When Mia was 14, she lastly typed the query she’d been too scared to ask: “Why can’t I cease pulling my hair?”
The web gave her a phrase she had by no means heard earlier than: trichotillomania, which is a body-focused repetitive behaviour (BFRB). An NHS web page described it as a “behavior”, nevertheless it didn’t really feel like one to Mia. It felt like one thing deeper, heavier and typically utterly exterior her consciousness. When she constructed up the braveness to talk to her college counsellor, they frowned and stated, “I don’t know what that’s, however perhaps attempt a stress ball?” This story is fictional however primarily based on the lived realities of many with trichotillomania (hair-pulling dysfunction).
Trichotillomania (TTM) and skin-picking dysfunction (SPD) will not be uncommon, but they continue to be misunderstood, minimised, or dismissed as “dangerous habits” (Mackay, 2023). Individuals normally describe two totally different experiences of pulling or selecting:
- centered episodes, a deliberate, acutely aware behaviour and
- computerized episodes, when it occurs with out them noticing, nearly like being on autopilot (Grant & Chamberlain, 2021).
Researchers are starting to discover what drives these behaviours.
One space of focus is early maladaptive schemas (EMSs). Schemas are made up of recollections, feelings and beliefs about ourselves and different individuals. EMSs develop when vital wants will not be met in childhood and may change into highly effective inner messages that affect how we handle troublesome emotions (Bishop et al., 2021; Ke & Barlas, 2018). EMSs have been linked to increased symptom severity in a number of psychological well being circumstances (Dostal and Pilkington, 2023), however we don’t know if these identical patterns are additionally related for TTM or SPD.
That is explored by Flagstad and colleagues (2025), who examine the connection between EMSs and symptom severity and pulling/selecting types in TTM and SPD, in addition to how this compares to obsessive compulsive dysfunction (OCD).
Hair-pulling and skin-picking issues have an effect on 2-4% of the inhabitants, but are under-researched, under-recognised and under-treated.
Strategies
This was a cross-sectional research utilizing baseline (pre-treatment) information from 283 treatment-seeking adults in Norway with a prognosis of TTM (n = 120), SPD (n = 75) or OCD (n = 88), the vast majority of whom have been girls (84.76%). There have been some vital variations between the teams, together with age, intercourse, employment standing. The researchers additionally famous that not all comorbidities have been totally assessed or obtainable, which restricted how a lot they might alter for these variations within the analyses.
EMSs was measured by the Younger Schema Questionnaire–Quick Type, alongside validated self-report measures of pulling/selecting severity and subtypes (computerized and centered). Clinicians additionally accomplished a ranking of total sickness severity utilizing the Scientific International Impression Severity scale (CGI-S) for the TTM and SPD teams.
The authors then used ANCOVA to check schema scores between teams (controlling for age and sickness period) and correlational analyses to discover relationships between schemas and symptom severity or pulling/selecting model.
Outcomes
No group variations in schema ranges
- Throughout TTM, SPD and OCD, there have been no vital variations in EMSs, with all three teams exhibiting equally elevated ranges.
- This means that elevated ranges of EMSs are transdiagnostic and never particular to at least one dysfunction.
- The OCD group didn’t present increased or decrease schema ranges than the TTM or SPD teams, despite the fact that some variations had been anticipated primarily based on earlier analysis.
Schemas have been linked with symptom severity
- There have been small to reasonable associations between EMSs and pulling or selecting severity.
- For TTM, increased scores on a number of schemas (together with failure and social isolation) have been linked with extra extreme pulling on self-report and clinician scores. Which means individuals who endorsed beliefs like “I’m not adequate,” tended to expertise extra intense or distressing pulling urges.
- For SPD, the sample was weaker however nonetheless current: schemas corresponding to disgrace and abandonment have been related to higher selecting severity. This means that individuals who maintain these beliefs additionally are likely to report extra extreme selecting, though the research can not clarify why these patterns happen.
