsson, ET; Bhullar, N (July 2011). "The efficacy of habit reversal therapy for tics, habit disorders, and stuttering: a meta-analytic review". Clinical Psychology Review. 31 (5): 865–71. doi:10.1016/j.cpr.2011.03.013. PMID   21549664.
  14. ↑ Ghanizadeh, A; Bazrafshan, A; Firoozabadi, A; Dehbozorgi, G (Jun 2013). "Habit Reversal versus Object Manipulation Training for Treating Nail Biting: A Randomized Controlled Clinical Trial". Iranian Journal of Psychiatry. 8 (2): 61–7. PMC   3796295 . PMID   24130603.
  15. ↑ Penzel, Fred. "Skin picking and nail biting: related habits". Western Suffolk Psychological Services. Retrieved 2008-03-22.
  16. ↑ Sarris, Jerome; Camfield, David; Berk, Michael (2012). "Complementary medicine, self-help, and lifestyle interventions for Obsessive Compulsive Disorder (OCD) and the OCD spectrum: A systematic review". Journal of Affective Disorders. 138 (3): 213–221. doi:10.1016/j.jad.2011.04.051. PMID   21620478.
  17. ↑ Koritzky, G; Yechiam, E (Nov 2011). "On the value of nonremovable reminders for behavior modification: an application to nail-biting (onychophagia)". Behavior Modification. 35 (6): 511–30. doi:10.1177/0145445511414869. PMID   21873368. S2CID   16277609.
  18. ↑ Davinroy, Donald L. (Oct 2, 2008), Nail biting deterrent device and method , retrieved 2016-09-29
  19. 1 2 Ghanizadeh, A; Derakhshan, N; Berk, M (2013). "N-acetylcysteine versus placebo for treating nail biting, a double blind randomized placebo controlled clinical trial". Anti-Inflammatory & Anti-Allergy Agents in Medicinal Chemistry. 12 (3): 223–8. doi:10.2174/1871523011312030003. PMID   23651231.
  20. ↑ Iorizzo M, Piraccini BM, Tosti A (March 2007). "Nail cosmetics in nail disorders". J Cosmet Dermatol. 6 (1): 53–8. doi:10.1111/j.1473-2165.2007.00290.x. PMID   17348997. S2CID   40739671.
  21. ↑ Pacan, P; Grzesiak, M; Reich, A; Kantorska-Janiec, M; Szepietowski, JC (Jan 2014). "Onychophagia and onychotillomania: prevalence, clinical picture and comorbidities". Acta Dermato-Venereologica. 94 (1): 67–71. doi: 10.2340/00015555-1616 . PMID   23756561.
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