Remember offices? Assuming that you do, and that you at some point worked in one, you’ve likely spent at least some time itemizing your colleagues’ annoying/conspicuous habits, or having your annoying/conspicuous habits itemized. Every ostensible workplace meeting is at the same time a showcase for a wide range of half-conscious behaviours including but not limited to foot-tapping, nail-biting, hair- and/or pen-twirling, etc. That anything ever managed to get with all those sneakers clacking on the linoleum and all those moist nail shards flying through the air remains a mystery of pre-virus life. But even without the presence of judgemental coworkers, there are reasons to want to quit these kinds of habits. For this week’s
Clinical Assistant Professor, Psychiatry and Behavioural Sciences, Stanford University, who researches the etiology and treatment of tic disorders, OCD and body-focused repetitive behaviours
Foot-tapping, nail-biting, and hair-twirling are among what we call body-focused repetitive behaviours. There’s certainly a spectrum: for some people these behaviours aren’t a big deal, and for others they might interfere with their lives or cause significant distress.
If these behaviours become problematic there is a standard approach many find effective, which stems from research beginning in the early 1970s and spanning the last 50 years. It’s a behavioural therapy technique called habit reversal training, which is a three step process.
The first step is to become more aware of when and where you’re engaging in the behaviour. I encourage people to create a kind of journal: when they catch themselves (or others catch them) engaging in the behaviour, they can note down where they were, what they were doing or thinking about, and any other factors associated with the situation. They should also note any other movements in a potential chain of behaviours that culminate in the problem (e.g., examining or rubbing fingernails, running hand through hair, searching or rubbing skin for “imperfections”, etc.). This provides people an opportunity to do some detective work but also tends to increase awareness of the behaviour itself. Maybe they are stressed out because they have a big test the next day, or a big proposal at work, and the hair-twirling or foot-tapping is serving as a kind of stress release. Or maybe they are more likely to do it when they are zoned out or bored.
Once you have a good idea of when and where it’s happening, you can change those variables in order to decrease the likelihood of the behaviour. If the behaviour is providing stress relief, I encourage people to seek out alternate practices — meditation, relaxed breathing, exercise, or whatever works for folks. If the behaviour functions to relieve boredom or restlessness it may be helpful for people to have items in their immediate environment to keep their hands busy, or they may need to break their day up in a way that prevents them from sitting for extended periods of time.
The second part of habit reversal training is to create a competing behaviour that interferes with your ability to twirl your hair, pick your skin, tap your foot, etc. For hair twirling, a common competing behaviour is folding one’s arms or clasping their fingers together as soon as they notice their hand creeping toward their hair, or if they catch themselves engaged in the twirling itself. We typically tell people to hold this competing behaviour for about a minute, or until the urge to engage in the problematic behaviour subsides.
The third part of habit reversal training is social support: you enlist the help of family or significant others or roommates to prompt you to use your replacement behaviour if they notice the body-focused repetitive behaviour. This is especially helpful for people who are less aware of when and where their problematic habits are occurring. If you decide to do this, be sure to have an agreed-upon method for prompting in order to minimise the likelihood of arguments.
Carol Mathews
Professor and Vice Chair for Strategic Development in the Department of Psychiatry and Director of the Centre for OCD, Anxiety and Related Disorders at the University of Florida
Habits are deliberate movements, but they’re done semi-consciously. You don’t say, ‘I’m going to bite my nails today’ — you do it automatically. At the same time, these behaviours are under your control. So the first thing to do is to bring them fully into consciousness.
It’s easy to say, once you’re aware of your habits, ‘I’ll just stop.’ But it’s very hard — often, you’ll just go back to doing them. What’s helpful in these cases is to put a kind of barrier in place. You can put bad-tasting nail polish or vinegar on your hands if you bite your fingernails, or, if you tap your feet, you can put taps on the bottom of your shoes; the taste and sound (respectively) bring the habit into consciousness.
The next step is to consciously focus on substituting these behaviours for a limited period of time. If you find you’re biting your nails in particular trigger situations — watching a movie, for example — you can consciously give your hands something else to do. I tell my patients who have nail-biting problems to learn to knit or crochet, because you can do that while watching television. If your issue is foot-tapping, you can try to cross your legs to make foot-tapping difficult.
