Understanding Body-Focused Repetitive Behaviors

To this day, Katie Koppel, a 23-year-old recent college graduate who lives in Boston, still remembers the exact moment she first pulled out her hair. She was a bored 7-year-old, sitting in front of the television. Mindlessly, her fingers wandered to her face and landed on her eyebrows. "I pulled out half my eyebrow in a couple of hours," Koppel recalls. "I just remember looking into the mirror and seeing what I had done, and not understanding what had just happened. I felt this tremendous sense of fear." Koppel's pediatrician thought her hair loss might be caused by lupus. Her parents were stymied. Nobody thought to ask Koppel – who by then had begun shutting herself in closets for hours at a time, yanking at her face and scalp with swollen fingers – if she was pulling her hair out herself. Eventually, Koppel's mother did a Google search for "unusual forms of hair loss."

She discovered a clinical term for her daughter's condition: trichotillomania. Trichotillomania is a condition in which individuals feel the compulsive urge to tug out their body hair. Leg hair, scalp hair, arm hair and armpit hair are all fair game, as is facial hair, eyelashes, chest and pubic hair. However, Koppel and her mother would soon learn that trichotillomania falls under an even broader umbrella of little-understood disorders called body-focused repetitive behavior, or BFRBs. These are behaviors that involve compulsively damaging one's physical appearance – picking at skin, pulling hair, biting nails and even chewing one's lips or the inside of the cheeks. But wait – doesn't everyone pull their hair or pick their skin from time to time?

According to Dr. Nancy Keuthen, a professor of psychology at Harvard Medical School and co-director of the Trichotillomania Clinic at Massachusetts General Hospital, individuals with BFRBs "have tried repeatedly to decrease or stop. [Their behaviors] cause distress and impairment in functioning," she says. "All of us do some skin picking or hair pulling, whether you're going to admit it or not, but the people who come in for treatment are the people who are seeing significant tissue damage or hair loss." About 1 to 3 percent of the population is thought to have trichotillomania, and about 1 to 5 percent is thought to have a skin picking condition known as excoriation disorder. The people who have this clinical level of the diagnosis, Keuthen says, will often start picking or pulling around puberty – although they can also start earlier or later in life. Both men and women struggle with BFRBs, although women are more likely to seek treatment. Patients with BFRBs might spend an hour or more a day picking, pulling, biting or thinking about it. They'll constantly try to manage their urges – which might negatively affect their relationships, friendships, family functioning and focus at school or work. There are also medical and cosmetic concerns. Those who pick at their skin might experience infections and scarring. Individuals who pull out their hair might find it difficult to grow back. In rare and extreme cases, people can pick down to the muscle or dig away at their nose so much that their septum collapses. And, of course, like many psychological conditions, trichotillomania, excoriation disorder and other related behaviors are accompanied by stigma. BFRBs are "disorders of isolation and of shame," says Koppel, who wears a wig to hide her hair loss. "I think in a lot of ways that's more damaging than any more physical or medical consequences could ever be. Every single person I know with trichotillomania has, at one point, felt like they were the only one who did this.

They didn't know it had a name, they didn't know it was diagnosable. And people were reinforcing that shame by telling them [they] could stop if they wanted to." Men with trichotillomania often escape scrutiny by shaving their heads or beards. With women, who tend to have longer hair, it's a little harder to hide. And those with excoriation disorders will often pick at areas covered by clothing or wear garments to conceal their marks. So why do people pick and pull? Doctors are still trying to figure that out. Trichotillomania and excoriation disorder are both listed in the Diagnostic and Statistical Manual of Mental Disorders; both are considered obsessive-compulsive spectrum disorders, though they're unique from OCD. (Nail biting, lip chewing, nose picking and other behaviors aren't yet listed; they aren't as often reported, nor are they as widely studied.) "OCD is really all anxiety-driven," says Carol Mathews, a professor of psychiatry at the University of Florida. "You feel a sense of relief when you've acted on your compulsion, but you don't feel a reward. With hair pulling, you feel a sense of relief, a sense of reward, if you got the right hair or you got that scab." Mathews adds that OCD is usually accompanied by obsessions – fears of contamination, or a thought that you might harm someone. Compulsions are in direct response to those thoughts. But rather than being triggered by thought, hair pulling and skin picking are driven by urges. "It's a very physical act," Mathews says. "There are mental compulsions that you can have with OCD, but it doesn't have to be a physical compulsion." BFRBs feel different for everyone. Some people feel an increased sense of tension or anxiety before they pick or pull, and a feeling of relief after. Yet others pick or pull – almost in an absent-minded manner – when they're understimulated or bored. And many individuals engage in both hair pulling and picking; Keuthen says that up to half of people with trichotillomania also have excoriation disorder. "They're kind of kissing cousins," she says. Angela Hartlin, a 29-year-old from Dartmouth, Nova Scotia, who has excoriation disorder, finds she's more prone to picking while dealing with stress.


