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.

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.

Recurrent Osteomyelitis Requiring Surgical Management Secondary to Nail-Biting: A Case Report.

CASE: Onychophagia, or nail-biting, is a common habit seen in both children and adults. Harmful effects include oral exposure to a variety of pathogens and concomitant damage to dentition and fingers. This report focuses on the most severe reported case of recurrent osteomyelitis of the bilateral hands with destructive changes secondary to onychophagia. CONCLUSION: Successful treatment relies on a multidisciplinary approach which in this case included surgical management and counseling on cessation, with referrals to other providers to address underlying psychiatric and/or psychologic conditions that may predispose to this compulsion.

Craving for menthol sweets: a case report. / Craving por mentolados: a propósito de un caso.

We describe a case of craving for menthol sweets in a 53-year-old woman with excessive consumption of menthol sweets (100 units/day). She was admitted with a history of rheumatoid arthritis, obesity, anxiety associated with onychophagia and pinching of the skin. Organic disorders were ruled out with paraclinical tests and in-hospital treatment was administered. At discharge, the patient's condition was stable, but because of exacerbated pain due to the rheumatological disease, she presented depressive symptoms, requiring her medication to be adjusted. CONCLUSIONS: The "food craving" and anxiety present pathophysiological similarities. Mints have different mechanisms or ways in which they can counteract or control these symptoms, including an increase in serotonin, binding to GABA-A receptors and stimulation of the nicotinic receptor in nerve cells.

Insights into recurrent body-focused repetitive behaviors: evidenced by New York Times commenters.

In September 2019, the New York Times (NYT) published the article "Fighting the Shame of Skin Picking," which discussed the cosmetic, social and emotional impacts of body-focused repetitive behaviors (BFRBs). BFRBs, including excoriation disorder, trichotillomania, onychotillomania, and onychophagia, are recurring actions that damage one's physical appearance. The aim of this study is to characterize the demographic information provided and themes raised in the 166 comments posted in response to the article. The most commonly reported condition was skin picking (38.2%), followed by trichotillomania and/or trichophagia (30.3%), onychotillomania (24.7%), and onychophagia (23.6%). All conditions had a female predominance. Treatment of body-focused repetitive behaviors was the most common topic of discussion, followed by shame and impact on appearance. Since commenters described significant impairments to quality of life, larger randomized controlled trials on skin picking, trichotillomania, onychophagia, and onychotillomania are necessary to provide evidence-based management to patients.

N-Acetylcysteine in psychodermatological disorders.

Treatment of psychodermatological conditions, particularly body-focused repetitive behavior disorders, is often unsatisfactory. Various psychopharmacological and non-pharmacological treatments have been used to ameliorate the symptoms of these disorders. N-Acetylcysteine (NAC) is a newer modality in the treatment of these disorders. This short review focuses on pharmacology, mode of action, and use of NAC in common body-focused repetitive disorders such as trichotillomania, skin-picking disorders, and onychotillomania (nail biting). Current research and literature review have been evaluated and will be discussed.

Self-induced dermatoses: A great imitator.

The self-induced dermatoses represent about 2% of dermatology patient visits, and include the recurrent body-focused repetitive behaviors (BFRB) (skin-picking or excoriation disorder, trichotillomania, onychophagia and onychotillomania), dermatitis artefacta, and features of other psychiatric disorders, for example, secondary to excessive grooming in body dysmorphic disorder, skin picking in delusional infestation, or secondary to self-harm in depressive disease. Among the BFRBs, onychophagia and onychotillomania are most likely to be associated with lesions that mimic other dermatologic conditions (eg, nail psoriasis, lichen planus, vasculitis, onychomycosis, melanoma). Dermatitis artefacta (DA) describes lesions that are self-inflicted with the intention of assuming a sick role in the absence of obvious external rewards. DA lesions can be bizarre-appearing or may be created intentionally to mimic dermatologic disease (eg, Munchausen syndrome). The manipulation of the integument can have a focused obsessive-compulsive behavioral style which is more responsive to the standard behavior therapies, or an impulsive-dissociative style where patients have partial or no recollection of having self-induced their lesion; dissociative patients tend to have more severe BFRBs and DA, and greater psychopathology. Self-induced dermatoses may both imitate and co-occur with primary dermatologic disease, and may not be readily identified unless the clinician maintains an index of suspicion.

Pediatric Onychophagia: A Survey-Based Study of Prevalence, Etiologies, and Co-Morbidities.

