# Case Report: Behavioral analysis guided intervention targeting triggers and urges in skin-picking disorder with comorbid onychophagia

## TL;DR

A man with skin-picking disorder and nail-biting saw significant improvement through a targeted behavioral therapy that focused on triggers and urges.

## Contribution

The study demonstrates a medication-free, personalized behavioral intervention guided by behavioral chain analysis for skin-picking disorder and onychophagia.

## Key findings

- Daily picking time decreased from 240 to 15 minutes after treatment.
- Urge intensity dropped by 60% following the intervention.
- The therapy combined stimulus control and urge management routines effectively.

## Abstract

Skin-picking disorder (SPD) often co-occurs with onychophagia and can cause substantial functional impairment. Although evidence-based psychotherapies are effective, benefits may be limited when behavioral analysis is not applied explicitly.

A 29-year-old man with SPD and onychophagia reported marked occupational impact. Baseline self-monitoring showed 240 min/day of nail-related behavior, 30 episodes/day, and high urge intensity. Using behavioral chain analysis, we mapped perceptual antecedents (visual/tactile irregularities) and diurnal variability of urges. A medication-free, nine-session outpatient program over 20 weeks was delivered, combining stimulus control, urge management routines, and habit reversal training. Outcomes were tracked by daily self-monitoring. Rapid improvement followed initiation of stimulus control and consolidated after urge management routines. By treatment end, daily picking time decreased to 15 min/day (-94%), episode frequency to 5/day (-83%), and urge intensity to 4/10 (-60%); no adverse effects were reported.

Making perceptual antecedents and diurnal moderators explicit based on chain analysis enabled a targeted, medication-free intervention that produced clinically meaningful reductions in behavior and urges. A chain-guided behavioral framework may help personalize treatment for SPD and related body-focused repetitive behaviors.