Matthew Pearson is an associate professor in the School of Journalism and Communication at Carleton University.
I have bitten my fingernails for more than 40 years. I don’t know exactly when my nail biting began, or why I started doing it in the first place. Perhaps it runs in families, as my parents and older siblings also bit or picked at their nails.
As a young boy, I’d often chew my fingernails and the skin around them with such malice that they’d become infected. I’d have to dip a swollen fingertip into a shot glass filled with warm salt water to ease the inflammation. I don’t get as many infections as an adult, but it still happens from time to time.
For years, I’ve hidden my hands in photos because the state of my nails is often so bad. I also notice other people’s hands and feel a small sense of relief when I spot tattered nails. I’m not the only one, I tell myself.
This is not a bad habit easily quit. Here are some of the things I’ve tried: Wearing an elastic band on my wrist and snapping it each time I catch myself biting a nail. Painting my nails with an ill-tasting anti-bite polish infused with marine algae, nettle extract and horse chestnut. Getting a manicure. Getting acrylic nails. Keeping a journal to track my nail biting throughout the day.
Sitting on my hands. Taking pictures of my fingers regularly to measure my meagre progress. Wearing gloves while driving. Spending weeks talking through the problem under the guidance of a patient psychologist. Wearing a smart bracelet that vibrates gently whenever my hand moves toward my mouth.
So far, nothing has helped me overcome the urge to bite. But ever since one of my children began biting their nails a few years ago, I have become more curious about why I do it, how it serves me and what it would take to give it up once and for all.
I’ve often thought of nail-biting as evidence of some deep-seated flaw – not to mention gross – which is why it surprised me a few years ago when a therapist suggested quite matter-of-factly that it was self-soothing. That, on some level, this repetitive and uncontrollable impulse calmed me down.
Nail biting has since become my entry point into the world of body-focused repetitive behaviours, often known by the acronym BFRBs. This cluster of common but commonly misunderstood behaviours also includes hair-pulling (known as trichotillomania), skin-picking (known as dermatillomania), lip-biting, cheek-biting and nose-picking.
For decades there have been efforts to understand these disorders, treat the sufferers and, in some circles, prevent the problems from occurring in the first place. Meanwhile, some people with BFRBs are creating online support groups, channelling their struggles into powerful creative outlets and taking a more harm-reduction approach, knowing a complete end to all picking, pulling or biting may be impossible for them.
Our natural grooming instinct on overdrive
By the time she founded a national organization to raise awareness about trichotillomania, Christina Pearson had pulled out her hair and picked her skin for more than two decades. At the time, she represented hair pullers on the national board of the Obsessive Compulsive Foundation, which is what brought her to a conference in San Francisco in November, 1990.
There, she met Dr. Charles Mansueto, a psychologist who gave what many consider the first national talk on trich, as those in the community call it. “I loved his presentation,” recalls Ms. Pearson.
The pair hit it off, and Dr. Mansueto soon joined the scientific advisory board of Ms. Pearson’s fledgling Trichotillomania Learning Centre.
Despite his friendly, soft-spoken demeanour, Dr. Mansueto is a giant in the field of BFRBs. As founder of the Behavior Therapy Center of Greater Washington and co-author of the book Overcoming Body-Focused Repetitive Behaviours, he has spent decades helping to unmask and explain a range of behaviours that many people, including me, have long felt ashamed to talk about openly.
“There are very few of us who decided to devote their attention to this obscure area,” he says, adding that his initial fascination was with obsessive-compulsive disorder. BFRBs have “ridden on the coattails” of OCD, he says.
It’s worth taking a moment here to debunk some common misconceptions about BFRBs.
Some think it’s a nervous habit, and that people could stop if they wanted to. Or that it’s a form of self-harm, like burning or cutting. Or that it’s the tip of the iceberg, hiding a deeper problem such as fear of intimacy, or that it’s the product of prior trauma, or the result of a rare psychiatric disorder.
Though Dr. Mansueto says there may be a correlation between people with BFRBs and past experiences with trauma, the trauma itself is not seen as the cause of the BFRB. Nor is anxiety or stress, as reducing a person’s anxiety may not cause them to stop the behaviour. As for self-harm, Dr. Mansueto says the goal of a BFRB is not to cause pain, but rather secure relief.
