Habit reversal treatment for fingernail biting

Update on Diagnosis and Management of Onychophagia and Onychotillomania

Onychophagia (nail biting) and onychotillomania (nail picking) are chronic nail conditions categorized as body-focused repetitive behavior (BFRB) disorders. Due to a limited awareness of their clinical presentations, embarrassment on the part of patients, and/or comorbid psychiatric conditions, these conditions are frequently underrecognized and misdiagnosed. This article reviews the prevalence, etiology, diagnostic criteria, historical and physical exam findings, and treatment options for these conditions. The PubMed/MEDLINE database was searched for relevant articles. Onychophagia and onychotillomania are complex disorders necessitating a detailed patient history and physical examination and a multidisciplinary treatment approach for successful diagnosis and management. Due to the dearth of clinical trials for treatment of nail biting and nail picking, large clinical trials are necessary to establish standardized therapies.

Reducing risky behavior with habit reversal: A review of behavioral strategies to reduce habitual hand-to-head behavior

Habit reversal training (HRT) has been a mainstay of behavior analysts' repertoire for nearly the last 50 years. HRT has been effective in treating a host of repetitive behavior problems. In the face of the current coronavirus pandemic, HRT has practical public health importance as a possible intervention for reducing hand‐to‐head behaviors that increase the risk of viral infection. The current paper provides a brief review of HRT for hand‐to‐head habits that is designed for a broad audience and concludes with practical suggestions, based on HRT, for reducing face‐touching behaviors.

Overcorrection: A review and critical analysis

This paper reviews the overcorrection literature with a focus on the subject populations, dependent variables, procedural variations and research methodology reflected in overcorrection research. It analyzes overcorrection in terms of its punishment characteristics, and based on this, offers suggestions for the effective use of overcorrection. It raises issues regarding generalization and maintenance and the lack of data supporting claims for an educative value of overcorrection. We conclude that overcorrection can be an effective response suppressing procedure with greater social acceptability than other forms of punishment, but that the staff time involved in its use constitutes a possible drawback. We suggest the need for analytic research to identify overcorrection's critical components and minimal effective duration. Finally, we offer a suggestion for the use of more descriptive and precise terminology with respect to overcorrection procedures.

The treatment of muscle tics with dissimilar competing response practice

Prior research has shown that muscle tics can be suppressed by the performance of a competing response contingent on the occurrence of the muscle tics. In an effort to determine whether the topography of the competing response was important to the muscle tic suppressing effects of contingent competing response practice, we evaluated the effects of a competing response that was topographically dissimilar to the muscle tic. Three subjects engaged in dissimilar competing responses contingent on the occurrence of a muscle tic; 2 of these subjects subsequently engaged in similar competing response practice. The results showed a decrease in objective measures of muscle tic frequency with the introduction of dissimilar competing response practice for each subject; subsequent exposure to similar competing response practice for 2 subjects resulted in no additional decrement in the level of muscle tics. These results suggest that the topography of the competing response may not be crucial for the suppression of muscle tics. Discrepancies between the objective measures of muscle tics and self-recorded measures are noted and discussed.

Psychodynamics of onychophagists

The authors offer three interpretations of onychophagia, a widespread but largely unstudied phenomenon. The first is phenomenological, and characterises onychophagia as a non-pathological behavioural symptom present in many pathologies and a distinct syndrome that is sometimes quite severe. The second is clinical, and indicates the convergent and divergent connections between onychophagia and the most frequent eating disorders. The third is psychodynamic, and suggests an interpretative hypothesis of onychophagia itself and the frequent sensation of trouble and refusal that it often provokes even in doctors and psychotherapists.

Comparing the effectiveness of similar and dissimilar competing responses in evaluating the habit reversal treatment for oral-digital habits in children

In the present study 26 children with chronic oral-digital habits were randomly assigned to 1 of 3 conditions. Group 1 received habit reversal using a similar competing response. Group 2 received habit reversal using a dissimilar competing response, and Group 3 served as a wait-list control group. Three videotaped observations were taken at pretreatment and again at posttreatment. In addition, social acceptability data were collected on the treatment groups at posttreatment. Results showed that the similar and dissimilar groups were engaging in significantly less oral-digital behavior at posttreatment when compared to the control group. However, the two treatment groups did not differ from each other in terms of treatment gains or acceptability. These results suggest that habit reversal is an effective treatment for oral digital habits in children. In addition, it appears that the competing response does not function as a physically incompatible behavior. Implications of the findings are discussed.

The self-mutilative nature of severe onychophagia: a comparison with self-cutting

OBJECTIVE

To investigate the psychophysiological pattern associated with severe and mild onychophagia, and to compare this pattern with that demonstrated by previous research on self-cutting.

METHOD

Comparisons between the psychophysiological responses accompanying 3 behaviours were made using a guided imagery methodology. Imagery of nail-related, skin-cutting, and neutral events were presented in 4 stages.

RESULTS

Experiment I distinguished participants exhibiting severe and mild onychophagia by the severity and frequency of nail-biting and by the pattern of psychophysiological response across the stages. Experiment II indicated that the change in psychophysiological arousal accompanying severe onychophagia was not as dramatic as that demonstrated for skin-cutting. The behaviour seems to be less effective in reducing tension.

CONCLUSION

Severe onychophagia appears to manage the level of tension experienced by an individual, instead of dramatically reducing it in times of crisis. Such a process is consistent with that demonstrated in individuals with obsessive-compulsive disorder.

