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an introductory case study of chronic nail biting
Stop Biting Your Nails! Acknowledgements This introduction to and case study of chronic nail biting was brought to you by PsychoBabble, a non-profit endeavour, which aims to bring cutting edge research in psychology to the general public, in easily accessible, multimedia formats. PsychoBabble is run entirely by psychology students at the University of Otago. For more information, questions, and suggestions, please contact the Editor-in-Chief of PsychoBabble, Jonathan Jong, at email@example.com or visit us online at http://www.psychobabbleblog.blogspot.com. Most, if not all, of the theoretical and empirical work summarized in this booklet have been taken from published psychological and medical articles. A complete bibliography of all the works consulted is included at the end of the booklet. Furthermore, a shorter annotated bibliography of the more accessible articles may be found on the PsychoBabble website. Finally, the case study would not have been possible were it not for Bob, one of our recent clients, who has kindly allowed us to publish the details of his nail biting behaviour. In order to protect his anonymity, we have decided to use a pseudonym. I’m sure there are many Bobs out there will chronic nail biting habits. They have nothing to do with this article, except by coincidence.
Stop Biting Your Nails! Preface
In this booklet, we decidedly moved away from the traditional way of introducing the causes and effects of, and interventions for health-compromising behaviors. Most booklets of this kind have taken more general or abstract approaches to such health-compromising behaviours. We are skeptical that there is such a thing as “chronic nail biting” in the abstract sense. Inferring explanatory and interventional pluralisms from the research reviewed herein, we decided that taking a more concrete approach – looking at a particular, typical case of chronic nail biting – would be more fruitful. The limitation of this approach is, of course, that our booklet cannot claim to be comprehensive or exhaustive. While we touch upon chronic nail biting as a symptom of underlying psychopathology, and as subclinical variants of anxiety or mood disorders, we devote most space to thinking of chronic nail biting as a learned behaviour. This booklet will therefore be more helpful to some chronic nail biters than to others. That having been said, we think we have done a fair job at introducing the different understandings of chronic nail biting. Our hope is that this booklet will be a starting point for clinicians and nail biters to better understand and treat this health-compromising behaviour. Finally, a note on authorship: The entire manuscript was written by one member of the PsychoBabble team, again in order to protect Bob’s anonymity. However, the entire PsychoBabble team provided indispensable help and input. This was, despite appearances, truly a team effort.
Stop Biting Your Nails! Table of Contents
Acknowledgments………………………………………………………………….......i Preface….……………………………………………………………………………...ii Table of Contents.…………………………………………………………………….iii Introduction………………..…………………………………………………………..1 Nail biting as a health-compromising behaviour……………………………………...3 What causes nail biting?……………………………………………………………….4 Treatment options…………………….………………………………………………..6 Treatment recommendations………….……………………………………………...13 Bibliography………………………………………………………………..………...17
Stop Biting Your Nails! Introduction: A General and Case Study of Chronic Nail Biting Nail biting is a common health-compromising habit that is rarely thought of as such. Instead, it is often thought of as a cosmetic problem, or a socially inappropriate behaviour. As a result, few nail biters seek help, although many do express the desire to stop the habit. Furthermore, healthcare professionals – both in the medical and psychological communities – are largely ignorant of the current research in the area. Thus, the few patients who do choose to seek professional help often find it ineffective. Bob (a pseudonym, of course) is one such nail biter who sought help from his general medical practitioner, but found the advice offered to be ineffective. Like most nail biters, Bob is motivated to stop biting his nails for largely cosmetic reasons. However, he is also aware that nail biting is an unsanitary behaviour, which may lead to health problems such as bacterial infections. In order to better understand Bob’s habit, I instructed him to keep a record, as best he could, of where he was and what he was doing whenever he discovered himself biting his nails. After a week of this selfmonitoring exercise, I interviewed Bob about his nail biting, and other relevant health matters.
