August 20, 2021 • 19 mins
These behaviors are more than bad habits when they result in bleeding and pain. In fact, they’re complex disorders. But they can be stopped. Dr. Saltz tells how.
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Episode Transcript
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Speaker 1 (00:05):
These are challenging times which you don't have to navigate
them alone. Welcome to how can I Help? I'm Dr
Gail Saltz. I'm a clinical Associate Professor of psychiatry at
the New York Presbyterian Hospital, the psychoanalyst, and best selling author,
and I'm here every week to answer your most pressing questions,
(00:27):
hopefully with understanding, insight and advice. Many people nibble on
a nail from time to time or pull out a hangnail.
Not as many people have a nail biding habit, one
they find hard or even impossible to stop, one that
embarrasses them. So today I'm answering a listener question from
(00:51):
a woman was pretty miserable about her nail biding. Body
focused repetitive behavior be f RB is a general term
for a group of related disorders that includes hair pulling,
skin picking, and nail biting, and effects at least five
percent of the population. These behaviors are not habits, and
(01:16):
they're not ticks. They are complex disorders that cause people
to repeatedly touch their hair and body in ways that
result in physical damage. Compulsive skin picking and nail biting
is specifically known as on a cophagia. This refers to
(01:40):
not the kind of little bits of rough nail or
cuticle that everyone picks at or bites at from time
to time, and it doesn't refer to the occasional pimple
that people might squeeze or pick. These people continually bite
and pick their nails past the nail head and their
(02:00):
cuticles until they bleed, and are frequently walking around with red, painful,
and sometimes even infected fingers. They often bite and pick
such that they have real pain. In the same category
of problem, those people who pick their skin compulsively often
(02:24):
have their faces or body parts covered with red sores
and scabs. This is actually known as acne xcorea, which
is a self inflicted skin disorder, so it's not actual acne.
It's from the picking, but it looks like acne. For
(02:45):
people with this problem, the smallest pimple or blemish has
to be opened. It has to be picked at or squeezed,
either with fingers or sometimes people use some other implement
like tweezers or hints. Having created such clear damage to
one's fingers, often nail biters keep their hands hidden, maybe
(03:10):
behind their backs or in their pockets. They feel embarrassed
and uncomfortable, and skin pickers may wear makeup or even
band aids on parts of their bodies or sometimes, in
worst case scenario, people who really struggle with this problem
may avoid going outdoors when they feel they're really looking
(03:33):
their worst. People who have these kinds of body repetitive
problems often feel shame and social embarrassment and experience and
out of control feeling at times because they just can't stop.
They wonder why can't they stop, and sometimes they question
(03:56):
because they can't whether or not this means they're crazy
and some way. Some people bite and pick in an
automatic way, meaning they're not even thinking about what they're doing.
They're just doing it out of awareness, which of course
would make it extremely difficult to stop. Often someone who's
(04:20):
biting or picking is involved in some other activity at
the time. Maybe they're reading or they're watching TV, and
they're zoned out and they're not aware they're doing those
things for other people, they do spend deliberate time picking
or biting their nails, and that's the main activity of
(04:42):
the time, and so you think why what is going
on in their minds? Basically what's going on is a
need to satisfy and urge they feel. Many people report
and almost uncontrollable feeling of needing to do it. Pulling, picking,
(05:06):
or biting seems for them to deliver a pleasurable or
alternatively a relaxed sensation. When the nail biter feels stressed,
doing the activity of biting, or if it's about skin
of picking, has a kind of soothing effect on their
(05:27):
nervous system. It's why so many people who dislike doing
it find it really hard to stop, because in fact,
they experience a positive reinforcement for it, a feeling or
relaxed or even some pleasure. It simply feels good at
the time, no matter what you know the later consequences are,
(05:52):
and that makes it particularly difficult to quit. Some fighters
are actually afflicted the kind of what's called compulsive perfectionism.