If you’re in a setting where you can’t sit with your legs crossed, or can’t crochet, there are more subtle techniques. If you’re in a meeting, you can put your feet firmly on the ground and give yourself 60 seconds to just keep your feet there; or you can sit on your hands, or pick up a notepad. You can also make a conscious effort to say: ok, i’m not going to bite my nails or tap my foot for 60 seconds, and then give yourself permission to go back to it. But sometimes 60 seconds is plenty, and you don’t go back to it — you get busy doing something else.
These kinds of habits are distinguished from tics in the sense that you have control over them. It’s an active act to teach someone with a tic disorder to suppress their tics: we can use similar approaches, but a tic is a little bit more like a sneeze, where you may know it’s coming but you may not be able to stop it. You can learn techniques to identify when it’s coming in and either supporess or modify it, but it’s an involuntary behaviour.
Katharine Phillips
Professor, Psychiatry, NewYork-Presbyterian and Weill Cornell Medicine
Foot tapping, nail biting, hair twirling, and other similar behaviours are sometimes called body-focused repetitive behaviours. Many of these behaviours are simple habits that aren’t problematic and don’t need treatment. But when they are repetitive, difficult to stop, and cause significant distress or impairment in functioning, they rise to the level of a mental health disorder; in such cases, treatment with a professional is recommended and can be very helpful. Two of these problematic types of body-focused repetitive behaviours are classified as separate mental health conditions in the field’s diagnostic manual (DSM-5): trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder. In some cases, these disorders are severe — for example, they can cause extensive hair loss or serious skin infections.
Usually, the first-line treatment for problematic body focused-repetitive behaviours is a behavioural technique called habit reversal training. This treatment typically entails awareness training (via daily self-monitoring and identifying triggers of the unwanted behaviour), stimulus control (modifying or avoiding triggers), and engaging in a “competing response” (doing something else with your hands like squishing a koosh ball or clenching your fist). Some therapists add elements such as relaxation training or therapy to help you better manage difficult emotions. Habit reversal training can also be used for less-problematic body-focused repetitive behaviours, such as those that are simply annoying.
For more problematic behaviours, a natural supplement, NAC (N-Acetylcysteine), can decrease hair pulling, skin picking, and similar body-focused repetitive behaviours. I recommend Swanson brand and about a 3 month trial. NAC can be started at 600 mg per day and then gradually increased to as much as 1,200 mg twice a day or even 1,800 mg twice a day if needed. You should consult your doctor about taking it and get advice about dosing. If your symptoms cause significant distress or impairment in functioning, you could also try a serotonin-reuptake inhibitor (SRI) medication, such as fluoxetine (Prozac), sertraline (Zoloft), or escitalopram (Lexapro). These are widely used prescription medications that can be effective for problematic body-focused repetitive behaviours. Trying an SRI medication is especially appealing if you also have other symptoms or disorders that are likely to improve with an SRI (such as depression, obsessive-compulsive disorder, or body dysmorphic disorder). Another class of medications called atypical antipsychotics (but in reality they can effectively treat a very broad range of symptoms) can also be helpful, but they are usually reserved for more severe repetitive behaviours or when other symptoms are present that may benefit from them. As with all medications or supplements, a prescribing clinician should carefully weigh the pros and cons of each option for each individual.
Clinical psychologist with extensive experience treating OCD in children, teens, and adults in inpatient and outpatient settings
Though one might consider foot tapping, hair twirling, and nail biting as “nervous habits,” they may not have the same origin nor solution. It is likely that each of these behaviours would be worsened by stress and therefore good stress management techniques would be the first logical intervention. Stress management includes things like yoga and relaxation, breathing exercises and mindfulness, but can also include positive social interactions, adequate sleep, a healthy diet, and regular exercise.
While foot tapping may be driven by anxiety, in some instances it can be a medication side effect or caused by a medical/neurological condition such as restless leg syndrome or dementia. A psychologist would be able to help you identify when the tapping occurs and suggest possible techniques to stop the habit.
Hair twirling often proceeds hair pulling in those with Trichotillomania and treatment for that is very specific. For ‘garden variety’ hair twirling one could try finding something else to keep the hands occupied or even temporarily use an obstacle (baseball cap) to make the habit more conscious and breakable.
