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

Self-Injurious Behavior in a Patient With Dementia: A Case Report and Literature Review

Self-injurious behavior (SIB) has frequently been associated with psychiatric illness and neurological lesions as means of reducing tension or diverting from pain. However, these explanations did not capture the complexity of SIB in the case of Mr. X, a 62-year-old patient who ingested his fingers in his sleep where cognitive testing was valuable in informing diagnosis. Mr. X's SIB was severe enough that he had chewed beyond the middle phalanx for most of his fingers. Clinical symptoms included daytime sleepiness, hypnogogic hallucinations, and bradykinesia. His cognitive profile revealed declines in his intellectual functioning as well as visuospatial and executive deficits in the context of preserved attention, language, and memory. His cognitive and clinical presentation suggested that Mr. X had a neurodegenerative disorder, which may have contributed to his SIB. We believed that the most probable diagnosis may have been rapid eye movement behavioral sleep disorder in the context of Lewy bodies dementia.

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.

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.

The mouse who couldn't stop washing: pathologic grooming in animals and humans

The basic science literature is replete with descriptions of naturally occurring or experimentally induced pathological grooming behaviors in animals, which are widely considered animal models of obsessive-compulsive disorder (OCD). These animal models rely largely on observed similarities between animal behaviors and human OCD behaviors, and on studies of animal pathological grooming disorders that respond to serotonin enhancing drugs. However, current limitations in assessment of complex cognition and affect in animals precludes the field's ability to match the driving primary processes behind observable phenomenology in animal "OCD" with human behavioral disorders. We propose that excessive grooming behaviors in animals may eventually prove to be equally, or possibly more relevant to, other conditions in humans that involve pathological grooming or grooming-like behaviors, such as trichotillomania, body dysmorphic disorder, olfactory reference syndrome, compulsive skin-picking, and onychophagia. Research is needed to better understand pathological grooming behaviors in both humans and animals, as animal models have the potential to elucidate pathogenic mechanisms and inform the treatment of these psychiatric conditions in humans.

Association of nail biting and psychiatric disorders in children and their parents in a psychiatrically referred sample of children

BACKGROUND

Nail biting (NB) is a very common unwanted behavior. The majority of children are motivated to stop NB and have already tried to stop it, but are generally unsuccessful in doing so. It is a difficult behavior to modify or treat. The objective of this study was to investigate the prevalence of co-morbid psychiatric disorders in a clinical sample of children with NB who present at a child and adolescent mental healthcare outpatient clinic and the prevalence of psychiatric disorders in their parents.

METHOD

A consecutive sample of 450 referred children was examined for NB and 63 (14%) were found to have NB. The children and adolescents with nail biting and their parents were interviewed according to DSM-IV diagnostic criteria. They were also asked about lip biting, head banging, skin biting, and hair pulling behaviors.

RESULTS

Nail biting is common amongst children and adolescents referred to a child and adolescent mental health clinic. The most common co-morbid psychiatric disorders in these children were attention deficit hyperactivity disorder (74.6%), oppositional defiant disorder (36%), separation anxiety disorder (20.6%), enuresis (15.6%), tic disorder (12.7%) and obsessive compulsive disorder (11.1%). The rates of major depressive disorder, mental retardation, and pervasive developmental disorder were 6.7%, 9.5%, 3.2%, respectively. There was no association between the age of onset of nail biting and the co-morbid psychiatric disorder. Severity and frequency of NB were not associated with any co-morbid psychiatric disorder. About 56.8% of the mothers and 45.9% of the fathers were suffering from at least one psychiatric disorder. The most common psychiatric disorder found in these parents was major depression.

CONCLUSION

Nail biting presents in a significant proportion of referrals to a mental healthcare clinic setting. Nail biting should be routinely looked for and asked for in the child and adolescent mental healthcare setting because it is common in a clinical population, easily visible in consultation and relatively unintrusive to ask about. If present, its detection can then be followed by looking for other more subtle stereotypic or self-mutilating behaviors.