This is when you try to bite off rough feeling
or broken bits of cuticle or nail that's sticking out
in some way seems uneven to you in order to
(06:15):
make your nail feel smooth or look or in their minds,
feel perfect or regular skin pickers will stand for hours
in front of the mirror closely examining their faces or
other body areas for the tiniest bump, but the smallest irregularity,
(06:36):
or any enlarged four and then try to eliminate it
or drain it in hopes of a clear and perfect
looking complexion. Sadly and paradoxically, they always end up looking
much worse in spite of their efforts, because at the
end of the day they're picking can never make the
(06:57):
perceived flaw perfect enough, and the behavior becomes destructive. It
may be an out of control grooming mechanism in the
brain that is to blame. It is normal for mammals
to groom, including humans, but too much grooming can be destructive.
(07:19):
This may relate to a normal evolutionary mechanism that has
gone awry. Most psychiatrists agree that this overly perfectionistic and
excessive need to groom fits into a form of obsessive
compulsive disorder spectrum. O c D has previously been regarded
(07:43):
as only a single disorder, but in fact it may
represent a range of related disorders, including issues like body
dysmorphic disorder, certain forms of eating disorders, something called trick
it to lamania, which is hair pulling, and on chiophagia,
(08:05):
which is this form of nail biting and skin picking.
How can I help with Dr Gail Salts will be
back after this short break. With this information at hand,
(08:28):
let's turn to our listener question and see how can
I help, dear Doctor Saltz. Since I was a child,
I have dealt with body focused repetitive behaviors. Of course,
it wasn't called such until recently. I am a fifty
three year old married woman with two college age sons,
(08:51):
and I still deal with this issue. As a young child,
through my teens and into early adulthood, I bit my
nails aggressively. In my twenties, I managed to stop that behavior,
but gained another in quotes habit. Instead, I pick up
(09:13):
my cuticles and the skin around my nails and fingers
to such a degree that I cause bleeding and pain.
I pick with my own hands as well as my teeth.
I usually have between one and five band aids on
my fingers at any given time. I also pick at
(09:33):
the skin on my upper arms, upper back, face, and
soles of my feet. I have tried everything, but I've
only ever managed brief periods of successfully stopping this behavior.
I have tried using foul tasting liquids on my fingers,
(09:54):
holding onto fidgets, and just plain white knuckling it. I
can't kick this unattractive and unhygienic behavior. What can I
do to stop these behaviors once and for all? Body
focused repetitive behaviors of this extreme are known to respond
(10:15):
best to medication plus a certain type of behavioral therapy.
Medication should not be considered the end game, but it's
really a short term tool in the beginning to help
you do the therapy. Medicines which remedy these problems do not, unfortunately,
(10:38):
work instantly. It takes a few weeks before you see results,
and they also important to understand, don't work entirely, which
is why doing the therapy is so important. You might see,
for example, a sixty to seventy improvement on a medication,
(10:58):
and that would be considered a good result. The medications
that are mainly used to treat picking or biting problems
are the ones that are used to treat obsessive compulsive disorder.
This group of meds is made up of the latest
and most potent antidepressants and includes such names as a naphrono,
(11:20):
rozac zolof paxel effects, or lou box and Saar zone.
Sometimes the issue is that the doses needed for treatment
of any type of obsessive compulsive disorder are quite a
bit higher than the dose to treat depression, clinical depression,
or anxiety disorders. No one drug is best because no
(11:47):
one drug works for everyone, which can be very frustrating
because ultimately you have to work your way through them
in a bit of a trial and error way to
find the one that is most defective for you. You
mentioned that you're on an S s R I, but
the question remains, is this treatment which you're taking for
(12:11):
depression and anxiety at a high enough dose to help
with picking it sounds like not, and is it the
one that is effective for you for the picking? This
also could be an issue. You won't know until you
speak with your prescriber about this and discuss an adjustment.
