Are skin picking, hair pulling, and nail biting behaviors among children and adolescents bad habits or psychological problems?

Author: Hu Manji, deputy chief physician of Tongji University Mental Health Center

Reviewer: Professor Zhao Xudong, PhD Supervisor, School of Humanities, Tongji University

Illustration: Gu Ye, Office Clerk at Tongji University Mental Health Center

1. The real distress of skin picking, hair pulling, and nail biting

Parent 1: Our child has had the bad habit of biting his nails, picking his skin, and tearing his lip skin since he was young. Now he is in junior high school. I thought it would get better as he grew up, but it happens more and more frequently. I don’t know if this is a disease or a bad habit. If it is a disease, what is it? If it is not a disease, it looks weird.

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Parent 2: Don’t mention it. Our daughter has been pulling out her hair since elementary school. Now she is in the second year of junior high school. I can see her scalp becoming bald in patches. I am so worried. I have scolded and beaten her, but it is no use. I am so worried. How could she have such a bad habit?

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Parent 3: I heard that these actions are not just "bad habits" but have something to do with the child's psychology. You should find a psychologist or go to a psychiatric hospital as soon as possible.

Youth 1: Hair plucking has taught me a painful lesson. When I was a kid, I would be severely scolded by my parents whenever I started plucking my hair at home. The more I feared being scolded, the harder I pulled out. I didn’t dare be seen, so I could only do it secretly. Part of the hair on my scalp has become sparse and conspicuous. At school, I have encountered all kinds of ridicule and teasing from my classmates, and all kinds of social suicidal scenes. When I fall in love, the scars on my scalp can scare people away. I can’t go out without a hat. It’s so painful!

2. Prevalence of Skin Picking, Hair Pulling, and Nail Biting

Skin picking, hair pulling, and nail biting are common behaviors, with the incidence of hair pulling, nail biting, and skin picking being 22%, 63%, and 90%, respectively. It usually starts in children or adolescents (between 5 and 13 years old), is more common in women, about 10 times that of men, and often co-exists with other mental illnesses such as anxiety, depression, obsessive-compulsive disorder, and destructive or addictive behaviors.

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3. Skin picking, hair pulling, and nail biting may be a mental illness

These behaviors may be more than just a "bad habit." If the symptoms are severe and affect life, it may be a mental disorder. The fifth edition of the American "Diagnostic and Statistical Manual of Mental Disorders" classifies repetitive skin picking (skin scratching, picking specific parts of the skin, tearing the lip mucosa, etc.), hair pulling, and nail biting as "Body-Focused Repetitive Behaviors (BFRBs) in Obsessive-Compulsive and Related Disorders." The diagnosis requires obvious emotional distress and impairment in at least one important area of ​​life (academic, occupational or social). For some patients, it can be a disabling mental disorder.

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The main characteristics of this disorder are:

1) Uncontrollable impulses, drives, and temptations to pull out hair, bite nails, pick at skin, etc.;

2) Before performing the behavior, the individual feels an increase in physical tension or alertness;

3) When performing the behavior, the individual feels pleasure, satisfaction, and relief;

4) After carrying out the behavior, the individual feels that the impulse is alleviated and may feel guilty about the behavior;

5) The disorder cannot be well explained by other mental disorders and is not caused by other physical diseases (such as skin diseases);

6) The disorder causes clinically significant depression and impairment in social, work, or other important functions.

4. Factors that trigger skin picking, hair pulling, and nail biting

Skin picking, hair pulling, and nail biting can be triggered by external stress, environmental factors, and internal emotional states, including the hair itself, lifestyle, emotions, physiology, addiction, and other related factors, as shown below:

Torales J, 2021

5. The pros and cons of skin picking, hair pulling, and nail biting (benefits and adverse consequences)

Benefits : Hair pulling, nail biting, and skin picking can indeed temporarily regulate children's negative emotions or stress, but this may lead to further reinforcement of these behaviors.

Adverse consequences:

1) Cause physical damage: alopecia areata, pathological changes in hair follicles, skin diseases, finger purpura, musculoskeletal injuries, carpal tunnel syndrome, tooth wear or breakage, gastrointestinal diseases caused by hair swallowing, etc.

2) Secondary or comorbid conditions: various mood disorders (anxiety, depression, obsession, etc.), eating disorders, addiction disorders and destructive behavior disorders, etc.

3) Inner pain and impairment of social function: Inner pain caused by loss of control, shame and guilt over hair pulling, skin picking and nail biting. This leads to damaged interpersonal relationships, social withdrawal, academic and work impairment, personality changes, etc.

6. What should I do if I start picking my skin, pulling out my hair, or biting my nails?

These behaviors have always been considered as one of many "bad habits", so individuals or their parents who pull out their hair, pick their skin, and bite their nails rarely actively seek psychological or psychiatric treatment. However, given that these behaviors are often related to stress and poor emotional regulation - such as various tensions, anxiety, and frustration; or related to poor parent-child relationships - parent-child conflicts caused by parents' high control or neglect of their children's feelings and thoughts. Therefore, once these behaviors are discovered, psychological counseling or psychiatric outpatient treatment should be sought as soon as possible. If diagnosed and treated appropriately at an early stage, up to 50% of people may be relieved at least in the short term.

A common method is to teach children how to identify and manage their emotions, which is helpful for children to have more non-harmful coping methods suitable for themselves when they encounter tension, anxiety and other emotions. In addition, psychological education is provided to parents: the importance of parents managing their own negative emotions to promote the psychological health and growth of their children; and the need for parents to attach importance to effective communication with their children in an equal and respectful manner.

References

Sani G, Gualtieri I, Paolini M, et al. Drug treatment of trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, and nail-biting (onychophagia)[J]. Current Neuropharmacology, 2019, 17(8): 775-786

Wang W. Reasons for the Emergence of Body-Focus Repetitive Behaviors in Students and the Impact of Body-Focus Repetitive Behaviors on Students[C]//2022 8th International Conference on Humanities and Social Science Research (ICHSSR 2022). Atlantis Press, 2022: 2353-2357.

Torales J, Ruiz Diaz N, Ventriglio A, et al. Hair‐pulling disorder (Trichotillomania): Etiopathogenesis, diagnosis and treatment in a nutshell[J]. Dermatologic therapy, 2021, 34(1): e13466.

American Psychiatric Association, Zhang Daolong. Diagnostic and Statistical Manual of Mental Disorders[M]. Peking University Medical Press, 2014.