Self-inflicted finger injury in individuals with spinal cord injury: an analysis of 5 cases

OBJECTIVE

To describe the occurrence of finger autophagia in 5 persons with traumatic spinal cord injury and to present a discussion of putative causes and potential treatments.

BACKGROUND

Minor self-mutilating actions, such as nail biting and hair pulling, are common in humans and usually benign. In some circumstances, these behaviors are associated with obsessive-compulsive personality traits. In humans, self-injurious biting behaviors are well described in the setting of mental retardation and psychosis and in persons with Lesch-Nyhan syndrome. Rare cases of human autophagia in persons with intact cognition have been reported, most commonly in the setting of acquired nervous system lesions. After spinal cord injury, it has been suggested that this behavior constitutes a human variant of animal autotomy and a response to neuropathic pain.

DESIGN

Case presentation narrative.

MAIN OUTCOME MEASURES

Photographic and radiological study, administration of Yale-Brown Obsessive-Compulsive Scale (YBOCS).

FINDINGS

In 5 patients with complete tetraplegia, pain in the hands was present in only one instance. The severity of autoamputation varied from minor to extreme. In all cases, damage was confined to analgesic body parts. In 3 cases, autophagia behavior was discovered in progress. Treatments included pharmacotherapy, counseling, and behavioral therapy, with mixed results. All patients were intelligent, willing to discuss their issues, and able to identify conditions of stress and isolation in their lives. Mild preinjury obsessive-compulsive behaviors, such as nail biting, were universal. On the YBOCS, only 1 patient scored in a range indicative of mild obsessive-compulsive symptomatology.

CONCLUSIONS

This group exhibited heterogeneous medical, social, and cultural characteristics. A link between pain and self-injurious behavior could not be demonstrated. This behavior may be viewed as an extreme variant of nail biting, with potential ominous complications. Treatment strategies have been employed with mixed results.

Brittle nail syndrome: a pathogenesis-based approach with a proposed grading system

Brittle nail syndrome is a heterogeneous abnormality, characterized by increased fragility of the nail plate. Brittle nails affect about 20% of the population and women are affected twice as frequently as men. The vast majority of patients experience brittle nails as a significant cosmetic problem and a substantial number indicate that these nail abnormalities are painful, impair daily activities, and may have a negative impact on occupational abilities. Pathogenic factors leading to brittle nails are factors that impair intercellular adhesion of the corneocytes of the nail plate or factors that cause a pathologic nail formation by involving the matrix. Clinical features of brittle nail syndrome are onychoschizia and onychorrhexis: the impairment of intercellular adhesive factors of the nail plate is expressed as onychoschizia, whereas the involvement of the nail matrix is expressed as onychorrhexis. Although impairment of life quality has not been evaluated for patients with brittle nail syndrome, the reduction of life quality in other nail problems has been studied and is evident. A proposed scoring system of key features of brittle nails is presented, and therapeutic approaches focussed on the pathogenic factors are discussed.

Pathologic hairpulling, skin picking, and nail biting

BACKGROUND

Pathologic hairpulling (HP), skin picking (SP), and nail biting (NB) are repetitive, intentionally performed behaviors that cause noticeable hair loss or substantial physical damage, and result in clinically significant distress or functional impairment. To date, HP, SP, and NB have received little attention in the psychiatric literature despite being widespread behaviors.

METHODS

The present article reviews the up-to-date research findings on these three forms of pathologic behavior, highlighting their similarities and differences.

RESULTS

Despite HP, pathologic grooming behaviors have not yet been explicitly included in the diagnostic nomenclature. Phenomenology, triggers, consequences and functionality of HP, SP, and NB are similar, which suggest their joint diagnostic categorization. Sufferers often fail to admit the self-inflicted nature of their physical damage out of shame and embarrassment, which complicates the recognition and differential diagnosis of sufferers. Thus, practitioners need to be particularly attentive to physical signs possibly related to these behavior disorders.

CONCLUSIONS

Research suggests that HP, SP, and NB are underrecognized problems that occur on a continuum ranging from mild to severe. Further research is needed, especially regarding the etiology of pathologic HP, SP, and NB, to foster the development of both effective and long-lasting treatments and prevention strategies.

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.

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.