Onychophagia as a clinical symptom: A pilot study of physicians and literature review

Although onychophagia is a medical condition and is associated with poorer health, there are no guidelines for assessment or treatment. The purpose of this study was to investigate the clinical aspects of nail biting from doctors' points of view, to estimate the prevalence of onychophagia among physicians, and to review the literature on and treatment methods for onychophagia. Twenty-four percent of doctors reported nail-biting periods during their lifetimes, and 2% of them remained active nail biters. A total of 64.4% of doctors see nail biting in their practices, and 60.6% never or only on request ask patients about nail biting and examine their nails. Family doctors and pediatricians ask their patients about nail biting most often. Attitudes and opinions on the treatment of nail biting are undefined and vary. Doctors reported usually treating nail-biting patients by referring them to another specialist or offering special nail polish. There is a need to improve physicians' knowledge of nail-biting treatment methods, but a lack of studies evaluating the clinical aspects of onychophagia and its relation to mental health and emotion dysregulation. Further research is needed. Clinical attitudes toward nail biting could be more precise in training and medical practice.

Pathological grooming: Evidence for a single factor behind trichotillomania, skin picking and nail biting

Although trichotillomania (TTM), skin picking (SP), and nail biting (NB) have been receiving growing scientific attention, the question as to whether these disorders can be regarded as separate entities or they are different manifestations of the same underlying tendency is unclear. Data were collected online in a community survey, yielding a sample of 2705 participants (66% women, mean age: 29.1, SD: 8.6). Hierarchical factor analysis was used to identify a common latent factor and the multiple indicators and multiple causes (MIMIC) modelling was applied to test the predictive effect of borderline personality disorder symptoms, impulsivity, distress and self-esteem on pathological grooming. Pearson correlation coefficients between TTM, SP and NB were between 0.13 and 0.29 (p < 0.01). The model yielded an excellent fit to the data (CFI = 0.992, TLI = 0.991, χ2 = 696.65, p < 0.001, df = 222, RMSEA = 0.030, Cfit of RMSEA = 1.000), supporting the existence of a latent factor. The MIMIC model indicated an adequate fit (CFI = 0.993, TLI = 0.992, χ2 = 655.8, p < 0.001, df = 307, RMSEA = 0.25, CI: 0.022-0.028, pclose = 1.000). TTM, SP and NB each were loaded significantly on the latent factor, indicating the presence of a general grooming factor. Impulsivity, psychiatric distress and contingent self-esteem had significant predictive effects, whereas borderline personality disorder had a nonsignificant predictive effect on the latent factor. We found evidence that the category of pathological grooming is meaningful and encompasses three symptom manifestations: trichotillomania, skin picking and nail biting. This latent underlying factor is not better explained by indicators of psychopathology, which supports the notion that the urge to self-groom, rather than general psychiatric distress, impulsivity, self-esteem or borderline symptomatology, is what drives individual grooming behaviours.

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.].

Psycho-Neurological Status in Children with Malocclusions and Muscle Pressure Habits

Non-nutritive sucking behaviors such as finger- and tongue-sucking, tongue thrust, lips- or cheek-sucking, nail-, lip- or tongue-biting and other pressure habits represent risk factors for malocclusion. The association between psycho-neurological disorders and different types of malocclusion in children with sucking habits was long studied. During neurological examination, many children with sucking habits are diagnosed as Minimal Cerebral Dysfunction or Attention Deficit Hyperactivity Disorder (ADHD) bearers. The aim of this study is to assess the psycho-neurological status and motor disorders in children with malocclusion and normal occlusion. 135 children, aged between 8 and 12 years old, were examined, 42 children with normal occlusion and 93 children with different types of malocclusion. Besides clinical examination, all children were studied by the following psychoneurological methods: 1) Parent's Questionnaire, 2) Diagnostic interview Kiddie-Sads 3) Physical and Neurological Exam for Subtle Signs and 4) stabilometric tests. This study shows as in presence of dentofacial anomalies, pressure habits, ADHD reports significant effects on the functional state of the motor system: increases are noted in all basic parameters of statokinesiograms (crossed distance, sway area and ellipse surface), which lead to increased physiologic energy costs to maintain the vertical position of the body.