Her skin picking "was personally driven by anxiety," Hartlin says, who once picked at her skin for hours a day and has experienced both infections and scarring. "I found it calming. So calming down the anxiety is something I have to do as part of my self-care routine. You have to know your own specific triggers and counter them." Hartlin eventually recognized her triggers. But it took help from a professional therapist, who started working with Hartlin after she appeared on a television show to talk about her experience with excoriation disorder. For years, Hartlin couldn't find help. Both Hartlin and Koppel faced a common problem that many patients with BFRBs experience – a difficulty finding a medical provider who understands their conditions. Many physicians have little clinical understanding of BFRBs and aren't trained to treat them. Or they'll mistakenly diagnose excoriation disorder or trichotillomania as an unrelated skin or psychological disorder. There are experts out there who treat BFRBs. But if you have a BFRB and don't live near a major hospital, your best bet is to seek a therapist who specializes in cognitive behavioral therapy, says Dr. Jon Grant, a professor of psychiatry at the University of Chicago. They should be well versed in these behaviors and can hopefully tailor their approach to fit your needs. Antidepressant medications like SSRIs, or selective serotonin reuptake inhibitors, are often prescribed for individuals with BFRBs. But although they might help with anxiety and depression – which, in turn, might alleviate skin picking or hair pulling – Grant says they show little efficacy for treating conditions like trichotillomania and excoriation disorder. However, studies have indicated that a pharmaceutical drug and nutritional supplement called N-acetyl cysteine might reduce patients' urges to pull or pick.

 Even then, treatment is highly individualized for each patient. Some people might respond to cognitive behavioral therapy, which teaches patients to recognize their thoughts and behaviors and change them. Yet others might not be motivated enough to fully engage in a series of sessions. N-acetyl cysteine might yield improvements in one individual, but not another. Bottom line? What works for you might not work for someone else – and vice versa. For instance, Koppel has not found much success with cognitive behavioral therapy, but she did once stop pulling for six months after trying hypnotherapy. And Hartlin didn't notice much of a difference with N-acetyl cysteine, but she greatly benefited from therapy. Is remission possible? Experts and patients alike agree it is – although "remission" might not necessarily mean that you'll never pick or pull again. Some people are able to stop completely. But you shouldn't be too hard on yourself if you occasionally find your hand straying toward your face or scalp, Grant says. Hartlin agrees. "Recovery is possible, but you need to accept yourself and where you're at with picking or pulling. Loving who you are will enhance your life," Hartlin says. "I'm in a state of recovery now where I … still have urges, but I can emotionally work through them." Hartlin still occasionally finds herself picking – but after many years, she says she's finally able to wear shorts for the first time.

She also finds it rewarding to spread awareness of BFRBs; she's formed support groups, and her memoir, "Forever Marked: A Dermatillomania Diary," recounts her years of struggle. And Koppel – who recently authored her own memoir – found her greatest source of solace through the Trichotillomania Learning Center, which was founded in 1991 to provide advocacy, awareness and support for individuals with trichotillomania. Since then, it has expanded to include those with other BFRBs. While Koppel isn't in "remission" per se, she is actively seeking treatment. Most importantly, she's no longer ashamed. "What I really attribute my emotional healing to is the Trichotillomania Learning Center's conferences," Koppel says. "I finally realized for the first time that I wasn't alone. It's one thing to read an article on the Internet, but another to be surrounded by people in a room who are going through the same experiences you are. That really drove things home in a way nothing else could."

Research suggests compulsive behaviors like nail-biting can help soothe boredom, irritation and dissatisfaction

SUSAN COSIER, SCIENTIFIC AMERICAN

Many people think of nail biting as a nervous habit, but the driving force may not be anxiety. Mounting evidence shows that people who compulsively bite their nails, pick their skin or pull their hair are often perfectionists, and their actions may help soothe boredom, irritation and dissatisfaction.

