Maraz, Hende, Urbán, and Demetrovics (2017) defined nail-biting, also referred to as onychophagia, as a condition where people bite and chew their fingernails repetitively without preference of which nail to bite. The condition affects 20-30 % of the population inclusive of all age and gender groups. Scholars from different educational fields such as psychology, dentistry, and psychiatry have tried to analyze the primary cause of the problem, but still, the issue remains unresolved (Marouane, Ghorbel, Nahdi, Necibi, " Douki, 2016). For instance, Halteh, Scher, and Lipner (2017) argued that genetics and environmental conditions trigger people to bite their nails reputedly. Marouane et al. (2016), on the other hand, claimed that out that onychophagia developed from boredom or working on challenging problems. Conversely, Singal, A. " Daulatabad (2017) described the etiology of the condition as a tension reducing mechanism. Therefore, the literature analysis depicts that different researchers have varied opinions about the primary cause of nail biting since there lacks a common etiology of nail-biting, which makes the origin of the problem unresolved to date.
Most cases of nail-biting begin at the age of three, which could continue until adulthood. Nail-biting often triggers psychological distress such as shame and low self-esteem because of the negative connotation attributed to the act (Halteh, Scher, and Lipner, 2017). Society describes nail-biting as unhygienic considering that the nail-biter can put dirty nails in their mouth unconsciously. Besides, the condition also affects the nail biters immediate surrounding such as parents and siblings who become stressed in the process of trying to help the affected person overcome the challenge of repeatedly biting their nails. Therefore, understanding the basics behind why people bite their nails regularly is a prerequisite to manage the issue
Maintenance
Roberts, O'Connor, and Bélanger (2013) argued that several nail-biters maintain onychophagia as an emotion regulator. For instance, persons who bite their nails repeatedly because of work frustration or stress find themselves in the act of biting their nails as a means of relaxation or temporary escape from the events that stress them outs. Whereas, in case of boredom, the habit of biting nails becomes a stimulus to override the boredom. Equally, the quest for perfection also maintains this behaviour such that it gets out of control once the habit sticks. Therefore, Roberts, O'Connor, Aardema, Bélanger, and Courchesne (2016) concluded that nail biters have a deficit in ER, which leads nail biters to sustaining the habits.
Conditioning principles such as operant conditioning also facilitate the maintenance of the habit since the process influences voluntary behaviour both positively and negatively (Olmstead " Kuhlmeier, 2015). For example, a nail-biter may want to stop the habit and to do so; the individual may incorporate either positive or negative reinforcements. Positive reinforcement may involve measures such as buying and applying an expensive nail polish as a way of motivating the nail bitter to stop the habit. If that approach fails to work, the nail-biter could consider a negative reinforcement such as applying pepper on the nails such that when the individual places the fingers in the nail, it will discourage the continuation of the habit.
Nail biting has both positive and negative outcomes. The positive results include curbing boredom, stress reliever, or overcoming frustration to name but a few. On the other hand, adverse outcomes of nail-biting comprise of low-self-esteem, shame, harm the teeth, nail damage, and an increase of acquiring infectious diseases attributed to biting dirty nails. Therefore, most nail biters who look forward to eliminating this habit look out for the consequences and causes of the behaviour and incorporate measures that will overcome the negative results.
Part 2
Treatment
Study 1
The study aimed at examining the effectiveness of using Habit reversal training as a CBT treatment option and compare it to object manipulation to establish the most successful for helping nail biters overcome the condition. The study was conducted by Ghanizadeh, Bazrafshan, Firoozabadi, and Dehbozorgi, and the outcome was published in 2013. The subjects were 91 children and adolescents diagnosed with onychophagia. The researchers monitoring method was checking the participants’ nail length within the first month of the study and after the third month. Therefore, the monitoring period lasted for three months. Core components of habit reversal training include awareness training to enable a person to acknowledge circumstances that trigger the nail-biting behavior. Whereas, the behavioral reward systems are incorporated to motivate the person to ignore nail-biting as a prerequisite to getting the reward. The efficacy of using HR training indicated that most subjects that adopted the HR training intervention stopped biting their nails by the third month while a majority who underwent the Object manipulation dropped out of the study (Ghanizadeh, Bazrafshan, Firoozabadi, " Dehbozorgi, 2013).