(12:31):
An adjustment is likely to be an increase in dose,
pushing it to its top level for a few weeks
to see if this has an effect, and if it doesn't,
considering a different a S s R I trial. But
the truth is that more important than the medication is
(12:52):
the type of therapy that you use to learn the
method of stopping. There are many kinds of therapies, and
certain therapies work better for certain disorders. As you've noted,
just giving yourself deterrence like bad tasting stuff on your
nails or holding fidgets doesn't work, and you would be correct.
(13:18):
You need a specific form of therapy techniques therapy for
this kind of disorder, which consists of something that's called
habit reversal training. It's a three step process which cheaches
you first awareness of your habits, which, as I referred
(13:39):
to earlier, is so important because often the person doing
it isn't even aware that they are. They're absorbed in
something else and that's when it happens out of their awareness.
So training yourself to first become aware whenever you're doing it,
then next you will learn and techniques of how to relax.
(14:03):
These are individual coping tools that teach you to be
able to destress yourself in an ongoing way and in
the moment. This is really important because when you're not relaxed,
when you're super stressed, it makes it much harder to
engage with the therapy to reverse this habit. And then
(14:29):
in learning to relax, you can focus and center yourself
and be taught to do the performing of a competing
and opposing muscle response. This is the most important part
of habit reversal. The response will be something that you
(14:49):
and the therapists come up with together, that is, in
some way that you can both define the opposite muscular
behavior of what you are trying to prevent. Yet it
will be related to the same area of the body
that you're having problems with. So, for example, in your
(15:10):
case the issue is nail biting, it could be that
you're competing behavior will be squeezing your hand in a
hard fist, so that you have an actual behavior to
do whenever you get the urge to bite your nail
or two in your case, now pick your nail. But
(15:31):
it's a different behavior and it makes it hard to
do the nail picking behavior at the same time. If
your hand is balled up in a fist and it's squeezing,
you're not really going to be able to pick your nail.
So it involves the area. It's a competing behavior because
you can't really do at the same time, and that
(15:54):
is the type of behavior that you will use as
you're using some relaxation to techniques and of course being
aware that the behavior is about to go on. It
is extremely useful if this is practiced daily and stubbornly.
You will probably start with literally just practicing this for
(16:14):
half an hour of focused effort, and then the time
will expand, and ultimately it will be the habit, the
new habit, the behavioral habit that you will replace the
old habit with. It has to become automatic as the
habit that you're aiming to eliminate, and that, as you
(16:35):
can see, will take time. These kinds of problems that
you're describing, the picking and the biting, they're stubborn problems
for two reasons. First, you have probably rehearsed this picking
or this biting, as you said, four hundreds or really
thousands of hours, especially in your case since you've been
(16:58):
doing it since a child. It's important to accept that
they will not simply be overcome in a few days
or a few weeks. Secondly, you are fighting the fact
that it feels good to do, even if it's not
terribly in your awareness, and so it's providing you short term,
(17:20):
short range satisfaction and soothing and relaxing of its own,
which is why part of the therapy is teaching you
other methods of self soothing and relaxation. It does take time,
and it does take a good deal of effort to master,
but ultimately habit reversal is very successful. It works extremely
(17:43):
well for body focused repetitive behaviors, and then ultimately the
plan would be to taper you off medication. Research has
shown this to be a very effective method. I hope
that was helpful. Even if you have more than one
of these repetitive behaviors, which frankly is not unusual, they
(18:07):
often come together. They can be overcome one by one
if you have the motivation at least As important is
learning also to destigmatize yourself. You are not crazy, you
are not helpless. You are not morally weak or totally
out of control, even though sometimes it might feel like
(18:30):
all of these things. Once you realize that you are
just a person with a problem that you like to fix,
you can start making some serious progress. While there isn't
a quick cure for such things, you can actually recover
if you work at it. Do you have a problem
(18:53):
I can help with? If so, email me at how
Can I Help? At Seneca women dot com. All centers
remain anonymous and listen every Friday to how can I
help with me Doctor Gale's salts
These are challenging times which you don't have to navigate
them alone. Welcome to how can I Help? I'm Dr
Gail Saltz. I'm a clinical Associate Professor of psychiatry at
the New York Presbyterian Hospital, the psychoanalyst, and best selling author,
and I'm here every week to answer your most pressing questions,
(00:27):
hopefully with understanding, insight and advice. Many people nibble on
a nail from time to time or pull out a hangnail.
