What is the function of nail biting: an analog assessment study

Is Self-Help Dangerous? Examination of Adverse Effects of a Psychological Internet-Based Self-Help Intervention for Body-Focused Repetitive Behavior (Free From BFRB)

Despite the proven effectiveness of psychotherapy for psychiatric disorders, adverse events or unwanted effects may occur. Unwanted effects, however, are rarely assessed. In self-help interventions, which usually are not supported by a therapist, such effects have received even less attention even though special caution is needed regarding unwanted effects such as those related to misapplication. For the present study, we present the newly developed Positive and Negative Effects of Psychotherapy Scale for Internet-Based Intervention (PANEPS-I) and examine possible unwanted effects of an internet-based self-help intervention in individuals with body-focused repetitive behaviors (BFRBs), aggregating three different techniques: habit reversal training (HRT), decoupling (DC), and decoupling in sensu (DC-is). Some HRT users have expressed concern that the suppression of the problematic behavior could lead to rebound effects, but this has not been examined rigorously. Following baseline assessment, 141 participants with at least one BFRB were randomly assigned to two intervention groups that differed only with respect to the delivery mode (video, manual); the content was the same. After 6 weeks, a post-assessment was conducted. Unwanted effects were assessed using the PANEPS-I. A total of 70% of the participants (both treatment groups combined) reported at least one positive effect of the intervention. Negative effects were reported by 14-92% of participants, depending on the effect. The highest agreement rates were found for "no positive goal orientation" (52.5%), "did not address personal problems" (48.8%), "time/performance pressure" (20.9%), shame (16.3%), and concerns about data privacy (14.3%). Participants in the manual intervention group reported unethical procedures (e.g., data privacy concerns) more often (Cohen's d = .44) than those in the video intervention group. Responders reported more positive effects and nonresponders more malpractice (|d| = .80, .54, respectively). HRT users (self-report) showed no significant differences compared to nonusers regarding negative effects. Stepwise hierarchical regression analyses indicated a dose-response relationship for reported positive effects and malpractice. Side effects may occur in any kind of intervention. Usage of HRT did not lead to more reported negative effects compared to nonusage. To improve the quality and effectiveness and ensure the safety of the user, especially those using digital self-help interventions, it is important to regularly assess unintended effects since there is no supervision of the patient in unguided self-help interventions.

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.

Hand-to-mouth and other hand-to-face touching behavior in a quasi-naturalistic study under controlled conditions

Data gaps exist in our understanding of hand-to-mouth touching behavior among adults, despite its relevance for accurately characterizing inadvertent ingestion exposures to chemical and pathogenic microbial agents and consequent associated health risks. The present study describes detailed observations of the frequency and nature of hand-to-mouth and other hand-to-face touching behavior among 14 male and female volunteers in a controlled, quasi-naturalistic setting. Participants performed four 15-min tasks: 1) installation of a brass object as part of a short home improvement project, 2) completion of a pen-and-paper survey, 3) engagement in a telephone conversation, and 4) use of headphones to listen to music. Video recordings of the participants performing each task were reviewed and coded for touches to the face with emphasis on specific regions of the face and palmar versus dorsal contacts. During the installation task, only one of the 14 participants was observed touching his face; this was to the nose, on two separate occasions. Summed across the three non-installation tasks, including palmar and dorsal contacts, participants touched their lips, their mouth, and anywhere on their face on average (range) 5.1 (0-19), 0.4 (0-3), and 27.7 (6-49) times, respectively. Facial contacts during these three non-installation tasks were predominantly with the palmar surface of the hand. The implications of these data are contextually specific, as the potential health impacts of face touching behavior among adults might differ based upon toxicity or virulence of hand contaminants of interest.

The Role of Self-Criticism and Shame in Body-Focused Repetitive Behaviour Symptoms

Body-focused repetitive behaviours (BFRBs), such as hair-pulling, skin-picking, and nail-biting, are non-functional habits associated with difficulties in emotion regulation. Although several models have been developed to explain the difficulties experienced by people suffering from BFRBs, a number of cognitive and emotional processes have yet to be explored. This study sought to investigate the psychological characteristics involved in the development and maintenance of BFRB symptoms. In particular, we aimed to evaluate the relationship of self-criticism, shame, and maladaptive cognitive emotion strategies with symptoms and examine if the relationship between perfectionism and symptoms was mediated by self-criticism and shame. Seventy-six participants from a community sample completed a number of self-report measures. Findings from our multivariate linear regression model supported that shame and maladaptive cognitive emotion regulation strategies significantly predicted BFRB symptoms. Results of our mediational analyses revealed that shame significantly mediated the relationship between perfectionism and BFRB symptoms. Interventions that target shame may be beneficial for treating these conditions. Future studies should replicate these findings with clinical populations and other BFRB subtypes.