If someone has a BFRB, there is a greater likelihood it will appear in immediate family members, Dr. Mansueto says. But while some people’s genetic makeup may make them more vulnerable, researchers are convinced life experiences influence whether such individuals will develop the disorder as well.
Among BFRBs, hair-pulling and skin-picking attract the most attention because both are documented psychological disorders, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, known as the DSM. It’s difficult to know exactly how many people are affected, but a reasonable estimate based on research findings is that three to six per cent of the general population could have a significant problem with hair-pulling or skin-picking at some point in their lifetime, according to Dr. Mansueto.
Other BFRBs that aren’t specifically named, including nail biting, are captured in the DSM as disorders related to OCD. Nail-biting may be even more common than specified disorders, but there is less reliable data because nail-biting hasn’t been studied as closely.
BFRBs aren’t necessarily a problem until they become one. As Dr. Mansueto notes in his book: “The personal toll it takes in terms of social and emotional consequences may range from mild to severe, and it may be disproportionate to the extent of your actual cosmetic damage.”
Dr. Jon Grant is a professor of psychiatry and behavioural neuroscience at the University of Chicago. He’s been writing about skin-picking for almost 20 years, though he says he first became interested in the late 1990s while he was in medical school.
“I’ve always been interested in behaviours that people feel like they can’t control,” he says.
Talking to Dr. Grant helped clarify something for me. It’s not a question of why some people pick, pull or bite and others don’t, but rather, why some people struggle to manage those impulses.
“Everybody does it,” he says. “There’s not a person that hasn’t picked around their fingernails, picked their nose, pulled out a weird hair. Every animal grooms themselves to varying degrees. And some people just cannot control the extent of it and stop it.”
In terms of connections between BFRBs and other mental health disorders, Dr. Grant says some studies have shown higher rates of anxiety in people with BFRBs, as well as some elevated rates of depression. But it’s unclear what this means and how it might affect a person’s behaviour.
If a person, for example, has picked at their face and is now worried about being seen in public where they might be asked about it, their anxiety level may be high. But did the anxiety cause the picking, or is it a byproduct of the picking?
I’ve often thought my fingernails are an external barometer of internal stress or struggle, and that 10 perfect nails might convey a certain message to the world. But it’s actually a red herring. Yes, when I’m feeling less stressed, there’s a good chance I am not relying on my BFRB to soothe me. But at the same time, mangled nails aren’t necessarily a cry for help.
Part of the challenge with understanding BFRBs is the dearth of research. The behaviours are far less studied than depression or schizophrenia, and the research that does exist is limited to the past 20 to 30 years, Dr. Grant explains.
“There are literally thousands of researchers all over the world looking at depression. There are probably a handful of researchers looking at these behaviours,” he says. “We know far less and that’s frustrating for people with BFRBs.”
Ms. Pearson says she started pulling out her hair when she was 11 and began picking at her skin four years later. There were also times when she bit her nails and chewed the inside of her cheek. She’d spend an average of three to five hours a day engaging in the behaviour.
“I knew something was very wrong, but I didn’t know what,” the 69-year-old, who has bright blue eyes and long white hair, tells me over Zoom from Grand Junction, Col.
She once asked a doctor about her hair-pulling and immediately regretted it. She felt so shamed by his stern reaction that she never mentioned it again. She has come to understand, however, that there is nothing unnatural about picking, pulling or biting.
“Where it crosses the line is when it causes you distress,” she says. “If it begins to interfere with your psyche, your day, your socializing, your self-esteem, then it becomes a problem and it should be addressed.”
Ms. Pearson eventually learned her BFRB was a reaction to being overstimulated by her thoughts or environment. She had to learn how to regulate her emotions in order to reduce the distressing reactions.
“Am I surprised that people are spending hours pulling their hair and picking their skin? Hell no,” she says. “We live in an overwhelming environment if you let any of it in. At the same time, our nervous systems are quite capable of filtering. I had to learn to tolerate what used to not be tolerable. I had to learn how to feel a negative emotion. I had to learn that it wasn’t going to kill me. I had to learn that if I let emotions arise as a natural flow, they will move on.”
That we are living in an era of overwhelm resonates deeply with me. Whether it’s wars and famine, climate grief, political polarization or just the non-stop messages in our social media feeds telling us to be, in the immortal words of Radiohead, “fitter, happier, more productive” versions of ourselves, it’s too much to bear some days. I can’t help but wonder: If BFRBs are such a good way to cope, why aren’t we all biting our nails all the time?
