Onychotillomania (nail picking)
En español: lee sobre esta manía en Fobias.org.
It might start with a rough edge or a lifted bit of cuticle that you just have to smooth out, and before you know it your fingers are sore. The relief does not last, and you are left with damaged nails you would rather keep out of sight.
What it is
Onychotillomania is the clinical name for repeated picking, tearing or pulling at the nails, the cuticles and the skin around the nails, to the point where it causes damage and is hard to stop. It is a body-focused repetitive behaviour, part of the same family as hair pulling and skin picking. It is not listed as a diagnosis of its own in the DSM-5, but it can be diagnosed under other specified obsessive-compulsive and related disorders, and it is often compared most closely with skin picking disorder. It is different from nail biting (onychophagia), which uses the teeth rather than the fingers, although some people do both.
Very little research has been done on nail picking, so nobody knows exactly how common it is, and it is thought to be underreported. One study of medical students found it in just under 1 in 100, while nail biting was far more common in the same group, and the few people studied had usually started in childhood. It can sit alongside anxiety, low mood and other repetitive habits such as nail biting or skin picking. Because people often feel embarrassed and hide their hands, many never mention it to a doctor.
How it differs from a phobia
A phobia is driven by fear and makes you want to avoid something. Nail picking works the other way round: a rough edge, a lifted cuticle or a build-up of tension pulls you towards picking, and doing it brings a brief sense of relief or satisfaction. That relief soon gives way to sore fingers, regret and a wish to hide your hands, which can add more stress and start the cycle again. The struggle is with an urge to do something, not a fear of something.
Read more about manias and phobias
Common signs
- Short, uneven or misshapen nails
- Red, swollen or sore cuticles and nail folds
- Ridges or grooves across the nails, often the thumbs
- Torn skin or small scabs around the nails
- Picking at nails without noticing until afterwards
- Running fingers over nails checking for rough edges
- Hiding hands in pockets, sleeves or gloves
- Picking more when stressed, bored or tired
When it tends to show up
- Feeling a rough or jagged nail edge
- A nail that looks longer or different
- A lifted or dry cuticle
- Boredom or sitting with idle hands
- Reading, watching TV or scrolling
- Feeling stressed, anxious or tense
- Waiting, such as in queues or on calls
- Feeling frustrated, ashamed or low
Symptoms
In your body
- Sore, tender or bleeding nail folds
- Thin, ridged or damaged nails
- Loss of the cuticle on some fingers
- A build-up of tension before picking
- A feeling of release straight after
In your mind
- A strong urge to smooth or even up a nail
- Feeling unable to stop once started
- Shame or embarrassment about how your hands look
- Worry that others will notice
- Frustration with yourself for not stopping
What you might do
- Picking or tearing at nails and cuticles repeatedly
- Trying to stop but going back to it
- Checking nails for anything that feels uneven
- Picking mainly in private or on autopilot
- Hiding hands or avoiding handshakes
- Avoiding things that show your hands
What causes it
The causes of nail picking are not well understood, partly because it has been studied so much less than hair pulling or skin picking. Body-focused repetitive behaviours seem to come from a mix of genetic, brain-based and environmental factors, and they are more common in close family members of people who have them. For many people, picking helps to settle strong feelings such as stress, anxiety or boredom, or eases an uncomfortable sensation, such as a nail that feels rough or uneven. The habit can then keep itself going, because each episode leaves new rough edges and damaged skin that invite more picking. It is not a lack of willpower.
How it can affect your life
Repeated picking can leave nails thin, ridged or misshapen, and in some people the damage to the nail can become permanent. Broken skin around the nails can let in infection, including painful infections of the nail fold. Many people feel self-conscious about their hands and avoid handshakes, manicures or anything that puts their fingers on show. Over time it can wear down confidence and add to stress, low mood or anxiety, and it can get in the way of work, study and relationships.
Treatment
There have been no large trials of treatment for nail picking, so advice is based on what helps other body-focused repetitive behaviours and on smaller reports. The main talking therapy is cognitive behavioural therapy (CBT), usually including habit reversal training, which helps you spot your triggers and early warning signs and swap picking for a less harmful action until the urge passes. Simple barriers such as plasters or dressings can protect the nails while they heal and make picking harder. A doctor may discuss medication in some cases, particularly if anxiety or low mood are also present, and a skin specialist may help if the nails are badly damaged. In the UK, your GP is the usual first step.
Things that can help day to day
- Note when and where you tend to pick so you can plan ahead
- Keep nails short and smooth so there are fewer edges to catch
- Keep your hands busy with a stress ball or fidget toy
- Cover your nails with plasters at your riskiest times
- Moisturise your hands and cuticles when the urge appears
- Ask someone you trust to gently let you know when you start
When to get help
It is time to see your GP if you cannot stop picking, if your nails are becoming damaged or misshapen, or if it is affecting your mood or daily life. If the skin around a nail becomes red, swollen, warm, painful or starts to collect pus, see a GP or pharmacist, as this can be a sign of infection. The TLC Foundation for Body-Focused Repetitive Behaviors (bfrb.org) has information on nail picking and online support groups. If you are also feeling very low, talk to your GP or call Samaritans free on 116 123.
How I can help
When I work with someone who picks at their nails, over Zoom, I use hypnotherapy and NLP alongside, not instead of, CBT and habit reversal training. Together we look closely at the moments just before the urge, such as the feel of a rough edge or a spike of tension, because so much nail picking happens on autopilot. In hypnosis we work on calming that tension and rehearsing a different response, so your hands and your attention have somewhere else to go. Many clients find that working on it in a calm, judgement-free space helps the urge feel less in charge.
Common questions
What is the difference between nail picking and nail biting?
Nail biting (onychophagia) means biting the nails with your teeth, and it is very common. Nail picking (onychotillomania) means picking, tearing or pulling at the nails and the skin around them with your fingers. They are related habits and some people do both.
Is nail picking a form of self-harm?
Usually not. Nail picking is generally a way of easing tension or a habit that runs on autopilot, and any damage is not the aim. Specialists in body-focused repetitive behaviours say these habits should not be treated as self-harm.
Will my nails grow back normally?
Often nails recover once picking stops, although fingernails take several months to grow out. With long-term picking some damage can be permanent, so it is worth getting help early and asking your GP to check any nail that has changed shape or colour.
My child picks their nails. What should I do?
A GP is the right first step for a child, especially if the nails or skin are sore, damaged or look infected. Try to stay calm and avoid telling them off, as shame tends to make the urge stronger rather than weaker.
Further reading: Lee and Lipner (2022): Update on diagnosis and management of onychophagia and onychotillomania, IJERPH · DermNet: Habit tic deformity · The TLC Foundation for BFRBs: Nail picking · The TLC Foundation for BFRBs: Learn about BFRBs · NHS: Nail problems
Ready to start?
Book a 30-minute consultation call over Zoom and we can talk it through, with no obligation to book anything afterwards. Use the code PHOBIA when you pay and the call is half price: £24.50 instead of £49.