Not as many people have a nail biding habit, one
they find hard or even impossible to stop, one that
embarrasses them. So today I'm answering a listener question from
(00:51):
a woman was pretty miserable about her nail biding. Body
focused repetitive behavior be f RB is a general term
for a group of related disorders that includes hair pulling,
skin picking, and nail biting, and effects at least five
percent of the population. These behaviors are not habits, and
(01:16):
they're not ticks. They are complex disorders that cause people
to repeatedly touch their hair and body in ways that
result in physical damage. Compulsive skin picking and nail biting
is specifically known as on a cophagia. This refers to
(01:40):
not the kind of little bits of rough nail or
cuticle that everyone picks at or bites at from time
to time, and it doesn't refer to the occasional pimple
that people might squeeze or pick. These people continually bite
and pick their nails past the nail head and their
(02:00):
cuticles until they bleed, and are frequently walking around with red, painful,
and sometimes even infected fingers. They often bite and pick
such that they have real pain. In the same category
of problem, those people who pick their skin compulsively often
(02:24):
have their faces or body parts covered with red sores
and scabs. This is actually known as acne xcorea, which
is a self inflicted skin disorder, so it's not actual acne.
It's from the picking, but it looks like acne. For
(02:45):
people with this problem, the smallest pimple or blemish has
to be opened. It has to be picked at or squeezed,
either with fingers or sometimes people use some other implement
like tweezers or hints. Having created such clear damage to
one's fingers, often nail biters keep their hands hidden, maybe
(03:10):
behind their backs or in their pockets. They feel embarrassed
and uncomfortable, and skin pickers may wear makeup or even
band aids on parts of their bodies or sometimes, in
worst case scenario, people who really struggle with this problem
may avoid going outdoors when they feel they're really looking
(03:33):
their worst. People who have these kinds of body repetitive
problems often feel shame and social embarrassment and experience and
out of control feeling at times because they just can't stop.
They wonder why can't they stop, and sometimes they question
(03:56):
because they can't whether or not this means they're crazy
and some way. Some people bite and pick in an
automatic way, meaning they're not even thinking about what they're doing.
They're just doing it out of awareness, which of course
would make it extremely difficult to stop. Often someone who's
(04:20):
biting or picking is involved in some other activity at
the time. Maybe they're reading or they're watching TV, and
they're zoned out and they're not aware they're doing those
things for other people, they do spend deliberate time picking
or biting their nails, and that's the main activity of
(04:42):
the time, and so you think why what is going
on in their minds? Basically what's going on is a
need to satisfy and urge they feel. Many people report
and almost uncontrollable feeling of needing to do it. Pulling, picking,
(05:06):
or biting seems for them to deliver a pleasurable or
alternatively a relaxed sensation. When the nail biter feels stressed,
doing the activity of biting, or if it's about skin
of picking, has a kind of soothing effect on their
(05:27):
nervous system. It's why so many people who dislike doing
it find it really hard to stop, because in fact,
they experience a positive reinforcement for it, a feeling or
relaxed or even some pleasure. It simply feels good at
the time, no matter what you know the later consequences are,
(05:52):
and that makes it particularly difficult to quit. Some fighters
are actually afflicted the kind of what's called compulsive perfectionism.