An effective coping mechanism
The Trichotillomania Learning Centre that Ms. Pearson founded has morphed into the TLC Foundation for Body-Focused Repetitive Behaviors. Its website provides useful information about a range of BFRBs, highlights the members of its distinguished scientific advisory board (including both Dr. Mansueto and Dr. Grant) and connects people to medical and therapeutic providers, as well as a wide range of peer-led support groups. Visitors to the site are assured, in all caps, “YOU ARE NOT ALONE.”
Some time during the COVID-19 pandemic, I stumbled across the men’s online peer support group, which meets on Zoom on the last Wednesday of every month. The group is facilitated by Gordon Hansen, a 40-year-old urban planner in Oakland, Calif., who describes BFRBs as a “simple dopamine injection system.”
Mr. Hansen’s journey with BFRBs began around the age of 13 – which is a common time for many people to develop these behaviours. He says he’s tried all of them, but hair pulling – whether it’s from his scalp, eyebrows, eyelashes, mustache, armpits, legs or other parts of the body – is what brings him the most relief when life gets stressful.
“I like the feeling I get from it and, in that sense, it is an effective coping mechanism because I am getting some pleasure, if not joy, from that kind of coping,” he says.
The barrier to entry is low and the supply is readily available, he adds. Plus, on a spectrum of available coping mechanisms, hair pulling is less harmful than drinking or smoking. “I don’t have to ingest anything. I don’t feel drunk, I don’t feel high,” he says. “It’s almost like the perfect little drug.”
Mr. Hansen has a gentle touch as the facilitator of the support group, which is free and attracts an average of eight participants a month. He begins each meeting by reminding participants he is not a clinician or mental health professional. He encourages people to speak from their own experiences, rather than prescribing remedies to others.
The meetings begin with each person sharing where they’re at with their BFRB. I often talk about my fingernails in terms of a percentage – if I have healthy nails on all but two fingers, I’ll say I’m a solid 80 per cent.
After, there is time for general discussion and offers of mutual support. I quickly realized during my first meeting that it was a safe space to talk about something I’d never talked about before with people who have similar behaviours which they’d also never talked about before.
Each 90-minute meeting ends with everyone setting a goal for themselves for the next 24 hours. During a meeting last summer, I jotted my goals on a pair of orange Post-It notes: “Be curious about why I need to be soothed in a particular moment” and “aim to get 10 fingernails and get a manicure.”
Turns out the manicure, which I had in the dying days of August, was the easy part.
‘I don’t get angry at my BFRB any more’
There are various treatment methods for BRFBs. Competing-response training is designed to strengthen motor habits that are incompatible with problem behaviours, such as clenching your fists whenever you feel the urge to pull your hair or bite your nails.
Meanwhile, the Comprehensive Behavioral Model, outlined by Dr. Mansueto and his colleagues in 1997, seeks to first identify the unique pattern of sensations, thoughts, feelings, movements and environmental factors that trigger and maintain BFRBs. Then, a range of self-management techniques are employed to help a person increase their control over their BFRB.
Abstinence has long been my goal and that of many others who struggle with BFRBs. However, thanks to the help of Gordon Hansen and other BFRB advocates, I’ve come to realize that a harm-reduction approach may be more achievable.
“I pull every day,” says Joyce Tran. “I’m a proud member of the Zero Days Pull-Free Club.”
Ms. Tran, who is 29 and lives in Victoria, says she can’t think of a time since she was eight years old that she either stopped pulling or didn’t have a strong urge to pull. Since childhood, she’s become good at deflection, blaming her visible hair loss on either having thin hair or a bad haircut. Her parents took her to see a dermatologist and a Chinese herbalist. She’s worn wigs, hats and beanies. She’s taped her hands and fingers. She’s countered urges by doing push-ups. She’s expertly hidden the condition, including from her boyfriend (now husband) for the first few years of their relationship. But the urge always won.
The physical damage caused by BFRBs may be easier for outsiders to spot, but it never tells the full story, Ms. Tran says. “The emotional side of BFRBs was actually the hardest part for me to live through, but everyone just focused on the part where I was kind of bald.”
Where once Ms. Tran says she felt ashamed to talk about trichotillomania, she has become more open about it in recent years, documenting her BFRB journey on Instagram and facilitating a biweekly online support group. People often tell her that being so open must be scary, but she disagrees.