The nail biting and its effects aside, Bob’s lifestyle is generally healthy. In précis, he maintains a nutritional and balanced diet, exercises sufficiently and regularly, and gets sufficient sleep. Furthermore, although no diagnostic measures have been performed, Bob does not appear to suffer from any psychological disorders. It is therefore unlikely that the nail biting is a result of an underlying anxiety disorder (e.g., obsessive-compulsive disorder). Bob thinks that he picked up 1
Stop Biting Your Nails! his nail biting habit from his father, who has been a chronic nail biter ever since Bob can remember. While the cause of Bob’s habit is now inaccessible, this is certainly a reasonable account. This assumption that Bob’s habit was learned independently of any underlying psychopathology is a significant one in choosing an intervention, as we shall soon see. According to his mother, whom Bob consulted, he began biting his nails when he was 10 or 11 years old. He has since made several personal attempts to break the habit, none of which have been successful. He has, as mentioned above, also sought advice from his general medical practitioner, who advised him to paint his nails with some kind of bitter substance. However, Bob had already tried this form of therapy as a child, to no avail. More information on this and other forms of aversion therapy will be reviewed later. Bob’s self-monitoring record showed that he bites his nails very frequently. He recorded doing so almost every waking hour of the day. More importantly, it revealed that he bites most often while attending lectures, working on the computer, and reading. Conversely, he bites least while cooking, eating, and exercising. Furthermore, Bob also reported biting his nails as a means of grooming, of removing rough edges of skin and nail. Bob expressed surprise at the frequency of his nail biting, but also admitted that he had probably bitten his nails more frequently than recorded. This is unsurprising, as nail biting episodes often occur without the biter’s conscious attention. Furthermore, Bob thought that the self-monitoring itself might have reduced the degree to which he bit his nails, because he would stop as soon as he was aware of it. However, it is unknown if it increased the number of times he initiated the behaviour. In summary, Bob’s nail biting behaviours began around puberty, probably from having learnt it from his father. He bites his nails frequently, except when both his hands and his mouth are engaged in other activities. As such, Bob’s case reflects those of the vast majority of chronic nail biters. The typicality of his problem will hopefully render it more easily treatable.
Stop Biting Your Nails! Nail Biting as a Health-Compromising Behaviour Besides being a cosmetic matter that might lead to self-esteem issues and other psychological problems, nail biting may compromise the biter’s physical health. While the folk association between nail biting and parasitic worm infections has yet to be justified, recent research has found that nail biters do carry more potentially harmful bacteria in their mouths than non-nail biters. Furthermore, nail biting has also been implicated in dental problems, especially the damage, bacterial infection, and inflammation of the gums. Finally, nail biting can also result in skin infections (e.g., paronychia) when the nail biter also bites the skin on his/her fingers to the point of bleeding. Bob is vaguely aware that nail biting is unsanitary, and has in fact occasionally blamed cases of stomach pain and diarrhoea on his nail biting. These prior beliefs about the harmfulness of nail biting, and further information about the possible negative effects of nail biting, should motivate Bob further in his quest to stop the habit.
Example of a mild case of paronychia
Stop Biting Your Nails! What Causes Chronic Nail Biting? Information about the causes of an undesirable behaviour is often useful in determining a treatment. Before exploring possible treatments for Bob, the possible causes of his habit should be discussed. Although virtually all psychologists now recognize that behaviours – maladaptive or otherwise – have both biological (e.g., neurophysiological) and environmental (e.g., operant learning) causes, the relative importance of nature and nurture are still debated for many behavioural disorders. Indeed, even the relationship between nature and nurture is still unclear. Nail biting is, as you might expect, one of these disorders for which the debate continues. Researchers in the more biological end of the explanatory spectrum claim that nail biting shares a neurophysiological root with anxiety disorders like obsessivecompulsive disorder (OCD). Specifically, they claim that both nail biting and OCD are caused by an imbalance in levels of glutamate (a neurotransmitter) in the nucleus accumbens (a structure in the basal ganglia). In this view, nail biting is treated as a sub-clinical variant of OCD, with low dosages of OCD medication. While this form of treatment will be reviewed later, Bob has expressed reservation against drugtreatments. Furthermore, the information he provided in the interview suggest that environmental factors play a more significant role in the origin and maintenance of his nail biting habit.