Bite the Stress Away? Nail Biting and Smoking Predict Maladaptive Stress Coping Strategies

Abstract. Psychological correlates of adult nail biting have received little empirical attention so far, despite its high prevalence and negative associations with physical and mental health. One possible correlate of nail biting is arousal modulation, which has also been linked to smoking (i.e., another oral behavior). Here, we link nail biting to an adaptive (i.e., Task-oriented) and two maladaptive stress-coping strategies (i.e., Emotion-oriented, Avoidance-oriented) as well as smoking while controlling for personality traits and socio-demographic characteristics. In all, 838 German-speaking adults ( Mage = 32.02, SD = 13.48; 431 women) completed measures of stress coping (CISS-SF), the Big Five personality traits (Mini-IPIP), and indicated nail biting and smoking behavior. In three theory-guided, hierarchical linear regressions we predicted each stress coping strategy by nail biting and smoking while controlling for personality and socio-demographic characteristics. Oral behaviors had differential effects on maladaptive stress coping strategies: The interaction between nail biting and smoking predicted Emotion-oriented coping, while smoking predicted Avoidance-oriented coping. Both behaviors were unrelated to adaptive, Task-oriented coping. In sum, our results show that nail biting and smoking are important predictors of maladaptive but not adaptive coping strategies, even when controlling for confounders.

Abnormal perceptual sensitivity in body-focused repetitive behaviors

OBJECTIVE

Several compulsive grooming habits such as hair pulling, skin picking, and nail biting are collectively known as body-focused repetitive behaviors (BFRBs). Although subclinical BFRBs are common and benign, more severe and damaging manifestations exist that are difficult to manage. Researchers have suggested that BFRBs are maintained by various cognitive, affective, and sensory contingencies. Although the involvement of cognitive and affective processes in BFRBs has been studied, there is a paucity of research on sensory processes.

METHODS

The current study tested whether adults with subclinical or clinical BFRBs would report abnormal patterns of sensory processing as compared to a healthy control sample.

RESULTS

Adults with clinical BFRBs (n = 26) reported increased sensory sensitivity as compared to persons with subclinical BFRBs (n = 48) and healthy individuals (n = 33). Elevations in sensation avoidance differentiated persons with clinical versus subclinical BFRBs. Sensation seeking patterns were not different between groups. Unexpectedly, BFRB severity was associated with lower registration of sensory stimuli, but this finding may be due to high psychiatric comorbidity rates in the BFRB groups.

CONCLUSIONS

These findings suggest that several sensory abnormalities may underlie BFRBs. Implications for the etiology and treatment of BFRBs are discussed.

Chronic Nail Biting in Youth

Nail biting, a common behavior seen in children, is typically short-lived and does not cause significant problems. However, when nail biting remains unresolved, physical and emotional consequences may occur. Exploring the etiological factors and underlying function of nail biting may help providers recommend appropriate interventions. [Journal of Psychosocial Nursing and Mental Health Services, 55(2), 23-26.].

The effect of psychological state and social support on nail-biting in adolescents: An exploratory study

Nail-biting is one of the most common behavioral problems in children. This study aimed to examine factors affecting nail-biting among adolescents and the effects of psychological state and social support on nail-biting. This cross-sectional study was conducted between January and May of 2014 in seven schools in Istanbul ( N = 724). Data were collected using the Personal Information Form, Brief Symptom Inventory, and Child and Adolescent Social Support Scale. This study found that 48.2% of adolescents in the 11- to 17-years-old age group had a habit of nail-biting. Anxiety, depression, negative self image, somatization, hostility, and three global index scores of adolescents who bit their nails were significantly higher than in those who did not. Social support scores of those who bit their nails were significantly lower than in those who did not in the ‘mother’ and ‘classmates’ subscales and total scores. Psychological state and social support were factors affecting nail-biting among adolescents.

The role of emotion regulation in body-focused repetitive behaviours

Body-focused repetitive behaviours (BFRBs) including trichotillomania, skin picking, and nail biting, are non-functional self-destructive habits, which have a severe negative impact on everyday functioning. Although BFRBs cause distress, they are maintained by both negative (relief) and positive (stimulation) reinforcement. The emotional regulation (ER) model proposes that people with BFRBs have a general deficit in ER and, as a consequence, engage in BFRBs to alleviate affect and reinforce the behaviour. The current study was designed to explore differences in ER between people with BFRBs and controls to identify specific emotions triggering BFRBs. Forty-eight participants (24 BFRB, 24 controls) completed questionnaires measuring Difficulties in Emotional Regulation (DERS), a Triggers Scale and an Affective Regulation Scale (ARS). Significant differences in people with BFRBs and controls were reported principally on the DERS subscales of lack of emotional clarity, difficulties in impulse control, and access to ER strategies. On the ARS, the BFRB group reported overall difficulty ‘snapping out’ of emotions. The majority of BFRBs were reported to be triggered by anxiety (78%), tension (70%), or boredom (52%). The clinical implication is that ER could be beneficially targeted in therapy for BFRBs.