Onychophagia is associated with impairment of quality of life

Onychophagia is defined as a chronic nail biting behaviour affecting about 20-30% of the general population. However, nail biting seems to be an ignored problem in a daily clinical practice. We have analysed the influence of onychophagia on quality of life (QoL) and stigmatisation level among 339 medical students with and without nail biting. Those with onychophagia demonstrated significantly higher QoL impairment compared to the controls (p < 0.001). Subjects who had been unable to stop nail biting behaviour in the past (p < 0.01) had visible nail abnormalities (p = 0.03), spent more time on nail biting (p = 0.02) and with a higher number of involved fingernails (p = 0.03), demonstrated further impaired QoL. Furthermore, tension before or when trying to resist nail biting (β = 12.5; p < 0.001), suffering due to nail biting (β  =12.6; p = 0.001) and nail eating behaviour (β = -7.5; p < 0.01) were independent variables influencing QoL. Participants with onychophagia also demonstrated higher level of stigmatisation (0.6 ± 1.2 vs. 0.2 ± 0.6 points, p < 0.01), although in both groups the stigmatisation level was low.

Onychophagia and onychotillomania: prevalence, clinical picture and comorbidities

Onychophagia is defined as chronic nail biting behaviour, which usually starts during childhood. Onychotillomania results from recurrent picking and manicuring of the fingernails and/or toenails, leading to visual shortening and/or estraction of nails. The aim of this study was to assess the prevalence of onychophagia and onychotillomania in young adults, and the comorbidity of these conditions with anxiety disorders and obsessive compulsive disorders (OCD), as well as to determine factors related to these behaviours. A total of 339 individuals were interviewed with a structured questionnaire. Onychophagia was present in 46.9% of participants (including 19.2% active and 27.7% past nail biters), and an additional 3 people (0.9%) had onychotillomania. The majority of subjects (92.2%) described nail biting as an automatic behaviour. Tension before nail biting was reported by 65.7% of nail biters, and feelings of pleasure after nail biting by 42%. Among the participants with lifetime onychophagia, 22.5% met criteria of anxiety disorder and 3.1% of OCD, while in the group without onychophagia at least one anxiety disorder was diagnosed in 26.2% and OCD in 5.0%. We did not find any correlation between nail biting and other anxiety disorders or OCD. In conclusion, no single condition was associated with nail biting or influenced such behaviour; multiple psychological factors were involved.

Coincidence and awareness of oral parafunctions in college students

OBJECTIVE

The aim of the study was to determine the prevalence and awareness of particular types of oral parafunctions in young healthy students and any association with temporomandibular disorders (TMD).

MATERIAL AND METHODS

The study was performed in a randomly selected group of 303 healthy students (mean age 18.8 years) from the vocational technical school in Wrocław, Poland, who underwent a routine clinical examination and functional analysis of the mouth. On taking the history all subjects were asked about their awareness of various forms of parafunctional activity in their mouth.

RESULTS

Almost all subjects revealed various oral parafunctions such as: bruxism, nail and pen biting, chewing gum, and biting the mucosa of lip or cheek. These habits were present singly or as double, triple or even fourfold coincidences in a single person. The most frequent oral parafunctions were habitual gum chewing and bruxism. Subjects were very seldom aware of the last parafunction. TMDs were more prevalent in the presence of bruxism than in other oral parafunctions.

CONCLUSIONS

The studied students revealed various types of oral parafunctions, however most of them were not aware of clenching and grinding their teeth.

Self-inflicted non-healing genital ulcer: a rare form of factitious disorder

Dermatitis artefacta is a factitious dermatological disorder with many forms of presentation that may occur on any part of the body. A diagnosis of dermatitis artefacta is often reached after rigorous and repeated investigations. Here we present the case of a 49-year-old single man complaining of a 4- month history of ulceration on the dorsal surface of the glans penis. In view of the unusual appearance of the lesion and the negative findings from clinical investigations, a diagnosis of dermatitis artefacta was made and the patient was referred for psychiatric evaluation. He was started on 20 mg/day of citalopram and titrated up to 40 mg/day by the 4th week, leading to complete remission in the following weeks. Thus, although rare, artefactual dermatitis should be considered in the differential diagnosis of unusual penile lesions.