Diagram of the brain, including the nucleus accumbens
Stop Biting Your Nails! Researchers who occupy the more environmental end of the spectrum agree with their biologically inclined colleagues that nail biting is like OCD. However, they unsurprisingly focus on the behavioural aspects of the disorder. Like patients with OCD, nail biters have learnt that a particular behaviour – in this case, biting one’s nails – is psychologically rewarding. Nail biting can be rewarding for many reasons. However, research on nail biting has focused on three possible reasons: Firstly, nail biting relieves stress-related anxiety or nervousness. Secondly, nail biting relieves feelings of boredom. Thirdly, nail biting is a grooming behaviour, which people find intrinsically relaxing. The three theories are not mutually exclusive, and may all hold true in any particular nail biter. For example, a nail biter might have learnt from someone else (e.g., via imitation) or by herself (e.g., just by accident) that nail biting is relaxing. The pleasure derived from the nail biting might then positively reinforce the behaviour. If subsequent nail biting successfully reduced stress-related anxiety, then the behaviour will be negatively reinforced. Finally, if nail biting also successfully reduced feelings of boredom, the behaviour will be further negatively reinforced. All these independent streams of reinforcement would strengthen the habitual nature of the nail biting until it becomes problematic. Now, in this perspective, cognitive-behavioural therapy seems particularly attractive. There are, of course, many different kinds of cognitive-behavioural therapy available, some of which will be reviewed later. Finally, there are also psychodynamic interpretations of nail biting. Psychodynamic or psychoanalytic theorists think that nail biting behaviour represents maladaptive catharsis of sexual desires or other forms of aggression and anxiety. Especially in the latter case, nail biting is compared to self-mutilation and eating disorders (as conceived in some strands of psychoanalytic theory), in that it is an attempt to somatize repressed feelings. Psychoanalytic theories inevitably lead to psychoanalytic solutions, to which we shall soon turn.
Stop Biting Your Nails! Treatment Options
Perhaps unsurprisingly, there are as many available treatment options for nail biting, as there are interpretations of the behaviour. For starters, those who interpret nail biting in psychoanalytic terms recommend psychodynamic therapy, which aims to persuade the nail biter to channel his/her latent sexual or otherwise aggressive feelings in more adaptive, appropriate manners. Unfortunately for neo-Freudians, however, I have failed to find empirical support for the effectiveness of this kind of treatment for nail biting.
Neat, manicured, unbitten nails.
Those of the cognitive-behavioural persuasion, on the other hand, prefer belief- and behaviour-modification therapies. On the cognitive side of things, education (and by extension, belief-modification) is considered integral in the effort to motivate the nail biter to kick the habit. Accordingly, intervention should begin by bringing the nail biter to understand the negative side effects – biological, psychological, and social – of his habit. Far from being wholly negative, most
Stop Biting Your Nails! cognitive therapies also include teaching nail biters techniques to care for their fingernails properly, and the benefits of having neat, unbitten nails. This includes, among other things teaching nail biters how to manicure their fingernails, and massage their fingers. While acknowledging the importance of cognitive interventions, most psychologists agree that education is insufficient. Education may motivate the nail biter to kick his habit, but must join forces with behavioural therapy to pull the job off. Practice, as they say, makes perfect. In this case, it should make perfect nails. Often, this behavioural therapy has come in the form of aversion therapy. Perhaps the most common folk remedy for nail biting – painting one’s nails with a bitter substance – may be construed as a form of aversion therapy, although it also acts by increasing one’s awareness of one’s nail biting behaviour.
Examples of commercially available products used in aversion therapy.