Study 2
Halteh, Scher, " Lipner (2013) analysed a study conducted by Allen in 1996. The empirical researched studied 45 chronic nail biters. The researcher used bitter tasting lacquer as the monitoring method which was observed, and the outcome analyzed every four weeks. The study lasted for 12 weeks. The study focused on the Aversive conditioning t as an intervention to help nail biters stop the habit. When using aversive therapy, the bitter lasting lacquer discourages nail-biting as a way of curbing the practice. Therefore, the outcome of the study concluded that mild aversion reduced nail-biting and it was more effective when combined with self-recording and physician motivation.
Study 3
Koritzky and Yechiam examined the efficacy of non-removable reminder as a CBT treatment. The study subjects included 80 nail biters who monitored their nail-biting behavior using wristbands. The researchers tracked the subjects at intervals of three, six, and five months since the study lasted for five months. The wristbands reminded nail biters to refrain from the habit by engaging in another distracting activity such as cooking. In the short term, 12 % as compared to 26 % of participants using non-removable reminder and mild aversive technique respectively dropped out from the study (Koritzky " Yechiam, 2011). The wristband group was more effective in the long run.
Method
Description of the Patient
The subject is a female university student who began sucking her thumb since childhood. The problem progressed to the target behavior of onychophagia. The act makes the subject self-conscious and with low self-esteem. Equally, the subject bites her nails when perplexed with a complicated situation. The issue affects the patient’s school performance and social life.
Operational Definition
The targeted behaviour of focus is nail-biting. As stated earlier, the condition is also known as onychophagia refers to the activity of placing fingers in mouth and biting the nails using teeth. When analysing onychophagia, nail biting is scored each time the individual uses the teeth to bite on nails and rip some part off from the nail. Moreover, biting the nails using teeth is scored, whereas only putting the fingers inside the mouth without direct contact between the nails and the teeth is not scored. Equally, pulling the remaining parts of the nail that is torn off by the teeth are counted. However, biting the skin on the side of the nail is not recorded.
Justification of the Monitoring Method
The most effective monitoring method when using the habit reversal training is observing the length of the nails. Monitoring the length of the nails will depict the efficacy of habit reversal technique. Moreover, recording the length of the nails can be done be independently by computing the range with a measuring tape or taking pictures when needed. Overall, the monitoring method is self-explanatory and easy to follow.
Results
SORCK
S
Stimulus
O
Organismic
R
Target Behaviour
C
Consequences
K
Contingencies
Historical
Childhood habit of thumb or finger sucking
Being fully concentrate in one situation results in the subject to be highly self-conscious
Involved in an activity that requires a lot of social interactions
Contextual
Attending university
Studying
Making conversation
Meeting new people
Immediate
Paying attention to a lectures’ class
Preparing for examination
Talking to people
Assigned in a group work with new classmates
Going to a social gathering
The subject high self-conscious and lacks of self-esteem are affecting her academic performance and social interaction. Therefore, she is constantly feeling anxious and nervous. The subject is also prompted to nail biting when she is overthinking about particular issues.
Onychophagia or Nail biting
A repeated behaviour of nail-biting using teeth.
Immediate
Rough surface of the nail
Distracting the anxious feeling
Dried the skin under the finger nails
Damage tissue around the nails
Long Term
Disease causing bacteria
Nail infections
Inflammation of the fingertips skin
Easily catch cold
Tooth fractures
Immediate
Positive punishment
Positive reinforcement
Positive punishment
Positive punishment
Long Term
Positive punishment
Positive punishment
Positive punishment
Positive punishment
Negative punishment
Behavioural Formulation
The SOCK findings describe the behavioural formulation. The results indicate that the subject recurrent cases of biting nails occurs when the individual is stressed or anxious. The stress develops when faced with the fear of meeting new people or surrounded by unknown population as described by the immediate stimulus. Moreover, the anxiety stems from self-consciousness and low self-esteem because the individual does not believe in herself. Therefore, the outcome of such situation prompts the subject into nail-biting. The findings also depict some of the consequences of nail-biting as part of behavioural formulation and they include damaged nail tissues, disease-causing bacteria, and rough nails surfaces among other effects.