Chew the Pain Away: Oral Habits to Cope with Pain and Stress and to Stimulate Cognition

The acute effects of chewing gum on cognitive performance, stress, and pain have been intensively studied in the last decade. The results have been contradicting, and replication studies proved challenging. Here, we review some of the recent findings of this topic and explore possible explanations for these discrepancies by incorporating knowledge derived from studies into oral habits and bruxism. Both stress and cerebral functional specialization (i.e., the involvement of specific brain structures in distinctive cognitive processes) are hypothesized to play a major role in the underlying physiological mechanisms of the diverse effects of chewing gum on cognition, stress, and pain.

The impact of emotions on body-Focused repetitive behaviors: evidence from a non-treatment-seeking sample

Body-focused repetitive behaviors (BFRBs) are repetitive, injurious, and non-functional habits that cause significant distress or impairment, including hair-pulling, skin-picking, and nail-biting. The emotion regulation (ER) model suggests that BFRBs are triggered by negative emotions and reinforced by alleviation of unpleasant affect. The frustrated action (FA) model suggests that BFRBs are triggered by and alleviate impatience, boredom, frustration, and dissatisfaction. Individuals with BFRBs are hypothesized to be particularly susceptible to these emotions because they demonstrate maladaptive planning styles characterized by high standards and unwillingness to relax.

OBJECTIVES

The objective of this study was to test these two models.

METHODS

This study compared urge to engage in BFRBs in a BFRB group (n = 24) and a control group (n = 23) in experimental conditions designed to elicit boredom/frustration, stress, and relaxation, respectively.

RESULTS

The BFRB group reported a significantly greater urge to engage in BFRBs than did the control group across conditions. Participants in the BFRB group reported a stronger urge to engage in BFRBs in the boredom/frustration condition than in the relaxation condition but not in the stress condition. Finally, the BFRB group presented significantly higher scores on maladaptive planning style, and maladaptive planning style was significantly correlated with difficulties with ER.

LIMITATIONS

Future studies may wish to exclusively use validated mood induction techniques and more stringent inclusion criteria.

CONCLUSIONS

The results highlight the role of boredom, frustration, and impatience in triggering BFRBs, and support the FA model.

Impact of a Healthy Nails Program on Nail-Biting in Turkish Schoolchildren

This study was conducted to examine the effect of a healthy nails program on nail-biting in Turkish schoolchildren. This quasi-experimental study was of pretest–posttest control group design. A total of 50 students of a primary school formed the intervention group, while 53 students from the same school formed the control group. Data were collected with a demographic form, a nail-biting follow-up form, and photographs of the fingernails. It was found that 68.9% of students were biting seven or more of their nails; 46.6% had damaged nail beds. In the intervention group, the rate of the children who were not biting their nails (baseline = 0%, 4th week = 56.0%, 8th week = 64.0%) increased significantly compared to the control group (baseline = 0%, 4th week = 15.1%, 8th week = 18.9%). Outcomes indicate the efficacy of the healthy nails program in reducing the nail-biting problem in schoolchildren.

Skin picking phenomenology and severity comparison

OBJECTIVE

Despite the substantial distress and impairment often associated with skin picking, there currently is only limited research examining various phenomenological aspects of this behavior. The present research contributes to the existing literature by investigating phenomenological variables related to skin picking, such as family involvement, anxiety, depression, and the emotional consequences of skin picking. Moreover, on the basis of symptom severity level, differences were explored between individuals with skin picking who were from a psychiatric population.

METHOD

Forty individuals with various clinician-ascertained DSM-IV diagnoses in addition to skin picking symptomatology participated in the present study, which was conducted from September 2002 through January 2003. Participants were administered a self-report questionnaire (which assessed demographic, symptom, and past diagnostic information) as well as the Beck Depression Inventory, the Beck Anxiety Inventory, and the Self-Injury Interview.

RESULTS

Phenomenological data on various aspects of individuals with skin picking are presented. Individuals with mild skin picking and individuals with severe skin picking were compared and found to differ in the level of distress they experienced (t = -2.35, p = .05) and the amount of damage caused by their picking behavior (t = -3.06, p = .01).

CONCLUSION

Overall, skin picking represents a behavior with its own unique characteristics and accompanying levels of distress and impairment that warrants specific attention by clinicians.