Stop Biting Your Nails! Basically, the bitterness of the substance should act as punishment for nail biting, thereby reducing the behaviour. Perhaps more radically, self-administered shock devices serve a similar purpose. Nail biters are expected to self-administer nonharmful, but painful electric shocks when they catch themselves biting their nails. Again, this punishment should reduce the nail biting behaviour. While there is some theoretical (i.e., from operant learning) and empirical evidence for the short-term effectiveness of this strategy, aversion therapy has been found to be lacking as a longterm solution. Bob is a case in point: One of the first things he – or rather, his mother – tried was painting a bitter substance on his fingernails. Both Bob and his mother recall this to have been very effective, at least at first. Whenever Bob put his fingers in his mouth, he would become immediately aware that he was about to bite his nails, and he would desist because of the bitter substance. However, Bob soon discovered that the bitter substance could be easily washed off with water. Furthermore, his mother became less and less vigilant at re-applying it, and Bob certainly wasn’t about to volunteer his fingernails to be coated with the foul-tasting chemical. Similar things can be said about self-administered shock therapy: Despite being purportedly selfadministered, shock therapy has been shown to be ineffective without accountability to a person with perceived authority, like an experimenter or clinician. Nail biters very quickly lose their motivation to quit biting their nails, and simply refuse to shock themselves. In other, perhaps more technical words, aversion therapies suffer from high drop out rates. While there is evidence that they can be very effective for many nail biters (a) in the short-term and (b) if the nail biter the nail biter is periodically checked upon by an experimenter or clinician, it appears to be a poor self-help, longterm strategy. Furthermore, if other clinician-based therapies are as effective as aversion therapies, the suffering caused by such therapies is gratuitous. Nail biters
Stop Biting Your Nails! should seek less painful means of treatment first. Furthermore, it is a truism in behavioural psychology that positively reinforcing techniques work better than punishing ones. This preference for positive techniques has also been borne out in research on nail biting. It is to such techniques that we now turn. In contemporary cognitive-behavioural therapy (CBT) of nail biting, habit reversal therapy (HRT) is the treatment of choice. While HRT is normally practiced as a package treatment, involving different cognitive and behavioural components, its most distinctive feature is the conscious replacement of nail biting with more acceptable, competing behaviours (e.g., clenching one’s fists; grasping an object). The nail biter is first taught to be more aware of his/her habit, and then to perform a competing behaviour that will interfere with nail biting, whenever he/she feels the urge to bite his/her nails. This is usually accomplished via operant conditioning. The competing behaviour is rewarded (or, in behavioural psychological parlance, positively reinforced), until the client learns to consistently performs the competing behaviour whenever he feels an urge to bite his nails.
Stress ball, often used with HRT as a competing behaviour.
One more advantage of HRT is that the pioneers and subsequent proponents of this technique have always recognized the importance of social support in behaviour modification. In their seminal research article on HRT, for example, N.H. Azrin, and
Stop Biting Your Nails! R.G. Nunn instructed clients’ friends and family members to provide periodical support and motivation. Given what has been said about the flaws of aversion therapy – that they are ineffective precisely as self-administered techniques – this social component of HRT is very important. Finally, psychiatrists and other more biologically inclined clinicians recommend drug-related therapy for nail biting. Those who think of nail biting as a sub-clinical variant of obsessive-compulsive disorder prescribe low dosages of OCD medication. For example, Clomipramine (commonly sold as Anafranil®), an important drug in treating OCD, has been shown to be effective at eliminating nail biting. However, the possible negative side effects of the drug – drowsiness, vomiting, diarrhoea, and constipation being among the milder of them – might render this cure worse than the disease.
Anafranil®, a commercial example of Clomipramine.
Thankfully, some recent research suggests that supplements of N-Acetyl Cysteine (NAC), an amino acid naturally produced by our bodies, may also be effective at eliminating the nail biting habit. NAC is therefore not known to have any negative side effects at the dosages given to nail biters. One possible, somewhat humourous exception is that it may cause increased flatulence in some individuals. On the flip side, NAC is only effective for some nail biters, presumably those whose habits are
Stop Biting Your Nails! caused by some neurophysiological deficiencies outlined earlier. Furthermore, like most other psychiatric medication, failure to comply with the prescription usually leads quickly to a relapse in nail biting. Finally, given that none of these (or any other) drugs have yet to be approved by the U.S. Food and Drug Administration for nail biting treatment, it might prove rather difficult to obtain them. Nail biters who wish to seek pharmacological solutions of this kind should consult a medical practitioner, preferably a psychiatrist. There are, of course, other possible treatment options that I have chosen not to cover. Hypnosis, for example, is sometimes used against nail biting. Exorcism, likewise, is also sometimes employed. However, while alternative techniques like hypnosis and intercessory prayer may well be effective, their heterogeneity renders assessment very difficult. The lack of good evidence for these techniques therefore precludes me from recommending them to clients.
Example of commercially available self-hypnosis CD.
