Self-Injury Of The Nails And Hands
Shelley A. Sekula ¹
Dermatology Online Journal 6(1):assembly

Abstract

Patients who pull out their hair, excoriate, scar, bite, pick and harm their own skin often present to the dermatologist rather than the psychiatrist. It is estimated that up to 30% of all dermatology patients have a neuro-psychiatric disorder that may contribute to their skin disease. Dermatologists should become acquainted with common psychiatric diagnoses such as depression, anxiety, obsessive-compulsive disorder, monosymptomatic hypochondriacal psychosis, Tourette syndrome, etc. Emphasis is on clinical office diagnosis, treatment, both pharmacological and behavioral, and when and how to refer. New treatment modalities, such as SSRI¹s and atypical antidepressants, may allow dermatologists to offer medical intervention without the need to seek the often-unobtainable psychiatric referral.

Self-injury to the fingers and hands is both conscious and sub-conscious. Thumb sucking is nearly ubiquitous in infants but is abandoned by most children by the age of six. When prolonged it can lead to nail and dental deformity. Onychophagia or nail biting is practiced in up to 50% of children, peaking between the ages of 10 and 18 years.[1 ]Other forms of self-injury to the nail include picking at nail plates, cuticles, and nail folds, onychotillomania or tearing the nail plate and pulling it out, and tapping the tops of the fingernail plates with the index fingers. This tapping may cause a midline longitudinal canal in a "Christmas tree" pattern known as median nail dystrophy, dystrophia unguis mediana canaliformis, or solenonychia.

Classification

Classification of negative, self-injurious behavior depends on the severity of the damage perpetrated on the body, the underlying psychopathology, and the amount of distress or gain provoked by the action. Categories that can explain self-injury are 1) habit, 2) tic, 3) obsessive-compulsive disorder, 4) masked depression, 5) impulse disorder, 6) psychosis, 7) dementia, 8) autism, 9) attention getting (secondary gain) behavior, etc.

Questions that may be helpful in elucidating the cause of the self-injury are:

Depression And Bipolar Questions

• Are you tearful, sad (dysphoric), or suicidal?
• Do you have trouble sleeping? Trouble thinking?
• Are you eating too much or too little?
• Have you lost the zest for living (anhedonia)?
• Have you lost interest in sex?
• Are you agitated or restless or do you feel sedated and subdued?
• Does depression run in the family?
• Do you ever feel you could run the world?
• Do you spend recklessly or deplete your finances on investments that others say are bad risks?
• Stay up all night thinking or planning projects that others feels are futile?

Obsessive-Compulsive Questions

• How long can you avoid the undesired activity?
• How long have you been trying to stop?
• What methods have you tried?
• Does this activity (the biting, picking, etc.) interfere with daily functioning?
• How much time a day do you spend on the activity?
• Will you become anxious unless you perform your action?
• Do you have other habits that you do not wish to continue or that embarrass you?
• Do you count, arrange, or organize excessively?
• Do you have trouble finishing a task or working with others because of perfectionistic tendencies?
• Do you have intrusive unwanted thoughts, fears, or obsessions?
• Do you have panic attacks?
• Do any of these behaviors run in your family?
• Is anyone else affected by your behavior? Any benefit gained?
• Do you have uncontrollable facial or body movements (motor tics) or make unintentional sounds or words (vocal tics)?

Dementia And Psychosis Questions

• Do you know your name, where you are, the day, date, and time?
• Can you repeat numbers backwards and forwards?
• Do you hear voices that no one else can hear, telling you to do things?
• Do you see things that no one else can see?
• Do you feel people are "out to get you"?
• Do you feel slowed down and subdued or speeded up and agitated?

For example, a woman who bites her nails to the point of bleeding and is unable to stop inspite of embarrassment and criticism from fellow employees has more that a habit. If she has mid-sleep insomnia, loss of appetite, and finds no fun in life, she probably suffers from depression. If she also has fears of her family dying because she did not turn off the stove or she washes her hands thirty times a day, she has OCD and depression.

Greist et al[2], have developed a checklist as another helpful way of determining if your patient has OCD. It can be completed by the patient while the doctor steps out of the room or with the doctor present. Score as follows:

Obsessive-Compulsive Checklist

A score above 10 suggests the possibility of OCD. A score above 20 supports the diagnosis of OCD more strongly.

Treatment of self-injury of the nails and hands parallels treatment of self-injury in other parts of the body. In a young child ignoring the behavior and allowing time to pass may be all that is necessary for the unwanted habit to disappear. Power struggles should be avoided. Most childhood thumb suckers and nail biters become normal adults inspite of parental anxiety over maligned teeth and unkempt fingernails. If the activity becomes problematic at school or the self-induced trauma is more serious direct intervention may be necessary.