As many as one in 20 people suffer from body-focused repetitive disorders, engaging in behaviors such as biting their nails or plucking out hair until they damage their appearance or cause themselves pain. These disorders are related to tic disorders and, more distantly, obsessive-compulsive disorder. As such, the repetitive behavior is extremely difficult to quit—yet many people continue to think they simply have a nervous habit and are too weak-willed to overcome it.

A new study adds evidence to a theory that perfectionism rather than anxiety is at the root of these behaviors. The researchers first surveyed 48 participants, half of whom had these disorders and half of whom did not, on their organizational behavior and ability to regulate their emotions. Those with the disorders scored as organizational perfectionists, indicating a tendency to overplan, overwork themselves and get frustrated quickly without high levels of activity.

Researchers then put the subjects in situations designed to provoke four different emotions: to incite stress, they showed a movie of a plane crash; to promote relaxation, they showed a movie of waves; to elicit frustration, they presented a difficult puzzle but said it was easy; and to evoke boredom, they made participants sit in a room alone. People who had the disorders engaged in the body-focused behaviors during all the situations except the relaxing movie.

The work, which was published earlier this year in the Journal of Behavior Therapy and Experimental Psychiatry, jibes with a recent theory that stress is far from the sole cause of these compulsions. Boredom and frustration, easily elicited by an underlying perfectionist personality, may be more important triggers. Past research suggests that the biting or scratching indeed makes people feel better temporarily—perhaps satisfying the perfectionist urge to be doing something rather than nothing. After the initial relief, however, comes pain, shame and embarrassment.

The findings could help therapists treat patients who suffer from the disorders; studies have shown that these types of perfectionist beliefs and behaviors can be eased with cognitive-behavior therapy. If patients can learn to think and act differently when tension builds, they may be able to stop the urge before it starts.

Understanding Body-Focused Repetitive Behaviors

Kirstin Fawcett

To this day, Katie Koppel, a 23-year-old recent college graduate who lives in Boston, still remembers the exact moment she first pulled out her hair. She was a bored 7-year-old, sitting in front of the television. Mindlessly, her fingers wandered to her face and landed on her eyebrows.

"I pulled out half my eyebrow in a couple of hours," Koppel recalls. "I just remember looking into the mirror and seeing what I had done, and not understanding what had just happened. I felt this tremendous sense of fear."

Koppel's pediatrician thought her hair loss might be caused by lupus. Her parents were stymied. Nobody thought to ask Koppel – who by then had begun shutting herself in closets for hours at a time, yanking at her face and scalp with swollen fingers – if she was pulling her hair out herself.

Eventually, Koppel's mother did a Google search for "unusual forms of hair loss." She discovered a clinical term for her daughter's condition: trichotillomania.

Trichotillomania is a condition in which individuals feel the compulsive urge to tug out their body hair. Leg hair, scalp hair, arm hair and armpit hair are all fair game, as is facial hair, eyelashes, chest and pubic hair. However, Koppel and her mother would soon learn that trichotillomania falls under an even broader umbrella of little-understood disorders called body-focused repetitive behavior, or BFRBs. These are behaviors that involve compulsively damaging one's physical appearance – picking at skin, pulling hair, biting nails and even chewing one's lips or the inside of the cheeks.

But wait – doesn't everyone pull their hair or pick their skin from time to time?

According to Dr. Nancy Keuthen, a professor of psychology at Harvard Medical School and co-director of the Trichotillomania Clinic at Massachusetts General Hospital, individuals with BFRBs "have tried repeatedly to decrease or stop. [Their behaviors] cause distress and impairment in functioning," she says. "All of us do some skin picking or hair pulling, whether you're going to admit it or not, but the people who come in for treatment are the people who are seeing significant tissue damage or hair loss."

About 1 to 3 percent of the population is thought to have trichotillomania, and about 1 to 5 percent is thought to have a skin picking condition known as excoriation disorder. The people who have this clinical level of the diagnosis, Keuthen says, will often start picking or pulling around puberty – although they can also start earlier or later in life. Both men and women struggle with BFRBs, although women are more likely to seek treatment.

Patients with BFRBs might spend an hour or more a day picking, pulling, biting or thinking about it. They'll constantly try to manage their urges – which might negatively affect their relationships, friendships, family functioning and focus at school or work.

