Nail-biting an obsessive compulsive disorder in new psychiatric classification

As a child, Larry Sargent remembers biting his nails until they bled.

“It wasn’t just the nails. Sometimes it would be the skin,” says Sargent. “I think it was likely a reaction to stress. There was a release because it took your mind away from what your problems were.”

Biting your nails isn’t just a bad habit. It’s now being reclassified as a full-blown psychiatric disorder.

A proposed move by the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) is expected to include nail-biting as a form of obsessive compulsive disorder (OCD) when it is revised for 2013.

Nail-biting joins hair pulling and other pathological grooming habits in the OCD classification. Previously, the DSM put nail-biting in the “not otherwise classified” section of disorders.

The manual is considered the bible of the trade, a classification of mental disorders used by mental health professionals that contains a listing of diagnostic criteria for every psychiatric disorder recognized by the U.S. health-care system.

“I think when it becomes problematic, it takes so much time that it takes away from and starts to impact your life,” says Sargent, who is a volunteer for Obsessive Compulsive Anonymous, a Toronto based self-help group that meets at the Centre For Addiction and Mental Health once a week.

Sargent says he eventually outgrew nail-biting, but that led to other compulsions, including constant ritualistic checking and eventually hoarding.

OCD is one of the top 10 mental disorders globally. Traits of OCD include common compulsions such as washing, checking, repeating words, hoards, tapping or touching. Obsessions might include superstitious or magical thinking, contamination fears, a worry about throwing things away or thoughts of doing harm to oneself or others, according to the Ontario Obsessive Compulsive Disorder Network.

“There is a wide spectrum from an occasional nail-bite to something that can be considered an illness,” says Debbie Sookman, director of the Obsessive Compulsive Disorder Clinic at McGill University Health Centre. “You have to look at among other things, how much of a compulsion it is, how much time in the day it takes away from that individual, and the impact on health.”

In general, if the compulsion takes more than an hour out of the day or “causes significant distress,” then it is considered more serious. Sookman says the DSM is the “gold standard” for classifying illness.

“When we look at treatment, we also look not only at the act of nail biting but the person in general to see how they deal with their inner experience and any stressful external events,” says Sookman, who is also president of The Canadian Institute for Obsessive Compulsive Disorders.

Psychiatrists have over the years been building a case for nail biting, also known as onychophagia, as a genuine disorder.

In a 2009 study by the departments of psychiatry and dermatology at Wroclaw Medical University in Poland, the authors concluded that “nail-biting is an under-recognized problem.”

Nail-biters were frequently referred to dermatologists, but the authors said in severe cases they should be referred to psychiatrists.

“Psychiatric evaluation of co-occurring psychopathological symptoms in these patients, especially those with chronic, severe or complicated onychophagia may be helpful in making a choice of individual therapy.”

Habitual nail-biting is a common behaviour of children and young adults and normally diminishes by the age of 18, according to the study. It has been associated with high anxiety and low self-esteem.

One patient evaluated in the study had “destroyed” both her thumb nails from biting.

Her symptoms were alleviated with drug treatment and painting her nails with lacquer. She also put false nails over her own nails as a deterrent.

Sookman says a variety of treatment options, ranging from the pharmaceutical to psychological, are possible.

One issue she says is getting accurate diagnosis and access to best practices treatment for patients across Canada.

“This is a very specialized field and the sooner patients get treatment, the better the results.”


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