• Reinforce and motivate - praise and point out progress and reward.
• Teach proper care of nails (skin, hair, etc.) - allow nail polish, even artificial nails can help reduce the urge to pick.
• Hypnosis
• Substitution - many people bite or pick when they are tired or bored. Hold, squeeze, or rub a small object instead of the self-destructive activity. Squeeze the arm of a chair or pinch the web space between the thumb and forefinger.
• Response prevention - if the child bites nails in front of the TV reward with more TV time if he /she does not bite the nails.
• Teach awareness - Point out good looking nails and pretty hands.
• Avoidance training - Have the patient perform the activity in front of a mirror. This often triggers revulsion and avoidance of the behavior. This will not work if the mirror is already incorporated into the ritual as in acne excoriée des jeunes filles.
• Relaxation therapy - relax the hands, mouth and jaw, practice yoga, exercise.

Medical intervention may be warranted If talk therapy and behavior modifications are not enough. Medications can help reduce the core symptoms of a psychocutaneous disorder.

Obsessive-compulsive self-mutilating behavior will often require treatment with a seratonin reuptake inhibitor (SSRI), such as paroxetine (Paxil), sertraline [SAS1] (Zoloft), fluvoxamine (Luvox), fluoxetine, or citalopram (Celexa)[3]. The second-generation tricyclic, clomipramine (Anafranil), also has serotonin uptake blocking ability and has a beneficial effect on OCD symptoms.[4] Paroxetine and venlafaxine (Effexor) not only raise the serotonin levels but also have been found to raise norepinepherine levels.

Depressed patients often respond within 1 to 3 weeks to the newer somewhat safer SSRIs. They have less anticholinergic effects than tricyclics but can cause weakness, nausea, diarrhea, somnolence, and abnormal ejaculation. Nonresponders may benefit from the atypical non-tricyclic, non-monoamine oxidase inhibitor antidepressants such as trazodone (Desyrel) which has caused priapism, bupropion (Wellbutrin) which lowers seizure threshold, or nefazodone (Serzone) which has some anticholinergic and gastrointestinal side effects. The older tricyclics theoretically work by potentiating central adrenergic tone by blocking uptake of norepinepherine at the nerve terminal. Nortriptyline (Pamelor), amitriptyline (Elavil), imipramine (Tofranil), are useful but have more anticholinergic effects, may cause cardiac arrhythmias and conduction delays, so a pre and post-treatment ECG may be useful. Overdose may cause death and is a sobering concern.

Monoamine oxidase inhibitors (Nardil and Parnate) can cause hypertensive crisis, interact with numerous other drugs, aged cheeses, preserved foods, and wines. They are rarely used.

Anxiety disorders may respond to anxiolytics such as buspirone (Buspar) or small doses of benzodiazepines such as, clonazepam (Klonopin), alprazolam (Xanax) or lorazepam (Ativan). Long term use of benzodiazepines has been associated with withdrawal symptoms such as dysphoria, insomnia, muscle cramps, sweats, and seizures.

Tic disorders, such as Tourette syndrome, may respond to alpha-adrenergic stimulants that have the effect of lowering adrenergic tone centrally. They are marketed as antihypertensives. Both clonidine (Catapres) and guanfacine (Tenex) have proven beneficial in treating poor impulse control associated with Tourette syndrome, as well as ADHD and other conditions.[5,6] Clonidine, short acting and dosed three to four times a day or by way of the transdermal patch, is better for hyperactivity while guanfacine, less potent but longer acting and dosed two times a day, is better for the attention deficit[7].

Nonresponders, especially those with severe symptomatology and features of psychosis, may require small doses of neuroleptics, such as haloperidol (Haldol), pimozide (Orap).[8] The newer antipsychotics, risperidone (Risperdal) and olanzapine (Zyprexa), produce improvement in positive symptoms -hallucinations, delusions, incoherence, and catatonia; as well as the traditionally more difficult to treat negative symptoms-lack of emotion, paucity of speech, impoverished thought, apathy, and anhedonia.[9] These drugs appear to block dopamine (D2) and serotonin (5HT2) receptors. Olanzapine also blocks histamine receptors and may directly reduce itch. They produce less pseudoparkinsonism than older antipsychotics and may carry less risk of tardive dyskinesia. Neuroleptic malignant syndrome, prolonged QT interval with potential for torsades de pointes, and an asymptomatic increase in prolactin are features shared with older neuroleptics. Clozapine (Clozaril) another new antipsychotic blocks D1-5 receptors as well as adrenergic, cholinergic, histaminergic, and serotonergic receptors. Laboratory evidence suggests that clozapine is more active in the limbic system than in the striatal dopamine which may explain its relative freedom from extrapyramidal side effects. Nevertheless, clozapine is reserved for refractory situations because it has been associated with a .004% rate of agranulocytosis, many of which are fatal, orthostatic hypotension, and 5% yearly incidence of seizures.[10]

Summary

As the primary care specialists of the skin dermatologists should be able to diagnosis and treat self-injury to the skin in its simpler forms. This can be made easier by utilizing simple questionnaires and a short mental status exam examination. Since referral to a psychiatrist has become more difficult in the age of managed care it behooves the dermatologist to learn one or two drugs from each class of psychotropic medication and to utilize them appropriately. The new SSRIs have less risk of anticholinergic, convulsive, and cardiac side effects, as well as less danger of overdose. The new antipsychotics also appear to be easier to use safely. With a little effort dermatologists can familiarize themselves with these useful medications thereby assisting their patients in stopping undesired behaviors.

References