This is when you try to bite off rough feeling
or broken bits of cuticle or nail that's sticking out
in some way seems uneven to you in order to
(06:15):
make your nail feel smooth or look or in their minds,
feel perfect or regular skin pickers will stand for hours
in front of the mirror closely examining their faces or
other body areas for the tiniest bump, but the smallest irregularity,
(06:36):
or any enlarged four and then try to eliminate it
or drain it in hopes of a clear and perfect
looking complexion. Sadly and paradoxically, they always end up looking
much worse in spite of their efforts, because at the
end of the day they're picking can never make the
(06:57):
perceived flaw perfect enough, and the behavior becomes destructive. It
may be an out of control grooming mechanism in the
brain that is to blame. It is normal for mammals
to groom, including humans, but too much grooming can be destructive.
(07:19):
This may relate to a normal evolutionary mechanism that has
gone awry. Most psychiatrists agree that this overly perfectionistic and
excessive need to groom fits into a form of obsessive
compulsive disorder spectrum. O c D has previously been regarded
(07:43):
as only a single disorder, but in fact it may
represent a range of related disorders, including issues like body
dysmorphic disorder, certain forms of eating disorders, something called trick
it to lamania, which is hair pulling, and on chiophagia,
(08:05):
which is this form of nail biting and skin picking.
How can I help with Dr Gail Salts will be
back after this short break. With this information at hand,
(08:28):
let's turn to our listener question and see how can
I help, dear Doctor Saltz. Since I was a child,
I have dealt with body focused repetitive behaviors. Of course,
it wasn't called such until recently. I am a fifty
three year old married woman with two college age sons,
(08:51):
and I still deal with this issue. As a young child,
through my teens and into early adulthood, I bit my
nails aggressively. In my twenties, I managed to stop that behavior,
but gained another in quotes habit. Instead, I pick up
(09:13):
my cuticles and the skin around my nails and fingers
to such a degree that I cause bleeding and pain.
I pick with my own hands as well as my teeth.
I usually have between one and five band aids on
my fingers at any given time. I also pick at
(09:33):
the skin on my upper arms, upper back, face, and
soles of my feet. I have tried everything, but I've
only ever managed brief periods of successfully stopping this behavior.
I have tried using foul tasting liquids on my fingers,
(09:54):
holding onto fidgets, and just plain white knuckling it. I
can't kick this unattractive and unhygienic behavior. What can I
do to stop these behaviors once and for all? Body
focused repetitive behaviors of this extreme are known to respond
(10:15):
best to medication plus a certain type of behavioral therapy.
Medication should not be considered the end game, but it's
really a short term tool in the beginning to help
you do the therapy. Medicines which remedy these problems do not, unfortunately,
(10:38):
work instantly. It takes a few weeks before you see results,
and they also important to understand, don't work entirely, which
is why doing the therapy is so important. You might see,
for example, a sixty to seventy improvement on a medication,
(10:58):
and that would be considered a good result. The medications
that are mainly used to treat picking or biting problems
are the ones that are used to treat obsessive compulsive disorder.
This group of meds is made up of the latest
and most potent antidepressants and includes such names as a naphrono,
(11:20):
rozac zolof paxel effects, or lou box and Saar zone.
Sometimes the issue is that the doses needed for treatment
of any type of obsessive compulsive disorder are quite a
bit higher than the dose to treat depression, clinical depression,
or anxiety disorders. No one drug is best because no
(11:47):
one drug works for everyone, which can be very frustrating
because ultimately you have to work your way through them
in a bit of a trial and error way to
find the one that is most defective for you. You
mentioned that you're on an S s R I, but
the question remains, is this treatment which you're taking for
(12:11):
depression and anxiety at a high enough dose to help
with picking it sounds like not, and is it the
one that is effective for you for the picking? This
also could be an issue. You won't know until you
speak with your prescriber about this and discuss an adjustment.