Onychophagia as a spectrum of obsessive-compulsive disorder

Onychophagia can be explained as a kind of a compulsion that may cause destruction of the nails. Habitual nail biting is a common behaviour among children and young adults. By the age of 18 years the frequency of this behaviour decreases, but it may persist in some adults. Nail biting is an under-recognized problem, which may occur on a continuum ranging from mild to severe. Nail biting has received little attention in the psychiatric and dermatological literature. Its position in widely accepted classifications of psychiatric disorders (ICD-10 and DSM-IV) remains unclear. This disorder seems to be related to obsessive-compulsive spectrum disorder. Here, we present three case reports of onychophagia and co-occurring psychopathological symptoms and discuss the close relationship of onychophagia to obsessive- compulsive spectrum disorder and possible treatment modalities. Psychiatric evaluation of co-occurring psycho pathological symptoms in patients with onychophagia, especially those with chronic, severe or complicated nail biting, may be helpful in making a choice of individual therapy. Serotonin re-uptake inhibitors seem to be the treatment of choice in severe onychophagia.

[Self-mutilation of the hand in a girl with total, persistent obstetric brachial plexus palsy--case report]

A case of hand self-mutilation in six years old girl with totals persistent obstetric brachial plexus palsy was presented. Self-mutilation involved biting the tips of the digits what lead to removal of nail of IV finger and partial V finger distal phalanx amputation. Furthermore, possible etiology, mechanism, evaluation of this behavior and literature was discussed in the text.

Examination of gender in pathologic grooming behaviors

Trichotillomania and pathologic skin picking are pathologic versions of grooming behaviors. Although mentioned in the psychiatric literature for decades, little is known about how gender influences clinical presentation of these behaviors. Seventy-seven adult subjects (12 men) with trichotillomania or pathologic skin picking were examined on a variety of clinical measures including symptom severity, functioning, and comorbidity. There were more similarities than differences between men and women with these behaviors. Some significant differences, however, were that men with grooming disorders had a later age of onset of the behaviors, had greater functional impairment due to the behaviors, and were more likely to suffer from a co-occurring anxiety disorder. This study suggests that gender may be an important clinical factor when assessing and treating these disorders. Further research is needed to validate our findings and identify whether treatments should be specially tailored differently for men and women with grooming disorders.

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

OBJECTIVE

To compare the frequency of nail biting in 4 settings (interventions) designed to elicit the functions of nail biting and to compare the results with a self-report questionnaire about the functions of nail biting.

DESIGN

Randomised allocation of participants to order of conditions.

SETTING

University Psychology Department.

SUBJECTS

Forty undergraduates who reported biting their nails.

INTERVENTIONS

Left alone (boredom), solving maths problems (frustration), reprimanded for nail biting (contingent attention), continuous conversation (noncontingent attention).

MAIN OUTCOME MEASURES

Number of times the undergraduates bit their nails.

RESULTS

Nail biting occurred most often in two conditions, boredom and frustration.

CONCLUSION

Nail biting in young adults occurs as a result of boredom or working on difficult problems, which may reflect a particular emotional state. It occurs least often when people are engaged in social interaction or when they are reprimanded for the behavior.

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.

Abnormal oral habits in the children of war veterans

Any kind of stress has a negative effect on the mood of people and stress resulting from war is no exception. Stress from war has not only has effects on war veterans but also on the families. Children of these families have been more susceptible to abnormal oral habits. In this observational, analytical and historical research, attempts have been made to determine the prevalence of abnormal oral habits in the children of war veterans (martyrs, freed prisoners of war and war cripples) and compare them with a control group. In this study of 520 children aged between 7 and 11 years were (238 in the study group and 282 in the control group), information was gathered via a questionnaire completed by the mothers of the students. Analysis of the received information showed that the prevalence of para functional and abnormal oral habits was more in the study group (P = 0.005). The prevalence rate was highest in children, whose family members had been both crippled and freed prisoners of war, while the rate was lowest in children whose parents had been only prisoners of war without any lasting physical injury. Most of these children had acquired these habits at the age of seven and these abnormal habits were most prevalent in children aged eight and nine.