There are also medical and cosmetic concerns. Those who pick at their skin might experience infections and scarring. Individuals who pull out their hair might find it difficult to grow back. In rare and extreme cases, people can pick down to the muscle or dig away at their nose so much that their septum collapses.

And, of course, like many psychological conditions, trichotillomania, excoriation disorder and other related behaviors are accompanied by stigma.

BFRBs are "disorders of isolation and of shame," says Koppel, who wears a wig to hide her hair loss. "I think in a lot of ways that's more damaging than any more physical or medical consequences could ever be. Every single person I know with trichotillomania has, at one point, felt like they were the only one who did this. They didn't know it had a name, they didn't know it was diagnosable. And people were reinforcing that shame by telling them [they] could stop if they wanted to."

Men with trichotillomania often escape scrutiny by shaving their heads or beards. With women, who tend to have longer hair, it's a little harder to hide. And those with excoriation disorders will often pick at areas covered by clothing or wear garments to conceal their marks.

So why do people pick and pull? Doctors are still trying to figure that out. Trichotillomania and excoriation disorder are both listed in the Diagnostic and Statistical Manual of Mental Disorders; both are considered obsessive-compulsive spectrum disorders, though they're unique from OCD. (Nail biting, lip chewing, nose picking and other behaviors aren't yet listed; they aren't as often reported, nor are they as widely studied.)

"OCD is really all anxiety-driven," says Carol Mathews, a professor of psychiatry at the University of Florida. "You feel a sense of relief when you've acted on your compulsion, but you don't feel a reward. With hair pulling, you feel a sense of relief, a sense of reward, if you got the right hair or you got that scab."

Mathews adds that OCD is usually accompanied by obsessions – fears of contamination, or a thought that you might harm someone. Compulsions are in direct response to those thoughts. But rather than being triggered by thought, hair pulling and skin picking are driven by urges. "It's a very physical act," Mathews says. "There are mental compulsions that you can have with OCD, but it doesn't have to be a physical compulsion."

BFRBs feel different for everyone. Some people feel an increased sense of tension or anxiety before they pick or pull, and a feeling of relief after. Yet others pick or pull – almost in an absent-minded manner – when they're understimulated or bored. And many individuals engage in both hair pulling and picking; Keuthen says that up to half of people with trichotillomania also have excoriation disorder. "They're kind of kissing cousins," she says.

Angela Hartlin, a 29-year-old from Dartmouth, Nova Scotia, who has excoriation disorder, finds she's more prone to picking while dealing with stress.

Her skin picking "was personally driven by anxiety," Hartlin says, who once picked at her skin for hours a day and has experienced both infections and scarring. "I found it calming. So calming down the anxiety is something I have to do as part of my self-care routine. You have to know your own specific triggers and counter them."

Hartlin eventually recognized her triggers. But it took help from a professional therapist, who started working with Hartlin after she appeared on a television show to talk about her experience with excoriation disorder.

For years, Hartlin couldn't find help. Both Hartlin and Koppel faced a common problem that many patients with BFRBs experience – a difficulty finding a medical provider who understands their conditions. Many physicians have little clinical understanding of BFRBs and aren't trained to treat them. Or they'll mistakenly diagnose excoriation disorder or trichotillomania as an unrelated skin or psychological disorder.

There are experts out there who treat BFRBs. But if you have a BFRB and don't live near a major hospital, your best bet is to seek a therapist who specializes in cognitive behavioral therapy, says Dr. Jon Grant, a professor of psychiatry at the University of Chicago. They should be well versed in these behaviors and can hopefully tailor their approach to fit your needs.

Antidepressant medications like SSRIs, or selective serotonin reuptake inhibitors, are often prescribed for individuals with BFRBs. But although they might help with anxiety and depression – which, in turn, might alleviate skin picking or hair pulling – Grant says they show little efficacy for treating conditions like trichotillomania and excoriation disorder. However, studies have indicated that a pharmaceutical drug and nutritional supplement called N-acetyl cysteine might reduce patients' urges to pull or pick.

Even then, treatment is highly individualized for each patient. Some people might respond to cognitive behavioral therapy, which teaches patients to recognize their thoughts and behaviors and change them. Yet others might not be motivated enough to fully engage in a series of sessions. N-acetyl cysteine might yield improvements in one individual, but not another. Bottom line? What works for you might not work for someone else – and vice versa. For instance, Koppel has not found much success with cognitive behavioral therapy, but she did once stop pulling for six months after trying hypnotherapy. And Hartlin didn't notice much of a difference with N-acetyl cysteine, but she greatly benefited from therapy.