“It was scarier to imagine how the rest of my life would go if I continued to hide it,” she says, adding she also didn’t like the idea of people speculating why she was losing her hair. “If people are going to question my hair, I want to be in control of the narrative.”
Adopting a harm-reduction mindset has also worked for Jason Yu, whose skin picking intensified while he was an undergraduate student at the University of British Columbia. Mr. Yu says he has accepted that he’s likely going to pick, but his goal is to minimize the amount of shame the picking causes him, as well as the extent of damage it causes to his hands, which is where he picks the most.
“If I begin picking and I can catch myself, do some deep breaths, walk around, get a glass of water, do a little journaling or whatever, maybe that snaps me out of my elevated state,” he explains. “I can regain control, I can stop myself.”
In addition to focusing on sleep hygiene, exercising, setting boundaries and saying no to things, Mr. Yu, 32, says he pays close attention to where he is physically when he feels an urge to pick.
I’m the same way: As a journalist and university professor, I spend a lot of solitary hours at my desk – thinking, word-smithing, worrying about the state of the world. It feels natural for my fingernails to end up in my mouth, almost without me realizing. It happens in the car, too, particularly if I’m running late. Biting my nails feels like a quick and easy way to burn off excess nervous energy as I draft an e-mail or race to an appointment. I’ve learned both of these locations are my zones of vulnerability. They’re when I – and my poor nails – are most at risk.
Mr. Yu, who worked for several years as a civil engineer, quit his job and is currently retraining to be a counsellor. He wants to work with people who have BFRBs. He’s already developed a workshop and offers individual coaching through Island Clinical Counselling, which has several locations on Vancouver Island.
A few years ago, Mr. Yu partnered with Cheyenne Goudswaard, a Dutch animator who also picks her skin, to create a delightful short film called Low Fuel Light. It explores Mr. Yu’s experience of having a BFRB, and how he’s learned to appreciate that his BFRB is his body’s way of communicating with him. At one point in the film, Mr. Yu says: “I don’t get angry at my BFRB any more. I now say thank you for letting me know.”
Instead of resenting the behaviour, Mr. Yu tells me he relies on it as a signal for when he’s working too much, sleeping too little or generally pushing himself too hard. “My skin picking is my body’s way of telling me, ‘Jason, you’re pushing yourself too hard, you need to slow down.’ ”
Zero days bite-free
Like Mr. Hansen and Ms. Tran, Mr. Yu is not 100-per-cent pick-free. He shows me a small cut on his index finger and says he’s a “rock-solid 95.” But a small bit of picking isn’t failure.
“You’re just human,” he tells himself. “You’re doing your best.”
It’s a message that resonates with me as I look down at my fingernails, which have paid the price after a difficult few months. At the start of the year, I snapped a couple quick photos of my fingers. Ten shiny fingernails all in a row, no jagged edges, Band-Aids or blemishes.
By the time the academic term ended several months later, I felt the jittery weight of things left undone, emails left unsent. The fingernail on my left thumb was the first to fall, followed soon after by the right thumbnail. Two down, eight still standing.
Then, the ring finger on my left hand got nipped in a moment of doom scrolling meets muscle memory. It happened so fast that what I had done didn’t register until later. That left seven. Seventy per cent. A B-minus in the crude language of marking.
A few weeks later, I returned to my hometown in southwestern Ontario to visit my mother in hospital. Within a week, she was diagnosed with metastatic ovarian cancer and told the disease had spread rapidly throughout her body. There would be no treatment. We took her home and did our best. Several times a day, when I would press a one-milligram hydromorphone tablet into the palm of her wrinkled hand, I felt the soft scrape of her fingernails as she closed her hand around the pill.
My 83-year-old mother, who had been a lifelong nail biter, had somehow quit. Her fingernails shone in the light, despite the darkness falling all around us. Mom and I compared nails. Hers were beautiful, mine were brittle. She died before I got a chance to ask her how – or why – she had stopped biting her nails after so many years.
I may not ever reach Zero Days Bite-Free, or, if I ever do, the streak may not last long. I’m starting to feel OK about that. What I’ve learned is that when I bite my nails, my body or mind are trying to tell me something. They’re trying to send me a message. And all I have to do is listen closely, take a deep breath and choose to respond in a different way.