Etiopathogenesis of parafunctional habits of the stomatognathic system

A broad consensus does exist among main authors on the importance of parafunctional habits in the etiopathogenesis of temporomandibular disorders (TMD). Mechanisms through which an intense parafunctional activity determined a pathological effect on the temporomandibular joints (TMJs) and their related structures have still not been definitively clarified; nevertheless, before investigating those mechanisms, it's useful to study predisposing, triggering and/or worsening factors of parafunctions themselves. At present the theory, once widely accepted, according to which occlusal interferences can trigger a muscular hyperactivity through the activation of periodontal receptors, has lost a lot of credit. Recently, the hypothesis that bruxism and other parafunctions have a central etiology has become more and more accepted. In such a context, the role of the psychic component assumes a strong relevance, particularly for its relation with the limbic system, which is the part of the central nervous system (CNS) that regulates emotions. Such a hypothesis is confirmed by clinical practice, but it doesn't explain why some patients have reported a worsening of parafunctional activities after occlusal adjustment. The aim of this study is to investigate this issue through a critical review of the literature, indicating how the 2 theories might be complementary for the development and worsening of a parafunctional habit. From this review, despite the number of clinical opinions, there emerges a lack of methodologically appropriate associative works and controlled clinical trials which consent to clarify the effective importance of psychic and/or occlusal factors in the etiopathogenesis of parafunctional habits.

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.

Evaluating the efficacy of habit reversal: comparison with a placebo control

BACKGROUND

The purpose of this study was to compare the effectiveness of habit reversal with a placebo control as a treatment for chronic nail biting in adults.

METHOD

Thirty adults with a chronic nail-biting problem (occurring > or = 5 times/day nearly every day for > or = 4 weeks and causing physical damage or social impairment) were randomly assigned to a placebo control or habit reversal group. Five participants withdrew from the study prior to the completion of treatment. The remaining individuals in both groups received a total of 2 hours of treatment over 3 sessions. Individuals in the habit reversal group (N = 13) received the components of awareness training, competing response training, and social support. Individuals in the placebo control group (N = 12) simply discussed their nail biting. At pretreatment, posttreatment, and a 5-month follow-up, nail length was measured, photographs were taken of the damaged nails and later rated by independent observers, and data on participant depression, anxiety, and self-esteem were obtained. Treatment compliance and acceptability data were collected at posttreatment only.

RESULTS

Results showed that habit reversal produced a greater increase in nail length at posttreatment and follow-up when compared with the placebo. Data from the independent raters confirmed these findings. Habit reversal was also viewed as a more acceptable intervention by the participants. At posttreatment, the habit reversal group had increased their nail length by 22% from pretreatment compared with a 3% increase for the placebo group. At follow-up, the habit reversal group maintained a 19% increase in nail length from pretreatment compared with a 0% increase for the placebo group.

CONCLUSION

Findings from this study suggest habit reversal is more effective than a placebo control and should be considered a well-established intervention for body-focused repetitive behaviors.

[Interdisciplinary approach to onychophagia]

Onychophagy is classified to the nail diseases caused by repeated injures. Nail-biting as autodestruction and onychophagy in its most aggressive form, is common not only among children but adults as well. Nail-biting in children belongs to the group of habits and habitual function, which allowed for relieving the anxiety, loneliness, inactivity in children deprived of safety feeling, love and nearest relationship. In most adults suffering from onychophagy psychiatric diseases are not diagnosed. There are different clinical symptoms of onychophagy depended on the degree and the way of performed injures. In this study we are promoting the multidisciplinary approach to the therapy of habitual nail-biting.