Stop Biting Your Nails! Bob prefers not to seek pharmacological treatment, despite their demonstrated success. If Bob is correct in thinking that he picked his nail biting habit up from his father, and subsequently found it psychologically rewarding, we should not expect anything to be amiss with him neurophysiologically. At any rate, we should not assume that his nail biting habit is necessarily a symptom of brain damage. If this is the case, pharmacological intervention should be considered a last resort. Assuming that Bob’s habit was learned, getting rid of the habit would mean unlearning it, or learning a more constructive habit to take its place. This, of course, is the bread and butter of cognitive-behavioural therapy. However, such therapy can be fairly costly and time-consuming. There is also, in Bob’s community, a social stigma against psychotherapy. Given these financial, temporal, and social costs of cognitivebehavioural therapy, I recommend a socially-supported, self-help programme, which incorporates principles gathered from research in cognitive-behavioural therapies for nail biting. The next and final section of this article is an elaboration of this programme.
Social support, to which psychologists often pay lip service but rarely put into practice.
Stop Biting Your Nails! Treatment Recommendations
Background Several useful principles may be gleaned from the research on cognitivebehavioural therapies summarized earlier. For starters, we now know that education concerning both the negative effects of nail biting, and the positive effects of having nice, unbitten nails works as a significant motivating factor in the quest to kick the habit. Secondly, one of the lessons we may learn from aversion therapy is that increased awareness of one’s nail biting helps to decrease the biting, at least in motivated individuals. Bob, for example, reported decreased biting during the week in which he was asked to monitor his nail biting behaviour. Thirdly, the success of habit reversal therapy is at least partially attributable to the fact that social support is an important part of the treatment package. Fourthly, habit reversal therapy’s novel contribution to the field is the idea that nail biters should replace nail biting behaviour with more adaptive behaviour. These four principles may be integrated to form a socially-supported self-help programme that will hopefully render the expensive services of a long-term professional clinician or therapist unnecessary. It is in this sense – of not requiring the long-term, continuous services of a professional – that the programme is a “self-help” programme. As the “socially-supported” part of the description insists, however, the client is not expected to attempt to break his habit unaided and alone.
The Programme While the programme described below has been tailor-made for Bob, it should be useful for anybody who is trying to break a habit similar to nail biting (e.g., skin
Stop Biting Your Nails! picking, nose-digging). However, some of the details here will have to be modified to best suit the person and habit in question. The programme consists, roughly, of six components. First, several close family members and/or friends will be recruited to encourage Bob, and to hold him accountable in his endeavour to eliminate his nail biting habit. Since the programme does not explicitly involve punishment, these individuals will never be put in relationally uncomfortable positions. Their role is to support Bob, to encourage him (e.g., by praising him as he shows reductions in nail biting behaviour), to periodically check on how he is progressing, and to go for manicures with him. Secondly, Bob (and the rest of his support group) will go for a professional manicure. They will also attend self-manicure or self-grooming lessons, offered at most manicure centres. Thirdly, Bob will be given in depth information about the negative psychological and physical side effects of nail biting, as outlined earlier. Furthermore, he will also be educated about the practical and aesthetic benefits of having neat, unbitten nails. Preferably, all this information should be conveyed in the context of a discussion or conversation, rather than a lecture-based session. In this case, I will act as a well-informed facilitator, to guide a discussion among Bob and his support group. Fourthly, Bob will be asked to monitor his own biting behaviour, just like he did the week before our interview. At least for the first few weeks, Bob will be required to keep a detailed written record of where he was and what he was doing when he engaged in the nail biting behaviour. These records will then be submitted to his support group. If Bob shows improvement after a few weeks, he will be excused
Stop Biting Your Nails! from having to make a written record. Instead, he will be asked to talk to at least one support group member about his progress (or lack thereof) on a regular basis. Fifthly, Bob will be asked to carry several objects with him at all times: A packet of chewing gum, a small stress ball, a nail file, and a pair of nail clippers/scissors. Whenever Bob catches himself biting his nails, or feels an urge to engage in nail biting, he should either chew gum, squeeze the stress ball, or groom himself, whichever is more appropriate. The rationale behind this is, of course, from habit reversal therapy. However, the four items were specifically selected for Bob. During the interview, Bob reported less nail biting when either his mouth or hands were busy. Hence, the chewing gum and stress ball. Furthermore, Bob reported that he bit his nails for grooming purposes. Having been taught self-grooming techniques during his manicure session, he will be expected to apply his new skills, instead of trimming his nails with his teeth.