Targeted pulling/selecting confirmed the strongest hyperlinks to schemas
- Schemas have been extra strongly related to centered pulling and selecting; the kind of behaviours individuals do deliberately or in response to emotional states.
- In TTM, centered pulling was considerably associated to 9 totally different schemas, whereas computerized pulling confirmed nearly no significant associations.
- The same sample appeared in SPD: centered selecting was linked to schemas corresponding to abandonment and distrust, however computerized selecting was not.
- Which means focused-driven pulling and selecting appears to be extra tied to individuals’s underlying beliefs, whereas computerized behaviours confirmed no such sample on this research.
People who’s pulling and selecting behaviours tended to be pushed by their feelings had increased ranges of early maladaptive schemas.
Conclusion
The authors conclude that EMSs (early maladaptive schemas) are frequent throughout Hair Pulling (Trichotillomania – TTM), Pores and skin-Choosing Dysfunction (SPD) and Obsessive Compulsive Dysfunction (OCD), supporting their transdiagnostic relevance.
In addition they recommend that schemas might deepen our understanding of why some individuals pull or decide in additional emotionally-driven, centered methods. They argue that assessing schemas in medical settings might assist clinicians develop a fuller image of sufferers’ experiences, together with underlying behavioural drivers, which can assist the tailoring of interventions.
This research supplies preliminary proof to recommend that early maladaptive schemas are frequent throughout hair-pulling, skin-picking and OCD, supporting their function as a shared, transdiagnostic characteristic of those circumstances.
Strengths and limitations
This research makes a worthwhile contribution to an space the place high-quality analysis is scarce. It attracts on one of many largest medical samples of TTM and SPD up to now, and it contains an OCD comparability group. That is helpful as a result of bigger samples enable extra correct estimates of schema patterns, and the OCD group supplies a significant benchmark for testing whether or not these patterns are shared throughout issues. The researchers used validated and broadly recognised measures, and their statistical method was cautious, with applicable checks for normality and changes for a number of comparisons. This helps improve our belief that the findings they reported are actual, quite than ensuing from likelihood or poor measurement.
Nonetheless, there are a number of limitations. One vital methodological omission is the absence of an influence calculation. Though the general pattern seems massive, with out realizing whether or not the research was adequately powered, we can’t be certain whether or not the similarities between teams replicate real psychological overlap or the bounds of the pattern measurement and analytical design.
The research was additionally cross-sectional, which means all information have been collected at a single time level. This makes it inconceivable to find out causality: we can not know whether or not sure schemas contribute to extra extreme pulling and selecting, or whether or not years of battling a BFRB form how individuals see themselves and others. Longitudinal designs are wanted to know directionality.
An extra limitation is the dearth of gender variety within the pattern, with most contributors being girls. Inhabitants research present that these circumstances have an effect on individuals of all genders (Grant et al., 2020), so the underrepresentation of males on this research limits the generalisability of those findings.
The dealing with of lacking information introduces additional uncertainty. Virtually a 3rd of the unique pattern didn’t full the schema questionnaire and there was a variety of lacking details about melancholy and anxiousness. Due to this, the researchers couldn’t alter for these circumstances of their predominant analyses. This issues as a result of the teams differed of their charges of melancholy, so a number of the “no distinction” findings might replicate unmeasured comorbidities quite than true similarity.
Lastly, some clinically vital experiences weren’t captured. For instance, many people describe “trance-like” pulling or selecting (Mayerson et al., 2025), which doesn’t map neatly onto the centered versus computerized distinction used within the research. It stays unclear how these dissociative or absorbed states relate to schemas, and this hole limits the research’s potential to totally characterize the lived expertise of TTM and SPD.
Many people who hair-pull or skin-pick describe being in a “trance”, getting into an altered state of consciousness that makes the behaviour really feel all-consuming. This kind of expertise was not accounted for throughout the research.
