Trichotillomania Study Reveals Boredom May Trigger Hair Pulling

Trichotillomania – pulling 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, including "the habit of plucking out the hair or of gnawing the nails."

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

In the United States, it affects 1-2 percent of people, occurs equally among both genders, and commonly 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: pulling hair may enable people to manage unpleasant emotions, such as anxiety, tension or frustration, before bringing relief once the act is complete.

Earlier research, however, has delivered mixed support for this emotional-regulation explanation. Hair pulling can also occur while a person is distracted or even without their awareness.

Seeking a clearer picture of 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 understand the urge itself, and what follows from it, in greater detail.

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How the real-time study tracked hair pulling

Instead of asking participants to look back on each day in an evening journal entry – a common method for gathering such information – the team used ecological momentary assessment.

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

Participants were sent seven prompts daily between 8 am and 10 pm. These asked about 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 episodes of hair pulling at the time they occurred.

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

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

Having pulled previously similarly increased the chance of another episode, pointing to a degree of persistence in the behaviour across a day.

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

Negative emotions – such as anxiety, anger, sadness, guilt and nervousness – coincided with stronger urges when participants felt them. Rumination, tiredness and boredom did too. By contrast, positive emotions were linked with weaker urges.

Boredom may be a key factor in hair-pulling episodes

One emotional or behavioural state was particularly notable: boredom.

Boredom predicted both hair-pulling episodes at a later assessment and pulling reported in the same assessment. Tiredness, in contrast, predicted more powerful urges but was not itself linked to pulling.

This indicates that hair pulling may not chiefly be a reaction to emotional distress. At times, the behaviour could be associated with negative stimulation, but also with 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 levels of internal stimulation, which could make hair pulling more likely in states of 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 emotions do not matter. Negative emotions and other internal states may form part of the experience of an urge, even where they do not consistently trigger the subsequent behaviour. The researchers also stress that trichotillomania may operate differently from one person to another, potentially involving subtypes.

The study has important limitations: its sample was comparatively small and mostly 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 quick shifts in emotions or urges may have taken place between prompts without being recorded.

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

Even so, the results imply that understanding trichotillomania may mean moving beyond the assumption that stress, sadness or anxiety makes a person pull their hair.

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

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.