Prevalence of oral habits in 563 Nigerian preschool children age 3-5 years

One of the contributory factors in the establishment of occlusion is the child's oral habits. A limited amount of information is available on oral habits of pre-school children especially on Nigerian pre-school children. With an increasing interest in the early recognition of mal-occlusion and a corresponding emphasis on preventive procedures, more information on pre-school children may prove to be useful. This study revealed the prevalence of oral habits among 563 Nigerian pre-school children aged 3-5 years at 13.14%: 6.74% for males, 6.4%for females. The acquired data were tested with chi-square(chi2). The results indicate significant gender difference for tongue thrusting/sucking only (P=0.01) using the fisher's exact test. The relationship between digital sucking habit and mal-occlusion was very significant (P<0.01).

Oral jaw behaviors in TMD and bruxism: a comparison study by severity of bruxism

The purpose of this study was to document the prevalence of oral jaw behaviors concomitant to bruxism in TMD+bruxing behavior patients and in nonbruxer controls. Clinical examination, questionnaires, and specific criteria to allocate patients to mild, moderate, and severe groups of TMD and bruxers were used. The sample consisted of 274 TMD+bruxing behavior patients and 52 control non-bruxing behavior groups evaluated at the Center for the Study of TMD. The mean age of the TMD+bruxing behavior group was about 33.11 years old (range 16.66, SD = 11.52) as compared to 34.90 years old (range 17-67, SD = 14.26) in the control group. Oral jaw behaviors were assessed in the mild, moderate, and severe TMD+bruxing groups, and in the corresponding control group. It was found that the prevalence of oral jaw behaviors was higher in the TMD+bruxing behavior group as compared to the control. Hence, concomitant oral jaw behaviors predominated in bruxers and increased with its severity. The data reinforce the need to assess TMD patients in terms of the presence of bruxism, its severity, and concomitant oral jaw habits. Such approach will enable the clinician to have better understanding about the role of these behaviors in TMD. Epidemiological data was also provided regarding jutting the jaw forward (a rarely-described oral jaw habit) in a relatively large sample of TMD+bruxing patients, suggesting a more clinical intervention in children and adolescents. This study is the first to document the prevalence of specific oral jaw habits in a relatively large sample of TMD+bruxing behavior classified by degree of severity. Results suggest that TMD+bruxing patients may present many other additional oral jaw habits which may concur to increase masticatory muscle activity thus leading to TMD signs and symptoms. Factors responsible for the increased frequency of oral jaw habits with the severity of bruxism behavior remain unknown and therefore further studies are needed.

Psychophysiological reactivity to stress in nail biters

Heart rate and skin conductance were measured for 83 college students (20 male nail biters, 19 male non-nail biters, 22 female nail biters, and 22 female non-nail biters) during baseline, task, and 3 stressors. Psychodiagnostic measures included the Beck Depression Inventory and the State-Trait Anxiety Inventory. A significant nail-biting status x sex interaction was found in skin conductance reactivity (task minus baseline) for all tasks. Male nail biters were significantly more reactive than the other 3 groups. There was no significant difference in heart rate reactivity in any of the tasks. None of the psychodiagnostic measures differentiated among any of the subgroups. Nail biting, for males, is associated with psychophysiological changes during stress, although the implication of this relationship remains to be clarified.

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.

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.

Operant learning (R-S) principles applied to nail-biting

The principles of R-S learning were applied to a 32-yr.-old Caucasian woman to reduce the frequency and duration of fingernail-biting activity in a reversal-replication (ABAB) research design. The undesirable behavior, fingernail-biting which included frequency and duration, antecedents, and setting events, was recorded during a 28-day study. Self-monitoring recordings indicated that anxiety was the most prevalent antecedent. Through the use of a preliminary questionnaire and interview, increase in self-awareness was judged to be most effective in the extinction of the undesired behavior. The systematic desensitization techniques of deep muscle relaxation and Transcendental Meditation were used during the treatment phase.

Nail biting in rheumatic diseases

To ascertain if nail biting (usually considered a manifestation of emotional tension) was associated with fibromyalgia, 387 patients attending the Rheumatism Clinic at the Leeds General Infirmary were studied prospectively. Bitten nails appeared to be a feature of youth rather than of fibromyalgia. Patients with a full set of dentures were less likely to bite their nails than others, but it can and was done by 7%. Posing the question about nail biting worried several patients, indicating the wisdom of seeking ethical approval even for "noninvasive" studies.