Implications for follow
This research gives an vital reminder that circumstances like TTM and SPD will not be merely “dangerous habits”. The associations between centered pulling or selecting and deeper perception patterns recommend that individuals could also be utilizing these behaviours to handle intense feelings, disgrace or fears of abandonment. For clinicians, this implies going past floor behaviours and asking what the pulling or selecting does for the particular person in moments of misery. Schema-informed formulations might assist individuals perceive why urges really feel overwhelming at sure occasions, why they fluctuate and why behavioural expertise alone are typically not sufficient (Haaland et al., 2011).
Many individuals, like Mia within the opening story, nonetheless encounter professionals who’ve by no means heard of those issues. Bettering primary data on the stage of colleges, GPs, and frontline psychological well being employees may scale back disgrace and velocity up entry to specialist care. For providers, the research indicators the significance of assessing comorbidities corresponding to melancholy and anxiousness, which can work together with schemas and form the expertise of pulling and selecting. As a result of the research couldn’t alter for these because of lacking information, future medical work ought to routinely display screen for and deal with them.
For researchers, these findings increase new questions:
- Do schema-focused interventions enhance outcomes when added to behavioural remedies like Behavior Reversal Remedy?
- How do trance-like or dissociative pulling episodes match into this image? and
- Might schemas assist clarify why some individuals transfer between computerized and centered pulling throughout their lives?
Bettering primary data of hair-pulling and skin-picking in faculties, major care, and frontline psychological well being care is a crucial first step to start lowering the disgrace related to body-focused repetitive behaviours, and velocity up entry to help.
Assertion of pursuits
Laura Lee – None.
Edited by
Dr Nina Higson-Sweeney.
Hyperlinks
Major paper
Ella Flagstad, Benjamin Hummelen, Erna Moen, Toril Dammen, Åshild Haaland, Tor Sunde, Bjarne Hansen, Diana Strand Johnsen, Douglas Woods, Torun Grøtte (2025). Early maladaptive schemas in trichotillomania and skin-picking dysfunction: Their relationships with symptom severity and subtypes. BMC Psychology, 13, 789. https://doi.org/10.1186/s40359-025-03096-y
Different references
Bishop, A., Younan, R., Low, J., & Pilkington, P. D. (2022). Early maladaptive schemas and melancholy in maturity: A scientific evaluation and meta‐evaluation. Scientific Psychology & Psychotherapy, 29(1), 111-130. https://doi.org/10.1002/cpp.2630
Grant, J. E., & Chamberlain, S. R. (2021). Automated and centered hair pulling in trichotillomania: Legitimate and helpful subtypes? Psychiatry Analysis, 306, 114269. https://doi.org/10.1016/j.psychres.2021.114269
Grant, J. E., Dougherty, D. D., & Chamberlain, S. R. (2020). Prevalence, gender correlates, and co-morbidity of trichotillomania. Psychiatry Analysis, 288, 112948. https://doi.org/10.1016/j.psychres.2020.112948
Haaland, A. T., Vogel, P. A., Launes, G., Haaland, V. Ø., Hansen, B., Solem, S., & Himle, J. A. (2011). The function of early maladaptive schemas in predicting publicity and response prevention consequence for obsessive-compulsive dysfunction. Behaviour Analysis and Remedy, 49(11), 781–788. https://doi.org/10.1016/j.brat.2011.08.007
Ke, T., & Barlas, J. (2020). Enthusiastic about feeling: Utilizing trait emotional intelligence in understanding the associations between early maladaptive schemas and coping types. Psychology and Psychotherapy: Concept, Analysis and Follow, 93(1), 1-20. https://doi.org/10.1111/papt.12202
Mackay, C. E. (2023). Trichotillomania: a perspective synthesised from neuroscience and lived expertise. BMJ Psychological Well being, 26(1). https://doi.org/10.1136/bmjment-2023-300795
Mayerson, T. F., Waite, P., & Mackay, C. (2025). The mediating function of disgrace within the relationship between adolescent hairpulling and co-occurring anxiousness and depressive symptomology. JCPP Advances, e70041. https://doi.org/10.1002/jcv2.70041
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