Augmenting simplified habit reversal in the treatment of oral-digital habits exhibited by individuals with mental retardation

We investigated whether a simplified habit reversal treatment eliminates fingernail biting and related oral-digital habits exhibited by individuals with mild to moderate mental retardation. Although simplified habit reversal did little to decrease the target behaviors for 3 of 4 participants, simplified habit reversal plus additional treatment procedures decreased the behavior to near-zero levels for all participants. These procedures included remote prompting, remote contingencies involving differential reinforcement plus response cost, and differential reinforcement of nail growth. Limitations of habit reversal for individuals with mental retardation along with directions for future research involving therapist-mediated treatment procedures, particularly those involving remote prompting and remote contingencies, are discussed.

Severe morbid onychophagia: the classification as self-mutilation and a proposed model of maintenance

OBJECTIVES

The aim of this review is to make a distinction between a mild and a severe form of onychophagia (nailbiting) that has not been adequately recognised in clinical research. Furthermore, the aim is to emphasise the need for greater understanding of the motivation for such self-injury as occurs in the severe form. The purpose of making the distinction is to evaluate whether a label of self-mutilation can be applied to the severe form. If this is the case, the tension-reduction model of self-mutilation can be proposed as the mechanism which may maintain the behaviour in the face of serious social and physical consequences.

METHOD

Examination was made of the literature relating to onychophagia and to self-mutilation. Treatment studies of onychophagia were examined to evaluate the mechanisms by which the behaviour may be maintained.

RESULTS

Considering the self-mutilative nature of the severe form and the common theme of tension reduction in the literature on onychophagia, application of the tension-reduction model of self-mutilation is warranted.

CONCLUSION

There is a need for empirical research as to the tension-reducing nature of severe onychophagia.

Applying behavior analysis to clinical problems: review and analysis of habit reversal

This article provides a review and analysis of habit reversal, a multicomponent procedure developed by Azrin and Nunn (1973, 1974) for the treatment of nervous habits, tics, and stuttering. The article starts with a discussion of the behaviors treated with habit reversal, behavioral covariation among habits, and functional analysis and assessment of habits. Research on habit reversal and simplified versions of the procedure is then described. Next the article discusses the limitations of habit reversal and the evidence for its generality. The article concludes with an analysis of the behavioral processes involved in habit reversal and suggestions for future research.

Chronic nailbiting: a controlled comparison of competing response and mild aversion treatments

Recent studies have suggested that competing response, an abridged version of Azrin and Nunn's (1973) habit reversal method (Behaviour Research and Therapy, 11, 619-628), is a key component in the treatment of chronic nailbiting (Horne & Wilkinson, 1980, Behaviour Research and Therapy, 18, 287-291; Silber & Haynes, 1992, Behaviour Research and Therapy, 30, 15-22). This study replicated and extended the latter by adding an 8 week follow-up period and by using a non-student sample. Forty-five chronic nailbiter Ss were divided into three experimental groups. One method involved the use of mild aversion in which Ss painted a bitter substance on their nails. A second method required the subject to perform a competing response whenever they had the urge to nailbite or found themselves biting their nails. Both methods included self-monitoring of the behaviour and a third group of Ss performed self-monitoring alone as a control condition. The study lasted 12 weeks. Mild aversion resulted in significant improvements in nail length, with the competing response method just failing to show significance in this regard. There was no significant improvement for the control group. The implications for further study and the benefits of competing response in the light of these findings are discussed in terms of treatment success and use of therapist time.

Habit reversal: a review of applications and variations

Research is reviewed on habit reversal treatment of tics and other nervous habits, and on the components of such treatment. Awareness training and the use of a competing response are found to be its essential components. Studies which evaluate the habit reversal procedure and its variations in the treatment of stuttering are also reviewed.

Treating nailbiting: a comparative analysis of mild aversion and competing response therapies

This study compared two methods of treating nail-biting. One method involved the use of a mild aversive stimulus in which subjects painted a bitter substance on their nails, and the other required the subject to perform a competing response whenever they had the urge to bite or found themselves biting their nails. Both methods included self-monitoring of the behaviour, and a third group of subjects performed self-monitoring alone as a control condition. The study lasted four weeks. Twenty-one subjects, seven per group, participated. Both methods resulted in significant improvements in nail length, with the competing response method showing the most beneficial effect. There was no significant improvement for the control group. The competing response condition also yielded significant improvements along other dimensions such as degree of skin damage and subjects own ratings of their control over their habit. These were not seen for the other two conditions. The benefits of this abridged version of Azrin and Nunn's (Behaviour Research and Therapy, 11, 619-628, 1973) habit reversal method in terms of treatment success, use of therapist time and client satisfaction, are discussed.

Self-biting with multiple finger amputations following spinal cord injury

We have observed mutilative self-biting leading to multiple finger amputations in two patients following C4 complete spinal cord injury (SCI). Both men were of normal intelligence without psychosis and each had a neurotic personality and history of fingernail biting. They related the self-biting to anxiety and depression. We believe these to be the first English language reports of multiple finger amputations due to self-biting following SCI.

A comparison of contingent vs non-contingent competing response practice in the treatment of nervous habits

Previous research found that two components of the habit reversal procedure, the practice of a competing response (CR) and awareness training, suppressed muscle tics to the same degree as Azrin's entire habit reversal program. This study compared the effectiveness of two variations of the competing response procedure (contingent vs non-contingent practice) on the nervous habits of nine subjects. The results showed the non-contingent competing response to be largely ineffective in decreasing the target behaviors. The contingent competing response procedure greatly reduced the nervous habits of most subjects, and the complete habit reversal procedure further decreased the behavior for two subjects. This research indicates that the competing response procedure is most effective when used in a contingent fashion.