Relationship of self-esteem, manifest anxiety, and obsessive-compulsiveness to personal habits

75 women and 64 men responded to the Coopersmith Self-esteem Inventory, the Manifest Anxiety Scale, and the Maudsley Obsessional-compulsive Inventory in addition to responding to a questionnaire on personal habits. The results indicated that more frequent hair-pullers and nervous twitchers scored lower on self-esteem and higher on anxiety. People who giggled and those who bit their fingernails more often scored higher on obsessive-compulsiveness. Self-reported gigglers were higher on manifest anxiety. If the criterion of self-assessed seriousness of the behavior problem was used, people who bit their nails, picked their noses, pulled their hair, chewed on objects, giggled, ground their teeth, twitched nervously, and picked at scabs scored lower on self-esteem. Higher manifest-anxiety scores were found among the people who regarded their nail-biting, hair-pulling, object-chewing, nervous twitching, or giggling as serious problems. Finally, people who regarded their nail-biting as more serious tended to have higher obsessive-compulsive scores. The results in general suggest that the frequency of several of these behaviors is anxiety-related and that it is the person's assessments of these behaviors as problems rather than simply their frequency that is related to higher anxiety and lower self-esteem.

Incidence of some oral-based habits among college students and their correlations with use of oral stimulants

This study explored the incidence of three personal habits and their correlates with popular tensional outlets. The 108 men and 202 women college students estimated how often they bit their fingernails, picked their noses, chewed on pencils or other objects, used specific tobacco products, used specific caffeine products, chewed gum, and exercised. Also, they rated their happiness on a seven-point scale in Likert format. The fingernail-biting incidence observed here was higher than was reported in previous samples of young adults, and more men than women were nail-biters. More men than women admitted to nose-picking; and about 61% of persons of either sex reported being occasional object-chewers. Men were more likely to exercise, use tobacco products, or consume iced tea than were women but were less likely to chew gum. The intercorrelations among the habits were not significant, and they were unrelated to lower self-reports of happiness. Both men and women who were object-chewers reported drinking greater amounts of cola beverages; otherwise, the relationships between these habits and product uses were not significant.

Dermatology and conditions related to obsessive-compulsive disorder

Patients with cutaneous disorders may have obsessive-compulsive symptoms but treatment for these symptoms has been limited. Advances in our understanding of obsessive-compulsive disorders have led to the concept of a spectrum with similar phenomenology, underlying neurobiology, and psychopharmacotherapeutic response. Many of these disorders, which include trichotillomania, neurotic excoriation, onychophagia, body dysmorphic disorder, and dermatitis artefacta may respond to specific therapeutic interventions.

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.

A double-blind comparison of clomipramine and desipramine treatment of severe onychophagia (nail biting)

Twenty-five adult subjects with severe morbid onychophagia (nail biting) and no history of obsessive-compulsive disorder were enrolled in a 10-week double-blind cross-over trial of clomipramine hydrochloride and desipramine hydrochloride. For the 14 subjects who completed the study, clomipramine hydrochloride (mean +/- SD dose, 120 +/- 48 mg/d) was superior to desipramine hydrochloride (mean +/- SD dose, 135 +/- 53 mg/d) in decreasing nail biting as measured by a repeated-measures analysis of variance on the Nail Biting Severity, Nailbiting Impairment, and Clinical Progress scales. The high dropout rate at every stage of the study was in sharp contrast to that seen with psychiatric populations. From a neuroethologic perspective, similar biologic systems are hypothesized to mediate a spectrum of grooming behaviors, including onychophagia, trichotillomania, and obsessive-compulsive disorder.

