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 genders, and frequently coexists with other mental-health conditions, including anxiety, depression, PTSD, OCD and ADHD.

Why people may pull their hair

A widely proposed account of trichotillomania centres on emotional regulation. In this view, pulling hair helps people manage unpleasant states such as anxiety, tension or frustration, with the act bringing a feeling of relief.

Earlier research, however, has offered mixed support for the emotional-regulation explanation. Hair pulling can occur while a person is distracted, or when they do not even realise they are doing it.

To better understand events as they unfold, researchers at Heidelberg University Hospital tracked 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 team writes in its new study, published in Comprehensive Psychiatry.

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

Tracking trichotillomania urges in real time

Instead of asking participants to reflect on their day in an evening journal entry – a common method of gathering such information – the researchers used an ecological momentary assessment.

This method asks people to log their emotions and behaviours as they happen, rather than trying to remember feelings from several hours before.

Participants were sent seven prompts daily from 8 am to 10 pm. They were asked to describe their current emotional state, rate the intensity of their urge to pull, and say whether they had pulled their hair since the prior assessment. They could additionally record episodes of hair pulling when they occurred.

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

People who described more intense urges were markedly more likely to report a hair-pulling episode in that assessment. A stronger urge at one assessment also forecast pulling at the next one.

Having pulled previously also raised the chance of another episode, indicating that the behaviour may persist across the course of a day.

Emotional states, though, were considerably less useful predictors than urges.

Negative emotions – such as anxiety, anger, sadness, guilt and nervousness – coincided with stronger urges when participants experienced them. The same was true of rumination, fatigue and boredom. By contrast, positive emotions were linked with less intense urges.

Boredom emerged as a notable factor

One emotional or behavioural state was particularly prominent: boredom.

Boredom predicted both hair-pulling episodes at the same assessment and episodes at the next assessment. Fatigue, in contrast, predicted more powerful urges but was not associated with hair pulling itself.

This suggests hair pulling may not chiefly be a reaction to emotional distress. The behaviour could sometimes relate to negative stimulation, but also to too little stimulation. “States of low energy may contribute to vulnerability for urges,” the authors write.

They refer to a theory proposing that repetitive behaviours regulate internal levels of stimulation, which could make hair pulling more likely 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.

This does not make emotions unimportant. Negative emotions and other internal states may form part of the experience of an urge, even where they do not consistently trigger the behaviour that comes next. The researchers also stress that trichotillomania may not operate identically in every person, as there may be subtypes.

The study had a relatively small sample that was predominantly female, while participants also needed to be sufficiently motivated to complete an intensive 10-day monitoring protocol. Both are important limitations of the research.

Assessments could be separated by up to four hours, so rapid shifts in emotions or urges may have taken place in between and not been 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 makes a person pull their hair.

A more helpful question may concern what occurs between an urge and an action, including boredom, stimulation, sensory experiences, environmental cues 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 spot an error, please let us know.