Examples of items to be carried with Bob at all times
Stop Biting Your Nails! Finally, I would recommend that Bob goes for a professional manicure every once in a while. This will serve two purposes: First, the manicurist will act as an additional accountability partner. Second, research suggests that nail biters are more reluctant to bite manicured nails, than already bitten nails. Regular visits to the manicurist will ensure that Bob always has kempt nails, which will hopefully deter him from biting them.
Expectations Given that this programme is based on research in cognitive-behavioural therapy, I am confident that Bob will be able to kick his nail biting habit. However, success is unlikely to be as sudden as those reported in studies of aversion therapy and pharmacological interventions. On the other hand, I expect Bob to show long-term positive outcomes, without the nasty side effects of the pharmacological options. The positive outcomes can be measured in two ways. Firstly, Bob’s self-reported nail biting (or, hopefully, lack thereof) may be used as a measure of performance. Secondly, and more objectively, periodical checking of his nails for signs of nail biting (e.g., length, appearance) will also provide information about the success of the programme. While I am confident that the programme will be successful, it should be noted that Bob’s success is largely contingent upon the co-operation of his support group. These individuals are effectively playing the role of a therapist, in encouraging Bob, motivating him, and keeping him accountable. If, contrary to my expectations, Bob fails to kick his habit through this socially-supported self-help programme, Bob should consider habit-reversal therapy with a trained clinician. At any rate, he can rest assured that this programme was relatively inexpensive, and arguably quite enjoyable.
Stop Biting Your Nails! Bibliography
Allen, K. W. (1995). Chronic nailbiting: A controlled comparison of competing response and mild aversion treatments. Behaviour Research and Therapy, 34, 269-272. Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619-628. Baydas, B., Uslu, H., Yavuz, I., Ceylan, I., Dagsuyu, I. (2007). Effect of a chronic nail-biting habit on the oral carriage of Enterobacteriaceae. Oral Microbiology and Immunology, 22, 1-4. Bohne, A., Keuthen, N., & Wilhelm, S. (2005). Pathologic hairpulling, skin picking, and nail biting. Annals of Clinical Psychiatry, 17, 227-232. Bucher, B. D. (1968). A pocket-portable shock device with application to nailbiting. Behaviour Research and Therapy, 6, 389-392. Cavaggioni, G., & Romano, F. (2003). Psychodynamics of onychophagia. Eating and Weight Disorders, 8, 62-67. Creath, C. J., Steinmetz, S., & Roebuck, R. (1995). Gingival swelling due to a fingernail-biting habit. Journal of the American Dental Association, 126. 1019-1021. Krejci, C. B. (2000). Self-inflicted gingival injury due to habitual fingernail biting. Journal of Periodontology, 71, 1029-1031. Odlaug, B. L., & Grant, J. E. G. (2007). N-Acetyl Cysteine in the treatment of grooming disorders. Journal of Clinical Psychopharmacology, 27, 227-229.
Stop Biting Your Nails! Ronen, T., & Rosenbaum, M. (2001). Helping children to help themselves: A case study of enuresis and nail biting. Research on Social Work Practice, 11, 338356. Teng, E. J., Woods, D. W., Marcks, B. A., & Twohig, M. P. (2004). Body-focused repetitive behaviors: The proximal and distal effects of affective variables on behavioral expression. Journal of Psychopathology and Behavioral
Assessment, 26, 55-64. Teng, E. J., Woods, D. W., Twohig, M. P., & Marcks, B. A. (2002). Body-focused repetitive behavior problems: Prevalence in a nonreferred population and differences in perceived somatic activity. Behavior Modification, 26, 340-360. Williams, T. I., Rose, R., & Chisholm, S. (2006). What is the function of nail biting: An analog assessment study. Behaviour Research and Therapy, 45, 989-995. Woods, D. W., Fuqua, R. W., Siah, A., Murray, L. K., Welch, M., Blackman, E., et al. (2001). Understanding habits: A preliminary investigation of nail biting function in children.
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