Skin Picking, Nail Biting and Tourette’s Syndrome: What’s The Connection?

Tourette’s Syndrome is a neuropsychiatric disorder that generally appears in early childhood. It is characterized by tics or involuntary movements or vocalizations.  Tics are sudden repeated twitches, movements, or sounds. People who experience tics cannot stop their bodies from doing them or, can only stop them briefly. The tics can change over time. Symptoms peak in early adolescence with most people becoming asymptomatic by early adulthood. It is quite common to see other conditions occur with Tourette’s. In fact, about 80% of people with Tourette’s Syndrome have at least one comorbid disorder.  One of the most common of these comorbidities is Obsessive Compulsive Disorder (OCD), present in over 50% of people who also have Tourette’s.

What’s The Connection to BFRBs?

Body-focused repetitive behavior (BFRBs) are a group of related disorders that includes hair pulling, skin picking, and nail-biting. They affect nearly 5% of the population. These disorders cause people to repeatedly touch their hair and body in ways that result in physical injury. For some, the compulsion to pull or pick is intense and irresistible. These behaviors are not tics or merely bothersome habits.

Skin picking sometimes referred to as excoriation disorder or dermatillomania, is a BFRB where someone repetitively and compulsively picks at their skin causing injury. These repetitive behaviors can include touching, rubbing, scratching, picking, or digging into the skin.

Hair pulling, also known as Trichotillomania or “trich”, involves repetitive and compulsive hair pulling resulting in injury and profound hair loss. These behaviors may include pulling, plucking, and sometimes even ingesting (trichophagia) the pulled hair resulting in medical complications.

Compulsive nail biting is a lesser-known BFRB known as onychophagia. While common nail-biting is a socially recognized “nervous habit”, compulsive nail-biting can be injurious and interfere with everyday functioning.

While these BFRBs may look similar to behaviors one might see with Tourette’s, they are not tic behaviors.  But there is a connection.

Not surprisingly, Body-Focused Repetitive Behaviors (BFRBs), are also seen with people with Tourette’s. BFRBs such as skin picking, hair pulling, and nail-biting are classified as obsessive-compulsive and related disorders in the DSM 5. OCD is already known to frequently co-occur with Tourette’s so it isn’t surprising that BFRBs would tend to co-occur with Tourette’s as well.

A 2016 study took a closer look at the association between tic disorders, OCD, and BFRBs. They found that children with trich more closely resembled children with a tic disorder than those with OCD. Kids with tics and trich reported fewer symptoms of anxiety or depression and fewer internalizing, externalizing, or thinking problems than those with OCD.

BFRBs and Tourette’s share a number of other similarities including:

• Both involve repetitive behaviors that create some impairment or distress
• Both tic and BFRB behaviors have a tension/release component
• They share similarities in onset and progression

But just what do these similarities mean for the understanding of BFRBs? What can we learn from children with Tourette’s who also have a BFRB?  A recent study takes a closer look at the relationship between Tourette’s and BFRBs. It is one of the few studies to look at BFRBs exclusively in a pediatric Tourette’s sample. It is also thought to be the first study to include compulsive nail-biting in any Tourette’s sample. Their results suggest that there are similarities and connections that might play an important role in the way BFRBs are conceptualized and treated.

This distinction is particularly important. Much of the current research has been conducted using adult subjects. It is generally accepted that children are distinctly different from adults with respect to not only BFRBs but other disorders as well. This study uses a true pediatric sample and eliminates the need to extrapolate results from an adult sample.

What The Findings Revealed

The study included children who were diagnosed with Tourette’s. All were assessed for the presence of skin picking, nail-biting, or hair pulling. Of those who were found to have a BFRB, 52% had one BFRB. Two percent had two BFRBs. None had all three of the BFRBs being studied. Subjects were also screened for OCD and ADHD.

Tic severity was significantly associated with BFRBs. The more severe the tic severity, the more likely there was to be a BFRB present. Tic severity and the presence of skin picking were significant predictors of having a hair-pulling disorder and nail picking disorder. The presence of OCD or ADHD were not significant predictors of having a BFRB.

The greatest risk factor for having anyone BFRB was the presence of another BFRB, except for hair pulling. The relationship between skin picking and nail biting appears particularly strong. This finding suggests that skin picking and nail-biting may be more closely related to each other than to hair pulling. Together with their association with greater tic severity suggests that having Tourette’s may increase the risk of developing one or more BFRBs.

Implications

With the relationship between BFRBs and Tourette’s becoming clearer, it begs the question, “What can this mean for treatment?” We know that there are effective treatments for Tourette’s and several approaches for treating BFRBs. If they are as strongly related as they appear, are there opportunities for cross treatments to be effective? History and research seem to say yes.

Habit Reversal Training (HRT) commonly used to treat BFRBs was originally developed to treat tic disorders. HRT is considered a first-line treatment for BFRBs and enjoys some success. 

Another method of therapy used with people who have tic disorders called the cognitive–psychophysiological (CoPs) model has shown some promise for treating BFRBs. When compared to participants with a tic disorder, the participants in one study showed a greater reduction in symptoms than their counterparts with tics.

While there is still much to learn about just how BFRBs and Tourette’s Syndrome are related, it is becoming clear that there is indeed a connection. Continued research is revealing connections that may lead to more effective treatments. That research inspires hope for all.

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