Is remission possible? Experts and patients alike agree it is – although "remission" might not necessarily mean that you'll never pick or pull again. Some people are able to stop completely. But you shouldn't be too hard on yourself if you occasionally find your hand straying toward your face or scalp, Grant says. 

Hartlin agrees. "Recovery is possible, but you need to accept yourself and where you're at with picking or pulling. Loving who you are will enhance your life," Hartlin says. "I'm in a state of recovery now where I … still have urges, but I can emotionally work through them."

Hartlin still occasionally finds herself picking – but after many years, she says she's finally able to wear shorts for the first time. She also finds it rewarding to spread awareness of BFRBs; she's formed support groups, and her memoir, "Forever Marked: A Dermatillomania Diary," recounts her years of struggle.

And Koppel – who recently authored her own memoir – found her greatest source of solace through the Trichotillomania Learning Center, which was founded in 1991 to provide advocacy, awareness and support for individuals with trichotillomania. Since then, it has expanded to include those with other BFRBs. While Koppel isn't in "remission" per se, she is actively seeking treatment. Most importantly, she's no longer ashamed.

"What I really attribute my emotional healing to is the Trichotillomania Learning Center's conferences," Koppel says. "I finally realized for the first time that I wasn't alone. It's one thing to read an article on the Internet, but another to be surrounded by people in a room who are going through the same experiences you are. That really drove things home in a way nothing else could." 

The psychology of why so many people bite their nails

by Joseph Stromberg

Excessive nail-biting is a surprisingly widespread human activity.

It goes back millennia: the ancient Greek philosopher Cleanthes, for instance, was said to be addicted to biting his nails. In the modern era, no one has any good data on how many of us share the affliction (technically called onychophagia), but small-scale studies indicate about 20 percent or so of adults bite regularly — which would suggest millions of Americans do it.

"Everybody picks and bites to a degree," says Fred Penzel, a psychologist who helps patients deal with nail biting, hair plucking, and other body-focused repetitive disorders. "When it gets to the point that people are doing damage to themselves, that's when we treat it as something other than an everyday behavior." This certainly applies to a much smaller number of people — but it's still, he says, a surprisingly common problem.

Even though excessive nail-biting is widespread, however, psychologists have only begun studying it within the last few decades. In fact, they're still trying to understand the basic question that many people with onychophagia spend so much time wrestling with: given that the rational part of our brain wants to quit, why do we keep on biting our nails?

The current hypothesis: nail biting helps even out our emotions. When we're bored, it provides stimulation; when we're stressed-out or frustrated, it provides a temporary calm.

Early theories on why we bite our nails have been rejected
Most of the early explanations of nail biting have been thoroughly disregarded. Sigmund Freud, for instance, believed that excessive nursing during infancy could lead to a so-called "oral receptive" personality — and a tendency to chew on nails and other objects, as well as a distinct preference for oral sex. He had no evidence for this idea, and subsequent followers of his ideas didn't turn up any either.

Later, some researchers considered nail biting, hair plucking (called trichotillomania) and skin-picking as mild forms of self-harm — the intentional injuring of oneself, often by cutting. Under this theory, biting one's nails would be sign of hostility towards oneself.

Undercutting this idea, however, is the fact that most nail biters aren't particularly fond of the damage that their habit causes — and for many people, it's the main reason they want to quit. Starting in the 1990s, most psychologists began distinguishing it and body-focused repetitive disorders from more severe forms of self-harm.

As they've begun to better understand the behavior, one big question is whether it should be grouped in with obsessive-compulsive disorder (OCD). Though the latest DSM (a text that's considered an authority on psychiatric diagnoses) puts nail biting in a broader category with OCD, many of those who specifically study body-focused repetitive disorders disagree.

"The word 'obsessive' doesn't really apply," says Penzel. "Every behavior that's repetitive is not necessary a compulsion."

Compulsions, for one, are usually associated with extreme levels of anxiety. Nail biting, on the other hand, is often accompanied by pleasure — the people who do it want to do it, except for the fact that it causes damage over time. Though people with OCD appear to have a greater chance of being nail biters, they seem to be distinct disorders.