Nail biting is considered a body focused repetitive behaviour and is often driven by perfectionism. In these instances, the nail appears or feels not perfect and the biting is an effort to fix the flaw. Cognitive-behavioural therapy that addresses the thinking errors and the compulsion is necessary to address nail biting.
Each of these observable behaviours could also be symptomatic of a motor tic. Genetic predisposition or vulnerability is often found in those with tics (someone else in the family also tics). People with tics often report an urge or feeling prior to the movement but can learn a competing response.
With each of these behaviours, increased awareness is the first step and finding an alternative behaviour is a reasonable thing to try. Avoiding triggers can help and adding relaxation is strongly suggested. A self-reflective cost-benefit analysis of the behaviour can help with motivation to change. Setting small reasonable, obtainable goals is essential for any behaviour change plan and supportive others can be a real bonus.
Seeing a mental health professional with a strong background in applied behavioural analysis and cognitive-behavioural therapy can help clarify the problem and get you on your way to a solution!
Sara O’Brien
Associate Professor, Psychology, Knox College, whose primary research interests include the assessment, classification, and diagnosis of mood and anxiety disorders
Research suggests that rewarding ourselves for a behaviour increases the likelihood of that behaviour happening again. Think of a small way to reward yourself for each time you don’t engage in the habit you are trying to break — if you like M&M’s as much as I do perhaps you grab a handful of them each time you don’t twirl your hair during the meeting. Over time, you’ll be less likely to twirl your hair, further breaking that automatic connection.
It’s also important to note that while habits like these are very common and usually harmless, there are severe forms that result in serious physical, psychological and social consequences. Trichotillomania (hair-pulling disorder) and excoriation (skin-picking disorder), for example, are clinical diagnoses that should be treated by a professional with relevant experience, as there are effective treatments based on many of the principles described above.
Finally, what triggers these behaviours in the first place? Both everyday and more severe expressions can be brought about by internal thoughts or emotions (e.g., anxiety, excitement, anger, boredom) and/or external circumstances (e.g., specific people, places, or situations). Self-monitoring can help you identify what the triggers are so you can address them. If you find that you are twirling your hair during the meeting because the meeting stresses you out, it might be important to not only work on reducing hair twirling but also tackle the cause of the stress.
Margo Thienemann
Clinical Professor, Psychiatry and Behavioural Sciences, Stanford University
You might tap/jitter your foot because of anxiety or impatience; for someone with trouble focusing, it could be a way to help tune out other distractions. The fact that it may annoy others would be the reason to stop; in itself that could be motivating enough and effective. But if foot tapping/bouncing helps you focus, and you are not bothering anyone, maybe you don’t need to stop.
If you tap your foot when you’re anxious or impatient, try to think of why you might be feeling that way and whether or not those feelings are rational. (What is coming up? How important is it? How time-sensitive is it? What can you control about it? What about it is outside your control? What are possible outcomes?) Once you’ve put it into perspective, you could practice some mindfulness meditation, or distract yourself from the thing that is bothering you, rather than tap your foot.
Biting nails is similar. It is not a good idea from any point of view: it’s not socially acceptable, it’s not an effective way of grooming, it can cause harm to nails and cuticles, and it puts one at an increased risk of getting sick (especially now, with COVID-19). If it’s a habit, then work to break it. For nail biting and some other repetitive body-focused disorders, treatment guidelines, resources and support are available at the Trichotillomania Learning Centre/TLC Foundation for Body-Focused Disorders.
I suppose that twirling the hair as a “one-off” could be like foot-tapping too — it might annoy others to be around. If it is a habit, causes hair to break or come out, then I recommend the above website.
Tics are common and usually transient, typically occurring in school-age children and more commonly in boys. If they last more than a month, then a visit is warranted to the healthcare provider for evaluation, as well as to identify possible other troubles that can come with tics, such as ADHD, OCD, handwriting difficulties. If, in children, tics start very suddenly, at the same other severe emotional symptoms, sleep trouble, bedwetting or frequent urination, they may be part of a syndrome called Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection (PANDAS) or Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). If this occurs, it is important to go to one’s healthcare provider for a diagnostic evaluation, treatment of a triggering infection if found, and other support.
Do you have a burning question for Giz Asks? Email us at tipbox@gizmodo.com.