Clinical profile of trichotillomania

Twenty-four cases of trichotillomania attending psychiatry outpatient department and child guidance clinic at Kalawati Saran Children's and Smt Sucheta Kriplani Hospitals over a period of 2 years from July, 1985 to November 1987 were studied. Females (66.7%) outnumbered the males (33.3%). Majority of cases belonged to age group 6-10 years (54.2%) and nuclear family (68.5%). Nail-biting (25.0%) was the commonest associated neurotic trait, followed by enuresis (20.9%), temper-tantrum (12.5%), etc. A past history of hysterical fits and neurotic depression was found in 3 cases (12.5%) and 2 cases (8.3%) respectively. Family history of neurosis was seen in mothers and fathers of 20.9% and 12.5% cases respectively. Trichobezoars and trichophytobezoars were found in 6 cases (25.0%) and 3 cases (12.5%) respectively. Majority of patients of trichobezoars presented with vague complaints like heaviness in the stomach (55.6%), inability to gain weight (44.4%), etc, while 22.2% cases were asymptomatic and detected only on screening.

[Behavioral somatic disorders in hospitalized children]

The research has investigated the occurrence of somatic and behavioural disorders in 100 hospitalised children. A hundred subjects, 55 males & 45 females, aged between 6 and 14 years were asked to fill in questionnaires. These, which were of a completely new type, related to 12 situations in a typical day. The results showed statistically significant differences between the two sexes. Girls manifested a much higher percentage of disorders than did boys. Further, young children and especially pre-adolescents (subjects aged 10-11) manifested more disturbances than did those in the adolescent category. Of the subjects 32% showed a number of disorders below the norm; 36% of the cases were within normal values, 17% were above the norm and the remaining 15% of the subjects were considered to be of particular interest. The most frequent somatic disorders were in heart-rate variations, abnormal sweating (especially of the hands when being orally tested at school), abdominal-aches and headaches. Of the behavioural disorders the most frequent were in the inability to stand still and nail-biting. Also worthy of note, though less frequent, were disorders in eating and in sleeping. It was especially at the end of the day ("before going to sleep") that all these problems occurred. They were also frequent, however, during the periods "at school", "during oral tests" and "watching television". The results obtained in parallel research on 125 primary school children confirm all of the above findings.

[Studies on the incidence and possibility of collective treatment of certain non-occlusal parafunctions in elementary school children]

A study was carried out on the incidence and possibility of collective treatment of non-occlusal parafunctions in 216 elementary school children aged 7-14 years. Two objectively detectable non-occlusal parafunctions were analysed: nail-biting and pencil-biting. The study included four meetings during which the fingernails and pencils were inspected in all children and a talk was given, explaining the harmfulness of motor habits in the masticatory system, and the children with these habits were told to replace them with other non-harmful movements as habits. Among 216 children 131 (60.6%) had such non-occlusal parafunctions with nail-biting in 51.9% of them, and pencil-biting in 31%. In 22.2% both habits were found. During the third control visit the overall incidence of both parafunctions was found to be decreased, from 60.6% to 37.9%. Elimination of nail-biting was obtained in 37.5% of cases, and pencil-biting in 64.2%, with the proportions of treated children varying in various classes. The study showed that nail-biting and pencil-biting are widely spread habits in the studied population and that collective treatment of these parafunctions is possible.

Nailbiting and oral aggression in a Turkish student population

The study investigated the relationship between the occurrence and intensity of nailbiting in a Turkish student population and the association with questionnaire measures of oral aggression, trait anxiety and intropunitive and extrapunitive hostility. The results indicated that the most consistent trait associated with nailbiting was oral aggression. Taken together with other previous research these findings are thought to offer some support to the construct of oral personality.

A comparison of relaxation training and competing response training to eliminate hair pulling and nail biting

A 17-year-old female with a 14-year history of hair pulling and nail biting was treated with relaxation training and competing response training. While introduction of relaxation training produced an initial decline in hair pulling, there was a gradual recovery of the maladaptive behavior to baseline levels. The competing response procedure consisted of clenching fists for 3 min whenever hair pulling or nail biting occurred or were likely to occur. By the use of the competing response hair pulling and nail biting decreased, eventually to zero. Follow-up over a 2-year period revealed that the treatment effects were maintained.

[Treatment of onychophagia]

Personal experience in the hypnotic management of nailbiting is presented. Confidence in this type of treatment is rested on the results observed in a set of 32 cases, 28 of which were fully and definitively resolved. An exhaustive account is given of the subject and the method applied. Stress is laid on its technical and therapeutic advantages.