The new theory: nail biting helps us balance out our emotions
Recently, psychologists have come to a more plausible theory of nail biting: that it can provide a temporary escape, distraction, bit of pleasure or relaxation for the biter.

Penzel points out that many people get the urge to bite when they're under-stimulated (i.e. bored) or overstimulated (stressed-out or excited). "When they're under-stimulated, the behaviors provides stimulation, and when they're overstimulated, it actually helps calm them down," he says. Like nicotine, the idea is that nail-biting can have a biphasic effect: it can stimulate under certain conditions, and relax in others.

It's still not proven, but to someone who's spent a lot of time biting nails, this explanation rings true — and a recent study conducted by Sarah Roberts and other researchers at University of Quebec at Montreal provides a bit of evidence for it.

In the study, people with onychophagia, trichotillomania, or other body-focused repetitive behaviors were put into situations designed to elicit frustration (they were given a difficult task that couldn't possibly be completed in the allotted time), boredom (they were left in a room with absolutely nothing to do for a while), anxiety (they watched a notoriously terrifying plane crash scene from the movie Alive) or relaxation (they watched a video of a beach, from a comfortable chair).

Obviously, these situations are somewhat artificial. Still, when the researchers observed the participants' behavior — and surveyed them afterwards on how strong their urge to bite was — they found something interesting.

"People had a higher urge to engage in the behavior in the stressed condition and the boredom condition, much more than in the relaxation condition," Roberts says. Other surveys of nail biters and hair pluckers have come to similar conclusions. "It seems fairly clear that there's some emotional regulation involved."

Why we bite our nails instead of other alternatives
Of course, this theory still prompts a more basic question: why does biting your nails — or plucking your hairs or picking at your skin — provide pleasure or distraction in the first place? Why do so many people become addicted to these grooming habits, rather than, say, balling their hands up into fists?

One possible answer relates to the finding that people with body-focused repetitive disorders tend to be perfectionists. It might be that ripping off an oddly-shaped nail can provide a satisfying sense of perfection for the biter — and the quest for this satisfaction eventually gets out of control.

It's also possible that the uncontrollable urge to groom excessively goes much deeper than we realize. Lots of other animals, after all, seem to do it too: some cats lick themselves excessively, leading to fur loss, while some horses bite their own flanks over and over. Perhaps the urge to groom past the point of usefulness — to the extent that we actually cause damage to ourselves — is a trait that can be traced way back to the evolutionary ancestors we shared with these other mammals.

Finally, there's a more mundane explanation. Maybe we just bite our nails because they're there. Psychologists believe that you can get psychologically (not chemically) addicted to pretty much anything: any activity that provides a reward can reinforce itself over time.

For an under-stimulated mind looking for a momentary distraction, the hands are always present. Biting and ripping off a nail can provide a distinct reward (it sounds weird, but to a biter, there's something distinctly satisfying about removing it). Nails grow back, so there's always a fresh one to bite. Do it enough times, and you start to get pleasure from the habit — so whenever you're bored, stressed, or frustrated, your brain unconsciously goes back to it.

How to quit biting your nails
Different psychologists recommend slightly different techniques for quitting, but they mostly boil down to one common strategy: identifying the circumstances that lead you to bite, and changing them. "We try to identify all the triggers and control them in various ways — either by blocking them, or finding substitutes," Penzel says.

For instance, if you habitually bite your nails while watching TV, you might chew gum or use your hands to play with an object whenever you sit down on the couch to watch. You might also set out signs and reminders next to the couch, reinforcing the idea that you do not want to bite.The same goes for different emotions or feelings that usually make you bite: if being frustrated is a trigger for you, try to alter the circumstances in some way, by giving yourself something else to do or making it harder to bite.

If you still can't stop, there's also a way to make nail biting way less palatable no matter what the circumstance: clear nail polishes that taste absolutely terrible. They're harmless, but once you paint these on, even brief contact between your mouth and your nails will leave a bitter, disgusting taste in your mouth until you eat something else. Some people have success combining this with other strategies.

Regardless of the particular technique you use, a big thing to keep in mind is that breaking your addiction might not come all at once, so if you break down and bite, it doesn't mean you have to give up completely. Abstaining for longer and longer chunks of time can still help break down the habit — until, someday, the bizarre habit of nail biting no longer has the same hold on your mind.