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Skin Picking and Nail Biting: Related Habits

  • Fred Penzel, PhD
  • Reprinted from In Touch #11 © 1995
  • © Trichotillomania Learning Center, Inc. 2008. All Rights Reserved

It may come as no surprise that there are other types of problem behaviors quite similar to Trichotillomania, specifically skin picking (excoriation) disorder and nail biting (also known as onychophagia). These may not sound serious, but neither does hair pulling to some people. Since I have met quite a number of people who have one of these problems in addition to Trichotillomania, I now routinely screen for them.

What I am referring to is not the kind of little bits of rough nail or cuticle that everyone picks at or bites from time to time, nor is it the occasional blemish that people might squeeze or pick. These nailbiters continually bite their nails past the nail bed and their cuticles until they bleed and are constantly walking around with red, sore, and sometimes infected fingers. Those who pick their skin compulsively have their faces and bodies covered, at times, with red sores and scabs known as "acne excoria" - a self-inflicted skin disorder that resembles acne. The smallest pimple or blemish must be opened and picked at or squeezed, either with the fingers or another implement such as tweezers, needles, pins, toothpicks, etc.

Just as those with trichotillomania wear hats, scarves, wigs and makeup, nailbiters keep their hands behind their backs or in their pockets, and skin pickers wear makeup or band-aids or just stay indoors when looking their worst. They feel the same shame and social embarrassment and experience that out-of-control feeling at times. They, too, wonder why they can't stop and they also question whether or not they are crazy.

Another similarity between these problems and trichotillomania is that they seem to happen when people are in one of two modes. Some do it in an automatic way, as if they are in a trance and not really thinking about what they are doing. Usually, they are involved in some other activity at the same time such as reading, watching TV, etc. For others, the deliberate picking or biting is their main activity at the time.

There is also a strong commonality seen in the various purposes behind these three problems. At the most basic level, they satisfy an urge. Many report an almost uncontrollable feeling of needing to do them. Pulling, picking or biting also seem to deliver a pleasurable or relaxed sensation. When sufferers feel stressed, doing these things has a kind of soothing effect on their nervous systems. It probably accounts for why so many people who dislike doing them find it so hard to stop. It simply "feels good" at the time, no matter what the consequences.

Another purpose also seems to be at work for many people. This involves a kind of compulsive perfectionism. Some hairpullers must pull "special" hairs that feel "different" or as if they don't belong due to their look or feel. Nail biters will often try to bite off rough-feeling or broken bits of cuticle or nail sticking out in order to make their nails feel smooth and look "perfect" or regular. Skin pickers will stand for hours in front of mirrors closely examining their faces or other body areas for the tiniest bump, irregularity or enlarged pore and then try to eliminate it, drain it, in hopes of a clear complexion. Paradoxically, all of those who pursue such goals always end up looking much worse in spite of their efforts.

What all these similarities seem to point to is that these three behaviors are probably all different aspects of the same problem. It may be that the same out-of-control grooming mechanism in the brain underlies them all. There are many who now believe that they form a subgroup of what is becoming known as the Obsessive Compulsive Disorder Spectrum. OCD has been previously regarded as only a single disorder. It may in fact represent a range of related disorders, including classic OCD, Body Dysmorphic Disorder, Anorexia Nervosa, Bulimia, Trichotillomania, Onychophagia, Skin Picking, and Tourette's Syndrome.

In my own practice I have seen quite a few hairpullers who also bite their nails and/or pick at their skin. While it has never been surveyed systematically, there may be many out there with multiple symptoms. Interestingly, quite a number of people don't realize that their several problems may be connected until it is pointed out.

As with Trichotillomania, these other two disorders appear to respond best to medication and behavioral therapy. Medication should not be considered an end in itself, but a tool to help you do the therapy. Drugs which remedy these problems do not work instantly - it may take several weeks before you see any results. They also may not work perfectly. Usually, 60 to 70 percent improvement on a medication is considered a good result. The medications mainly used to treat picking or biting problems are the same group as those used for Trichotillomania and OCD. This group is made up of the latest and most potent antidepressants and includes Anafranil, Prozac, Zoloft, Paxil, and Effexor. Two recently approved medications, Luvox and Serzone, may also prove to be useful. No one drug is best, since no one drug works for everyone. You have to work your way through them in a trial-and-error way, until you find the one that is most effective for you.

Therapy for these disorders would consist of Habit Reversal Training, a three-step process which teaches you awareness of your habits, how to relax, focus and center yourself, and to perform a competing and opposing muscle response. (I have described this technique in a previous TLC InTouch article on cognitive/behaviors therapy for Trichotillomania, which I'm sure you can get copies of.) It can be extremely useful if practiced daily and stubbornly, as it must become as automatic as the habit you are aiming to eliminate. These are stubborn problems for two reasons. First, you have probably rehearsed the unwanted behaviors hundreds or even thousands of times. It is important to accept that they will not simply be overcome in a few days or weeks. Second, you are fighting the fact that they feel good to do, and provide much short range satisfaction and soothing. It takes time and a good deal of effort to master, but I believe it is worth it. Research shows it to be an effective technique.

Even if you have more than one of these problems, don't despair. They can be overcome. More important is learning to "de-stigmatize" yourself. You are not crazy, helpless, morally weak or totally out of control, even though you may feel like some or all of these things at times. Once you get down to realizing that you are just a person with a problem you can start to make some serious progress. There isn't a 'cure', but you can find a recovery if you work at it.

If you have one of these other habits, discuss it with your doctor or therapist. One further note - there is a book, now out of print, that was written in 1977 by Nathan H. Azrin, Ph.D., and R. Gregory Nunn, Ph.D., entitled HABIT CONTROL IN A DAY. It deals with the behavioral control of hair pulling, nail biting, ticcing, etc. Perhaps you can find a copy at your local library. It is an extremely useful book on the subject, and probably the best written so far. If you cannot find a therapist who is familiar with the use of Habit Reversal, it might help you to get started.

About the Author

Fred Penzel, Ph.D. is a psychologist and executive director of Western Suffolk Psychological Services, a private clinic in Huntington, NY. The number of the clinic is (516) 351-1729. He specializes in treatment of obsessive compulsive disorders, and sits on the science advisory boards of both the Trichotillomania Learning Center, Inc., and the Obsessive Compulsive Foundation, Inc. He is currently working on a self-help book for those with the different obsessive compulsive disorders.

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