For people who can’t stop biting their nails or picking at their skin, a new study suggests that a simple technique could help.
Body-focused repetitive behaviors — compulsively pulling or picking at your hair or skin, unable to stop yourself even if the behavior leads to scabs, scars and bald spots — affects about 5% of people worldwide, according to the TLC Foundation for Body-Focused Repetitive Behaviors, an advocacy group for people with the conditions. (One common repetitive behavior is nail-biting.)
The research, published Wednesday in JAMA Dermatology, found that an approach called habit replacement may help reduce these behaviors.
While the new technique — which involves gently rubbing the fingertips, palm or back of the arm at least twice a day — didn’t help everyone, about 53% of people in the study said they had at least some improvement compared with about 20% of people in a control group. (A video here shows some of the variations people can try.)
“The rule is just to touch your body lightly,” said lead study author Steffen Moritz, head of the clinical neuropsychology working group at University Medical Center Hamburg-Eppendorf, in Hamburg, Germany. “If you’re under stress, you might perform the movements faster, but not with more self-applied pressure.”
The study was considered “proof-of-concept” research — early research that needs further confirmation. Still, experts said the results were encouraging.
In the six-week study, Moritz and colleagues looked at 268 people who had trichotillomania (a condition in which people pluck out hair in response to stress or to self-soothe) or repeatedly bit their nails or the inside of their cheek.
The researchers randomly assigned the volunteers into two groups. One group was given a manual and video that showed them how to form the new, less harmful habit by gently rubbing their fingertips, palm, or arm any time they felt the urge to bite their nails or engage in the harmful behavior. They were also instructed to practice the new habit when they weren’t feeling the urge to pull, pick or bite.
People in the control group were told that they were put on a waitlist for treatment, and only got the habit replacement training after the study was concluded.
Overall, nearly 80% of the people in the treatment group said they were satisfied with the training and 86% said they would recommend it to a friend. People who bit their nails seemed to benefit the most from the habit replacement technique.
How can rubbing your arm stop you from biting your nails?
The new approach is a variation of other behavioral techniques for body-focused repetitive behaviors, which include habit reversal training and something called decoupling. While some medications, including antidepressants are prescribed off-label to people with body-focused repetitive behavior, there are no FDA-approved drugs specifically for the condition. Cognitive behavioral therapy is thought to be the most effective approach.
In habit reversal training, people are taught “competing responses,” said Natasha Bailen, a clinical psychologist at the Center for OCD and Related Disorders at Massachusetts General Hospital and Harvard Medical School.
“So they might involve, for example, clenching your fists really tight when you have an urge to pull your hair or pick your skin. It might be sitting on your hands,” she said. The aim is to use a group of muscles so that you can’t physically perform the harmful behavior.
In decoupling, a habit is unlearned by performing a similar movement but switching it up at the last minute. For example, if you bite your nails, you might put your hand to your face but touch an earlobe instead of your mouth.
Moritz said that the study’s habit replacement training differs in that it aims to replace the sometimes pleasurable sensation of picking and pulling with something that also feels good but won’t be harmful — gentle touch. In fact, the training manual in the study recommends that people avoid touching their bodies in ways that are rough or apply too much pressure, like scrubbing their skin in the shower or brushing their teeth too hard.
“I would say one-third to half of the patients with BFRB [body-focused repetitive behavior] benefit from decoupling, but the rest do not,” Moritz said. “And so the idea was to find another technique that is perhaps more suitable for these nonresponders.”
The training also recommends that people treat themselves to things like a massage, a warm bath, or applying lotion “both consciously and, ideally, lovingly.”
More research is needed
John Piacentini, president of the board of directors of the TLC Foundation for Body-Focused Repetitive Behaviors, said it “is fantastic that this study will raise awareness of BFRBs because they’re really poorly understood, oftentimes misdiagnosed or missed completely.”
“There are reasonably good treatments out there that most clinicians aren’t aware of or don’t do,” he said.
However, he did note some of the study’s limitations, including that the control group wasn’t undergoing some type of alternative treatment, the study was relatively short at only six weeks, and it wasn’t clear if the intervention was affected by other conditions like anxiety or depression or helped reduce impairment.
“In this population, we’re really looking for treatments that are going to really impact or really reduce the severity of these specific symptoms,” he said.
The study authors also listed several limitations, including that the participants were recruited from social media, lacked diversity (most were white women in their 30s), and did not have their diagnoses confirmed.
“I was very excited that there’s more work that’s being done in this self-help area,” Bailen said, adding that habit replacement techniques might be helpful for those who are waiting for treatment, or in combination with other therapies.
“Getting access to mental health services can be a real challenge these days and waitlists can be incredibly long,” she said. “But I think that the more research that we’re able to do, and the more we’re able to develop these self-help materials, we can help narrow that treatment gap. And that’s definitely important.”
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