BACKGROUND: Onychophagia, defined as habitual nail biting, is a common disorder affecting 6-45% of the population and is more prevalent in children. OBJECTIVES: Our primary objective was to determine the prevalence of nail biting in the pediatric population. Secondary objectives were to assess the presence of psychiatric co-morbidities associated with nail biting, and the effect of treatment on nail biting. METHODS: An anonymous voluntary survey was administered to participants at an outpatient academic pediatric clinic at Weill Cornell Medicine. Age, sex, psychiatric diagnosis, treatment sought, family history, and frequency of nail biting were analyzed across 282 enrolled patients aged 3-21 years. One patient was subsequently excluded due to incomplete data. RESULTS: Of 281 patients, 101 (37%) reported past or present nail biting lasting more than a month. Median age of onset was 5 years old (range 1-13 years). A significantly higher percentage of biters (18%; 19/104) than non-biters (6%; 11/177) were diagnosed with a psychiatric disorder (p < 0.01). Amongst biters, concurrent fingernail and toenail involvement was much less common (12%; 12/104) than that of fingernails alone (88%; 92/104). However, the ratio of fingernail and toenail biters to fingernail biters alone was greater in those with psychiatric diagnosis (0.36) than without (0.09) (p = 0.07). CONCLUSIONS: Our study highlights behavioral patterns as well as familial, psychiatric, and other factors associated with pediatric nail biting. Familiarity with such factors, the clinical presentation of onychophagia, and available treatment options may aid in reducing its severity in affected patients and overall prevalence.

The effectiveness of a nail-biting prevention program among primary school students.

PURPOSE: This study aimed to demonstrate the effect of a program called "Do Not Bite Your Nails, Cut Your Nails," which is based on a health promotion model to change the nail-biting habit among primary school students. DESIGN AND METHODS: This quasi-experimental study was conducted using the pre- and post-test and interrupted time series design. The study sample included 299 students. Nurse observation form and nail follow-up chart were used to evaluate behavioral outcomes. This program was conducted under the guidance of school nurses and lasted 6 weeks. The data were analyzed using McNemar and Cochran Q tests. RESULTS: The number of those who selected "yes" for "I cut my nails this weekend" and "I didn't bite my nails today" increased. However, the number of the students that selected "yes" for "I pulled out my nails," "I pulled out and ate," "I pulled out my nail skin," "My cuticle bled today," and "My nails hurt today" decreased significantly and statistically compared with pretest, first and second observation, and post-test (P < 0.001). The rate of the students with minimum one abnormal finger was 83.9% according to observations, and 6% following the intervention (P < 0.001). New insights were provided into the program to diminish nail-biting habit. PRACTICE IMPLICATIONS: The program significantly reduced the nail-biting rate among primary school students. The nurse that implement this program will be able to do a comprehensive evaluation of students' nail-biting habits, perform solution-focused interventions, and prevent advanced complications that might develop in connection to nail-biting. Thus, the effectiveness of nursing implementations will improve in the prevention of nail-biting habit, early diagnosis, and changing students' habits. "Do Not Bite Your Nails, Cut Your Nails" program can be applied again in different schools.

Clinical Characteristics and Comorbidity of Pediatric Trichotillomania: the Study of 38 Cases in Croatia.

BACKGROUND: The main goal of this study was to analyse and show clinical characteristics and psychiatric comorbidity in 38 participants aged between 10 and 17 with DSM-IV diagnoses of Trichotillomania (TTM) that we were treating at Children's Hospital Zagreb from 2008 to 2017. SUBJECTS AND METHODS: We analyzed the data obtained from semi-structured interviews by the criteria of DSM-IV, Youth Self Report (YSR) (Achenbach & Rescorla 2001) and survey that we created. RESULTS: From 38 participants 21 were girls. The activities during which the participants state that they mostly pull hairs are as follows: doing homework and learning, working on PC, in the toilet, watching TV etc. The most common sites on the body from which participants pulled hair were scalp and among nonscalp sites eyebrows and eyelashes. We found nail biting in more than a half of participants. In 22 participants one or more comorbid disorder has been found, of which ADHD (n=6) and tics (n=5) are most co-occurring disorders. The internalized and externalized problems were nearly evenly represented. Trichophagia was reported by two participants. The results indicate that more than two thirds of participants isolate themselves during hair pulling and half of them try to hide consequences. Median time from the first occurrence of the symptoms to the first visit to a child psychiatrist caused by TTM problem was 9 months (min 5; max 24) what we consider a very long period of time that increased the probability of complications. CONCLUSIONS: Knowledge about this disorder and cooperation among pediatric experts is extremely important for recognizing it at an early stage and starting the treatment especially considering habit-forming mechanism, the burden of an emotional distress and frequent comorbidity. Further research is needed.

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.

Initial psychometrics, outcomes, and correlates of the Repetitive Body Focused Behavior Scale: Examination in a sample of youth with anxiety and/or obsessive-compulsive disorder.

