Nose Picking (Rhinotillexomania)

When compulsive skin picking takes on the form of nose-picking (rhinotillexomania), there is an increased risk of severe illness. Nose-picking behaviors can include using the fingers to pick at mucus and material inside the nasal cavity, or using the fingers or tools to remove hairs from inside the nose.

The Greek origins of the medical term for nose-picking (rhinotillexomania) can be translated as "nose" (rhino) plus "habitual picking" (tillexis) plus "rage, fury" (mania). Everybody picks his or her nose from time to time. According to the records inscribed on a papyrus scroll from ca. 1330 BC, the ancient Egyptian pharaoh Tutankhamen provided the food and lodging of his own personal nose picker. The imperial nose picker was paid three heads of cattle for his work, too.

How common is this? 

The exact prevalence of compulsive nose-picking is unknown. A study conducted in 1995 of the general population of Dane County, Wisconsin, found that out of 254 survey responses, 91% admitted to picking their nose and believed everyone does. Of those survey respondents, 1.2% picked their nose ever hour, and only 0.8% caused impairment. Two of the respondents experienced perforation of the nasal septum as a complication of rhinotillexomania. Another study of 200 adolescents reported that they pick their noses an average of four times per day. Therefore although most people do it sometimes, very few people do it to the point where it causes other physical consequences.

What causes it?

As with other body-focused repetitive behaviors, there is no known cause for the disorder, but there may be similar correlates for the behaviors.  

Bad habit or disorder?

Compulsive nose-picking may be classified as a bad habit, but when the behaviors become severe and cause damage, clinical attention is required. For compulsive nose-picking to be diagnosed as a mental health disorder, the following conditions must be met:

1. Behavior takes up a lot of time
2. Behavior results in repeated injury and infection
3. Multiple failed attempts to stop the behavior 
4. Negatively affects social, occupational, and relational life

Complications

Co-morbid Disorders

Nose-picking  does not always occur alone, and the following conditions are often associated with the behaviors

• Anxiety
• Obsessive-compulsive disorder
• Other body-focused repetitive behaviors such as skin-picking and hair-pulling

Physical Complications

Because of the use of fingers in the nose and nasal cavity, there are multiple physical complications noted in medical research:

• Upper respiratory infections
• Inflammation, pain, redness
• Increased sinus infections
• Nosebleeds
• Eating extracted contents can cause digestive issues
• Nasal septum perforation
• Acute hemorrhage of the nostril, nasal cavity or nasopharynx
• Risk of infections getting to the brain due to tissue damage in the nasal cavity

Impact on quality of life

First and foremost, nose-picking in public is not only very unattractive but also perceived as socially inappropriate. Therefore, people known to pick their nose compulsively may suffer from social alienation or choose to isolate themselves from others for fear of rejection.

For those who cannot control the behaviors, the psychological impact on the quality of life compounds the issues. Often, people believe they are weak, which leads to embarrassment, guilt, and shame. For those who experience physical complications due to nose-picking, the pain and outward appearance of infection or disease create personal discomfort and stigma from others. 

Finally, compulsive nose-picking can interfere with school or work. Since the behavior requires the hands either to engage with the nose directly or to use tools, it means a person’s attention is directed away from other activities. Further, if the behaviors are public, people may not want to work that individual.

What treatment options are available?

Treatment for disordered nose-picking depends on the level of impairment, the complications, and the type of behavior. Therefore, a full assessment can help determine treatment options. A medical assessment is important to determine the effects of complications while a psychological or mental health assessment can narrow behavioral treatments to an effective method. 

Treatment options include behavioral, pharmacological, and mechanical interventions.

Behavioral

Behavioral treatment helps people unlearn unhealthy habits and create healthier behaviors. Assessment is essential to determine a person’s picking habits and triggers. The first phase of treatment works on improving self-awareness about when picking occurs, how often, and what triggers it. Once a person has more awareness, a therapist can guide them through therapies such as cognitive-behavioral therapy or habit reversal training to create other things for the hands to do while resisting the urge to pick.

Pharmacological

There are no pharmacological treatments indicated for compulsive nose-picking. However, for people triggered by anxiety, stress, or depression, medication may alleviate those conditions, which may result in decreased picking.

Mechanical

Mechanical therapies create a barrier between the hands and the nose or help improve self-awareness. For example, keeping something like a fidget tool in the hands or wearing gloves will make it difficult to pick. Wearable devices such as the Keen from HabitAware increases awareness of picking behaviors by measuring the movements of the hands toward the face and alarming the wearer.

Nose-picking, although a common behavior when disorder can cause significant impairment, physically, emotionally, and socially. A thorough assessment can determine which treatment options will be appropriate. The good news is that some people grow out of the behaviors while others require treatment to manage them. Either way, recovery is possible and attainable.