Pediatric psychocutaneous disorders: a review of primary psychiatric disorders with dermatologic manifestations

Psychocutaneous disorders (PCDs) are conditions that are characterized by psychiatric and skin manifestations. Classifications of PCDs and their nomenclature are matters of debate. For the purpose of this review, we adopted the classification that distinguishes primary dermatologic disorders with psychiatric co-morbidity (PDDPC) from primary psychiatric disorders with dermatologic manifestations (PPDDM). PDDPC includes the psychophysiologic disorders such as atopic eczema, psoriasis, vitiligo, and alopecia areata. PPDDM includes impulse control disorders, obsessive-compulsive disorders, factitious disorder, factitious disorder by proxy, self-mutilation, delusions of parasitosis, psychogenic purpura/Gardner-Diamond syndrome, and cutaneous sensory disorders. Diagnosis and treatment of PCDs are challenging and require that the underlying psychopathology be addressed. A specific PCD may have different underlying psychopathologies and, at times, multiple overlapping psychopathologies may coexist. Most often, both non-pharmacologic management and psychopharmacologic treatment are necessary. The choice of psychopharmacologic agent depends on the nature of the underlying psychopathology (e.g. anxiety, depression, obsessive-compulsive disorder, psychosis). This article reviews the spectrum of PPDDM in children.

A Randomized Controlled Trial of a Novel Self-Help Technique for Impulse Control Disorders

Nail-biting is currently classified as an impulse control disorder not otherwise specified. Although seldom targeted as a primary symptom, nail-biting is often associated with somatic complications and decreased quality of life. The present study assessed the effectiveness of an innovative self-help technique, titled decoupling (DC). DC aims at attenuating pathological nail-biting by performing motor sequences that decouple and rearrange the behavioral elements involved in the habit. A total of 72 participants with excessive nail-biting were recruited via specialized self-help forums and were randomized to either DC or progressive muscle relaxation (PMR) groups after baseline assessment. Four weeks later, participants underwent a similar assessment as before and were asked to rate the effectiveness of the intervention. The primary outcome parameter was the Massachusetts General Hospital Scale (MGH) adapted. Relative to the PMR group, the DC group showed significant progress in withstanding the urge to bite their nails. Furthermore, they appraised the appearance of their nails as considerably less compromised at the end of the treatment relative to participants undergoing PMR. At statistical trend level, the DC group showed a significantly greater decline on the adapted MGH relative to PMR. Despite methodological limitations, the present study asserts that the effectiveness of DC, previously shown for trichotillomania, extends to nail-biting.

Prevalence of nail biting and its association with mental health in a community sample of children

Background

This study evaluates onychophagia or nail biting (NB) prevalence and association with mental health of a community sample of children from Shiraz, Iran.

Findings

The parents of 743 primary school children, selected by random sampling, reported NB behavior of their children and themselves. Children's mental health problem was assessed using the Strengths and Difficulties Questionnaire (SDQ). 22.3% (95% CI: 19.3 to 25.3) of children had NB behavior in the last three months (girls: 20.1% (95% CI: 15.9 to 24.2). The rate in boys was 24.4% (95% CI: 20.1 to 28.7). 36.8% of the children with NB had at least one family member with nail biting. Older age was associated with a higher prevalence of NB while a higher score on the prosocial score was associated with a lower prevalence of NB.

Conclusions

NB is a very common behavior in both genders in children and their family members. Children with NB have less prosocial ability than those without it.

Emotion regulation in pathological skin picking: findings from a non-treatment seeking sample

Pathological skin picking (PSP) is characterized by excessive picking of the skin, resulting in significant distress or functional impairment. The aim of the present study was to investigate the emotion regulation hypothesis of PSP. University students with PSP (n = 55) and without history of PSP (n = 55) were asked to retrospectively rate the intensity of affective states before, during, and after skin picking episodes. The results showed that for a majority of the PSP sufferers, intensity of certain negative affective states (i.e. anxiety, tension or boredom) was pronounced just before picking, and diminished significantly in the period from before to after picking. Relief and gratification increased during picking whereas guilt increased afterwards. A similar pattern emerged in the control group, although a much lower level of intensity was reported. Participants were also asked to fill out questionnaires concerning emotion regulation difficulties, emotion reactivity, depression, anxiety and worry. Hierarchical logistic regressions demonstrated that emotion regulation difficulties as well as emotion reactivity predicted PSP diagnosis after depression, anxiety and worry were controlled for. Furthermore, emotion regulation difficulties statistically mediated the relationship between emotion reactivity and PSP. Overall, the findings support an emotion regulation model of PSP.

Functional Analysis and Treatment of Nail Biting

This study applied functional analysis methodology to nail biting exhibited by a 24-year-old female graduate student. Results from the brief functional analysis indicated variability in nail biting across assessment conditions. Functional analysis data were then used to guide treatment development and implementation. Treatment included a simplified habit reversal package that was modified based on results of the functional analysis. Following treatment implementation, nail biting decreased as evidenced by consistent nail growth and participant self-recorded data. Results are discussed in terms of treatment utility of functional analysis methodology for novel populations and response topographies.