BACKGROUND: Body-Focused Repetitive Behaviors (BFRBs), including skin-picking, hair-pulling, and nail-biting, commonly occur in youth, even at elevated/problematic levels, and are associated with a number of other psychiatric symptoms. The present study examined the internal consistency of a brief screening tool for BFRBs as well as the prevalence, severity, and correlates of BFRBs in a sample of youth with a primary anxiety or obsessive-compulsive disorder (OCD). METHODS: Ninety-three youth-parent dyads presenting for treatment for anxiety or OCD completed study measures including the Repetitive Body Focused Behavior Scale - Parent (RBFBS), which includes subscales for skin-picking, hair-pulling, and nail-biting, as well as a number of additional clinician-, parent-, and child-rated scales. RESULTS: The RBFBS demonstrated good to excellent internal consistency. BFRBs were endorsed in 55% of youths, with elevated levels in 27%. Skin-picking was the most common BFRB (38%), followed by nail-biting (34%) and hair-pulling (4%). Youth with BFRBs, as compared to those without, were rated as more avoidant by their parents. Among those with BFRBs, more avoidant tendencies, anxiety sensitivity, and child-rated panic, separation, and generalized anxiety symptoms were associated with elevated BFRB severity. BFRBs were equally common but more likely to be elevated among youth with a primary anxiety, than OCD, diagnosis. DISCUSSION: Results provide initial support for the RBFBS as a brief screening tool for the three common BFRBs. In addition, the results suggest avoidant tendencies and physical manifestations of distress may be particularly relevant to the escalation of BFRB symptoms in youth.

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.].

Onychophagia: A nail-biting conundrum for physicians.

Onychophagia, defined as habitual nail biting, is a common disorder affecting 20-30% of the population and all age groups. It may lead to significant psychosocial problems, have a negative impact on quality of life, and cause complications involving both the nail unit and the oral cavity. The objective of this paper is to review the prevalence, etiology, history, physical examination, complications and management of nail biting. Since onychophagia is a challenging disorder to treat, a multi-disciplinary approach should be taken involving dermatologists, internists, pediatricians, psychiatrists and dentists.

Nail tic disorders: Manifestations, pathogenesis and management.

Nail tic disorders are classic examples of overlap between the domains of dermatology and psychiatry. They are examples of body-focused repetitive behaviors in which there is an irresistible urge or impulse to perform a certain behavior. The behavior is reinforced as it results in some degree of relief and pleasure. Nail tic disorders are common, yet poorly studied and understood. The literature on nail tic disorders is relatively scarce. Common nail tics include nail biting or onychophagia, onychotillomania and the habit tic deformity. Some uncommon and rare nail tic disorders are onychoteiromania, onychotemnomania, onychodaknomania and bidet nails. Onychophagia is chronic nail biting behavior which usually starts during childhood. It is often regarded as a tension reducing measure. Onychotillomania is recurrent picking and manicuring of the fingernails and/or toenails. In severe cases, it may lead to onychoatrophy due to irreversible scarring of the nail matrix. Very often, they occur in psychologically normal children but may sometimes be associated with anxiety. In severe cases, onychotillomania may be an expression of obsessive-compulsive disorders. Management of nail tic disorders is challenging. Frequent applications of distasteful topical preparations on the nail and periungual skin can discourage patients from biting and chewing their fingernails. Habit-tic deformity can be helped by bandaging the digit daily with permeable adhesive tape. Fluoxetine in high doses can be helpful in interrupting these compulsive disorders in adults. For a complete diagnosis and accurate management, it is imperative to assess the patient's mental health and simultaneously treat the underlying psychiatric comorbidity, if any.

Onychotillomania: An underrecognized disorder.

Onychotillomania is an uncommon and likely underreported condition in which patients repetitively manipulate the different constituents of the nail unit. Onychotillomania is characterized by a range of nonspecific findings, including bizarre morphology of the nail plate and damage to the nail bed and periungual skin. Histopathological changes are also nonspecific, but may be viewed as analogous to lichen simplex chronicus and prurigo nodularis of the skin. Clinical history is essential to making this diagnosis, as effective treatment modalities may focus on behavioral therapies and psychiatric medications.

Evidence-Based Psychosocial Treatments for Pediatric Body-Focused Repetitive Behavior Disorders.

Habits, such as hair pulling and thumb sucking, have recently been grouped into a category of clinical conditions called body-focused repetitive behavior disorders (BFRBDs). These behaviors are common in children and, at extreme levels, can cause physical and psychological damage. This article reviews the evidence base for psychosocial treatment of pediatric BFRBDs. A review of academic databases and published reviews revealed 60 studies on psychosocial treatments for pediatric BFRBDs, 23 of which were deemed suitable for review. Based on stringent methodological and evidence base criteria, we provided recommendations for each specific BFRBD. Individual behavior therapy proved probably efficacious for thumb sucking, possibly efficacious for several conditions, and experimental for nail biting. Individual and multicomponent cognitive-behavioral therapy was named experimental for trichotillomania and nail biting, respectively. No treatment met criteria for well-established status in the treatment of any BFRBD. Recommendations for clinicians are discussed. Reasons for the limitations of existing research in children and adolescents are explored. Several recommendations are presented for future pediatric treatment research on BFRBDs.

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.