Discussion
Review of the Aim and Results of the Study
Different learned behaviors including nail biting can be reversed depending on the applied intervention to hamper recurrence situations. The subject can unlearn the nail-biting behavior through the application of a response based operant conditioning. McSweeney and Murphy (2014) described operant conditioning as a learned process enforced by using consequences to measure and control behavior frequency. The SORCK findings depict several outcomes attributed to the subject’s behavior of nail-biting. The outcomes of the study revealed both short and long-term effects that could address the nail-biting problem. For instance, the results mentioned rough surface of the nail, distracting the anxious feeling, the dried skin under the fingernails, and damaged tissue around the nails as short-term effects. Whereas, disease-causing bacteria, nail infections, inflammation of the fingertips skin, prone to colds, and tooth fractures as long term consequences. The treatment plan aims at using operant conditioning as the suitable technique to reverse the habit. Consequently, the appropriate intervention based on operant conditioning principles that could be used to address the subject’s problem include the use of expensive nail polish and the application of pepper on the subject’s nails.
Detailed Treatment Plan
The subject will be conditioned to purchase an expensive nail polish and in other situations applying bitter-tasting polish on her nails with the aim of reversing the habit. The costly nail polish will act as reinforcement while applying bitter-tasting polish should serve as a punishment. The treatment plan should be conducted and observed for at least six months whereas the subject should observe and measure the nail length once every week for the first two months. For the remaining four months, the subject should consider checking the nail lengths once every fortnight.
Planning is essential for the progress. Therefore, the subject should start the treatment after purchasing the nail polishes for reinforcement and punishment purposes. Moreover, a habit reversal training awareness could help the nail-biter understand the significance of the problem. Habit reversal training awareness prepares people to identify factors that stimulate the nail-biting behavior. In this case, the subject identified several stimuli that remains essential for the treatment process.
The individual discovered that some historical factors stimulated the nail-biting behavior. For instance, the person in question had a habit of finger and thumb sucking. Additionally, involvement in activities that required constant social interactions conditioned the subject to put her hand in the mouth and eventually bite her nails due to anxiety. Another historical context that the subject became aware of was being self-conscious when concentrating on a particular situation.
The subject also mentioned some contextual factors that stimulated the habit of nail-biting. The individual became aware that she bit her nails while studying, meeting new people, attending university or making conversations. Such situations were linked to anxiety or stress since the individual had self-esteem issues.
Finally, the subject became aware of the immediate stimulus that also increases the likelihood of nail-biting. Currently, the student finds herself putting her fingers in her mouth and biting her nails regularly when she pays attention to a class lecture. Equally, the process of preparing for examinations also increased the habit because of anxiety and the need to pass the exams. When the subject talks to people, she feels nervous and the only way she addresses such a situation involves biting her nails. Finally, the subject always gets uneasy when working on group assignments with new classmates. The fretfulness also accentuates when attending social gatherings. Consequently, the subject subconsciously bites her nails as a means to control the apprehension. The awareness will enable the individual to concentrate on the treatment plan to maintain the positive consequences.
On the first day of the treatment, the subject should clip the nails and file them to the same length. Later, the student should measure the length of the nails before applying the bitter-tasting nail polish. During the first four weeks, the bitter nail polish should discourage the student from biting the nails. The goal for that month should be implemented to discourage rough surface of the nail, avoiding dryness of the skin under the fingernails, and avoiding damaged tissues around the nails. Whereas, in the following month, the subject should use the expensive nail polish as a reward for meeting the first month's goals. The costly nail polish will act as a positive reinforcement to realize the goal of distracting anxious feelings that could be developed for fear of getting back to the habit of nail biting that she managed to prevent for the first month. During these two months, the subject should check the length of the nails every Sunday and reapply the nail polish where necessary to avoid deviating from the process.
In the remaining four months, the student should consider using the bitter nail polishes only. By the third month, the subject should have adapted to the process and possibly reduced the urge to bite nails when feeling anxious by substituting the feeling with another hobby such as getting more involved in social activities to boost confidence. Maintaining the nail polishes every two weeks should aim at addressing long term effects such as disease-causing bacteria, nail infections, inflammation of the fingertips skin, and catching colds easily. The subject will categories the contingencies for these outcomes as positive punishments as they weaken the behavior of nail-biting to avoid any chances of realizing the identified outcomes. Equally, the bitter nail polish will act as a negative punishment in the long term to discourage tooth fractures. After the six months, the subject should have adopted the new reversed behavior, which can be determined by the length of the nails. Overall, the treatment plan will suit the subject if observed cautiously.
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