(12:31):
An adjustment is likely to be an increase in dose,
pushing it to its top level for a few weeks
to see if this has an effect, and if it doesn't,
considering a different a S s R I trial. But
the truth is that more important than the medication is
(12:52):
the type of therapy that you use to learn the
method of stopping. There are many kinds of therapies, and
certain therapies work better for certain disorders. As you've noted,
just giving yourself deterrence like bad tasting stuff on your
nails or holding fidgets doesn't work, and you would be correct.
(13:18):
You need a specific form of therapy techniques therapy for
this kind of disorder, which consists of something that's called
habit reversal training. It's a three step process which cheaches
you first awareness of your habits, which, as I referred
(13:39):
to earlier, is so important because often the person doing
it isn't even aware that they are. They're absorbed in
something else and that's when it happens out of their awareness.
So training yourself to first become aware whenever you're doing it,
then next you will learn and techniques of how to relax.
(14:03):
These are individual coping tools that teach you to be
able to destress yourself in an ongoing way and in
the moment. This is really important because when you're not relaxed,
when you're super stressed, it makes it much harder to
engage with the therapy to reverse this habit. And then
(14:29):
in learning to relax, you can focus and center yourself
and be taught to do the performing of a competing
and opposing muscle response. This is the most important part
of habit reversal. The response will be something that you
(14:49):
and the therapists come up with together, that is, in
some way that you can both define the opposite muscular
behavior of what you are trying to prevent. Yet it
will be related to the same area of the body
that you're having problems with. So, for example, in your
(15:10):
case the issue is nail biting, it could be that
you're competing behavior will be squeezing your hand in a
hard fist, so that you have an actual behavior to
do whenever you get the urge to bite your nail
or two in your case, now pick your nail. But
(15:31):
it's a different behavior and it makes it hard to
do the nail picking behavior at the same time. If
your hand is balled up in a fist and it's squeezing,
you're not really going to be able to pick your nail.
So it involves the area. It's a competing behavior because
you can't really do at the same time, and that
(15:54):
is the type of behavior that you will use as
you're using some relaxation to techniques and of course being
aware that the behavior is about to go on. It
is extremely useful if this is practiced daily and stubbornly.
You will probably start with literally just practicing this for
(16:14):
half an hour of focused effort, and then the time
will expand, and ultimately it will be the habit, the
new habit, the behavioral habit that you will replace the
old habit with. It has to become automatic as the
habit that you're aiming to eliminate, and that, as you
(16:35):
can see, will take time. These kinds of problems that
you're describing, the picking and the biting, they're stubborn problems
for two reasons. First, you have probably rehearsed this picking
or this biting, as you said, four hundreds or really
thousands of hours, especially in your case since you've been
(16:58):
doing it since a child. It's important to accept that
they will not simply be overcome in a few days
or a few weeks. Secondly, you are fighting the fact
that it feels good to do, even if it's not
terribly in your awareness, and so it's providing you short term,
(17:20):
short range satisfaction and soothing and relaxing of its own,
which is why part of the therapy is teaching you
other methods of self soothing and relaxation. It does take time,
and it does take a good deal of effort to master,
but ultimately habit reversal is very successful. It works extremely
(17:43):
well for body focused repetitive behaviors, and then ultimately the
plan would be to taper you off medication. Research has
shown this to be a very effective method. I hope
that was helpful. Even if you have more than one
of these repetitive behaviors, which frankly is not unusual, they
(18:07):
often come together. They can be overcome one by one
if you have the motivation at least As important is
learning also to destigmatize yourself. You are not crazy, you
are not helpless. You are not morally weak or totally
out of control, even though sometimes it might feel like
(18:30):
all of these things. Once you realize that you are
just a person with a problem that you like to fix,
you can start making some serious progress. While there isn't
a quick cure for such things, you can actually recover
if you work at it. Do you have a problem
(18:53):
I can help with? If so, email me at how
Can I Help? At Seneca women dot com. All centers
remain anonymous and listen every Friday to how can I
help with me Doctor Gale's salts
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