Nail biting or onychophagia involves damage to fingernails by means of habitual biting. Although not specifically indexed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), nail biting is currently classified under Obsessive-Compulsive and Related Disorders in the DSM-5 and is considered to be a body-focused repetitive behavior.

Signs and Symptoms

Nail biting is often associated with visible nail damage, tension prior to or when attempting to resist nail biting, feelings of pleasure after biting, nail eating, and psychological distress. Many describe the behavior as “automatic.”

While few scientific studies have examined nail biting, it is believed to be a common behavior that typically begins in childhood. It is estimated that 20%-30% of the general population engages in chronic nail biting although prevalence estimates greatly vary, with estimates ranging from 12% to 44%. In addition to hair pulling disorder and skin picking disorder, frequently co-occurring behaviors include bruxism (teeth clenching or grinding), and cheek biting.

Diagnosis and Treatment

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What other behaviors are associated with BFRBs?

Body-focused repetitive behaviors include any repetitive self-grooming behavior that involves biting, pulling, picking, or scraping one’s own hair, skin, or nails that results in damage to the body.

Some of the BFRBs listed below are not specifically indexed in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5). They are classified as “other specified obsessive-compulsive and related disorders", with specification of “body-focused repetitive behavior.”

What is cheek biting?

Chronic cheek biting (morsicatio buccarum) is a compulsive behavior whereby an individual repeatedly bites the inside of their cheek, causing damage to the tissue. This behavior may result in ulcerations, sores, and infections within the oral tissue.

Furthermore, repetitive biting in a target area typically leads to the development of white patches of keratosis– a callus-like formation. Cheek and lip biting are estimated to occur in approximately 3% of U.S. adults, with more than half of individuals reporting childhood onset. Similar to skin picking (excoriation) and hair pulling (trichotillomania), chronic cheek biting is classified as Other Obsessive-Compulsive and Related Disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

What is skin picking or excoriation?

Skin picking (excoriation), is characterized by the repetitive picking of one’s own skin. Individuals who struggle with this disorder touch, rub, scratch, pick at, or dig into their skin in an attempt to improve perceived imperfections, remove rough patches/scabs, smooth areas, or accomplish some goal. Skin picking often results in tissue damage, discoloration, or scarring.

Occasional picking at cuticles, acne, scabs, calluses, or other skin irregularities is a very common human behavior; however, research indicates that approximately 2%- 5% of the population picks their skin to the extent that it causes noticeable tissue damage and marked distress or impairment in daily functioning. An estimated 75% of people experiencing skin picking disorder are female. The behavior typically begins in early adolescence, although skin picking disorder can begin at any age. Without treatment, skin picking disorder tends to be a chronic condition that may wax and wane over time.

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What treatment options are available for BFRBs?

Research into treatments for BFRBs, particularly hair pulling disorder and skin picking disorder, has grown steadily over the past decade. Although no one treatment has been found to be effective for everyone, a number of evidence-based treatment options have shown promise for many people.

What is hair pulling or trichotillomania?

Hair pulling disorder or trichotillomania (trick-o-till-o-may-nee-uh) (TTM or “trich”) is characterized by the repetitive pulling out of one's hair. Hair pulling disorder is one of a group of behaviors known as body-focused repetitive behaviors (BFRBs) and are technically classified as Obsessive-Compulsive and Related Disorders. BFRBs can be thought of as self-grooming behaviors in which individuals pull, pick, scrape, or bite their hair, skin, or nails, resulting in damage to the hair or body. Hair pulling can occur on any part of the body that grows hair.

Research indicates that approximately 1 or 2 in 50 people experience hair pulling disorder in their lifetime. Hair pulling disorder usually begins in late childhood/early puberty, and occurs about equally in boys and girls. By adulthood, 80-90% of reported cases are women. Hair pulling varies greatly in its severity, location on the body, and response to treatment. Without treatment, hair pulling disorder tends to be a chronic condition; it may come and go throughout a lifetime.

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