Trichotillomania Study Reveals Boredom May Predict Hair Pulling

Trichotillomania – pulling out hair from the scalp, eyebrows, eyelashes or other areas – is far from a newly recognised condition.

Historical records suggest its first written references occur in Hippocrates' Epidemics III, dating to 410 BCE. In about 350 BCE, Aristotle discussed vices in the Nicomachean Ethics, referring to "the habit of plucking out the hair or of gnawing the nails."

Also known as hair-pulling disorder, trichotillomania is categorised as a body-focused repetitive behaviour. It can result in hair loss as well as considerable psychological or social impairment.

In the US, it affects 1–2 percent of people, occurs equally across both genders, and frequently coexists with other mental health conditions, including anxiety, depression, PTSD, OCD and ADHD.

Trichotillomania, urges and emotional regulation

A widely held account of trichotillomania centres on emotional regulation: hair pulling may help people manage difficult emotions, such as anxiety, tension or frustration, and bring relief once the action is complete.

Yet earlier studies have offered mixed support for this emotional-regulation explanation, since people may pull their hair while distracted or without recognising that they are doing so.

To better understand events as they unfold, a team at Heidelberg University Hospital monitored 61 adults with trichotillomania over 10 days.

"The majority of existing studies focus predominantly on the behavior, neglecting the urge and underlying factors that may influence it," the researchers write in their new study, published in Comprehensive Psychiatry.

The team therefore aimed to learn more about the urge itself and what follows from it.

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How the 10-day trichotillomania study tracked behaviour

Instead of asking participants to look back over their day in an evening journal entry – a standard method for gathering this type of information – the researchers used ecological momentary assessment.

This method asks people to log their emotions and behaviour at the time, rather than trying to remember feelings they experienced hours previously.

Participants received seven prompts daily from 8 am to 10 pm. Each asked them to report their current emotional state, the intensity of their urge to pull, and whether they had pulled their hair since the last assessment. They were also able to record hair-pulling episodes as they occurred.

The resulting dataset contained 2,557 momentary assessments and 702 hair-pulling episodes for analysis.

People reporting more intense urges were considerably more likely to report a hair-pulling episode in that same assessment. An intense urge in one assessment also forecast pulling at the next one.

Earlier hair-pulling episodes similarly increased the likelihood of another episode, indicating that the behaviour can persist during the course of a day.

Emotional states, however, were far less predictive than urges.

Negative emotions – such as anxiety, anger, sadness, guilt and nervousness – coincided with stronger urges when participants experienced them. Rumination, fatigue and boredom were linked to stronger urges as well. By contrast, positive emotions were associated with less intense urges.

Boredom may predict hair-pulling episodes

One emotional or behavioural state was particularly notable: boredom.

Boredom predicted both hair-pulling episodes at the same assessment and episodes at the following assessment. Fatigue, on the other hand, predicted stronger urges but was not linked to pulling itself.

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This suggests that hair pulling may not chiefly be a reaction to emotional distress. At times, the behaviour may be connected with negative stimulation, but also with too little stimulation. "States of low energy may contribute to vulnerability for urges," the authors write.

They cite a theory proposing that repetitive behaviours regulate levels of internal stimulation, which could make hair pulling more probable during under-arousal or boredom.

"The consistent predictive role of boredom and tiredness in particular suggests that models focusing exclusively on emotional dysregulation may be insufficient," the researchers write.

That is not to say that emotions do not matter. Negative emotions and other internal states may form part of an urge, even where they do not consistently trigger the behaviour that comes afterwards. The researchers also stress that trichotillomania might not operate identically in every person, as there may be subtypes.

The research has important limitations: the sample was comparatively small and mainly female, while participants also needed sufficient motivation to complete an intensive 10-day monitoring programme.

Assessments could be separated by up to four hours, so rapid shifts in emotions or urges may have occurred between prompts without being recorded.

Related: Hidden Pulses Within Your Brain May Hold Your Thoughts Together

Even so, the results indicate that explaining trichotillomania may mean moving beyond the assumption that stress, sadness or anxiety leads a person to pull their hair.

A more useful question may concern what occurs between an urge and an action, including boredom, stimulation, sensory experiences, environmental signals and awareness of the urge itself.

The research was published in Comprehensive Psychiatry.

This article was fact-checked by Rachel Garner and edited by Rebecca Dyer. Although we take pride in our process, we are only human. If you notice an error, please tell us.