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”, however it didn’t really feel like one to Mia. It felt like one thing deeper, heavier and typically fully exterior her consciousness. When she constructed up the braveness to talk to her college counsellor, they frowned and mentioned, “I don’t know what that’s, however possibly attempt a stress ball?” This story is fictional however based mostly 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). Folks normally describe two completely different experiences of pulling or choosing:
- centered episodes, a deliberate, acutely aware behaviour and
- computerized episodes, when it occurs with out them noticing, virtually 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 essential wants will not be met in childhood and might turn into highly effective inside messages that affect how we handle troublesome emotions (Bishop et al., 2021; Ke & Barlas, 2018). EMSs have been linked to larger symptom severity in a number of psychological well being situations (Dostal and Pilkington, 2023), however we don’t know if these similar 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/choosing kinds 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 examine utilizing baseline (pre-treatment) knowledge from 283 treatment-seeking adults in Norway with a analysis of TTM (n = 120), SPD (n = 75) or OCD (n = 88), nearly all of whom had been girls (84.76%). There have been some important variations between the teams, together with age, intercourse, employment standing. The researchers additionally famous that not all comorbidities had been absolutely assessed or out there, which restricted how a lot they might modify for these variations within the analyses.
EMSs was measured by way of the Younger Schema Questionnaire–Quick Type, alongside validated self-report measures of pulling/choosing severity and subtypes (computerized and centered). Clinicians additionally accomplished a score of general sickness severity utilizing the Medical 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 length) and correlational analyses to discover relationships between schemas and symptom severity or pulling/choosing type.
Outcomes
No group variations in schema ranges
- Throughout TTM, SPD and OCD, there have been no important variations in EMSs, with all three teams displaying 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 larger or decrease schema ranges than the TTM or SPD teams, regardless that some variations had been anticipated based mostly on earlier analysis.
Schemas had been linked with symptom severity
- There have been small to average associations between EMSs and pulling or choosing severity.
- For TTM, larger scores on a number of schemas (together with failure and social isolation) had been linked with extra extreme pulling on self-report and clinician scores. Because of this individuals who endorsed beliefs like “I’m not ok,” tended to expertise extra intense or distressing pulling urges.
- For SPD, the sample was weaker however nonetheless current: schemas corresponding to disgrace and abandonment had been related to larger choosing severity. This means that individuals who maintain these beliefs additionally are likely to report extra extreme choosing, though the examine can’t clarify why these patterns happen.
Targeted pulling/choosing confirmed the strongest hyperlinks to schemas
- Schemas had been extra strongly linked to centered pulling and choosing; the kind of behaviours individuals do deliberately or in response to emotional states.
- In TTM, centered pulling was considerably associated to 9 completely different schemas, whereas computerized pulling confirmed virtually no significant associations.
- An analogous sample appeared in SPD: centered choosing was linked to schemas corresponding to abandonment and distrust, however computerized choosing was not.
- Because of this focused-driven pulling and choosing appears to be extra tied to individuals’s underlying beliefs, whereas computerized behaviours confirmed no such sample on this examine.
People who’s pulling and choosing behaviours tended to be pushed by their feelings had larger ranges of early maladaptive schemas.
Conclusion
The authors conclude that EMSs (early maladaptive schemas) are widespread throughout Hair Pulling (Trichotillomania – TTM), Pores and skin-Selecting Dysfunction (SPD) and Obsessive Compulsive Dysfunction (OCD), supporting their transdiagnostic relevance.
Additionally they counsel that schemas could deepen our understanding of why some individuals pull or decide in additional emotionally-driven, centered methods. They argue that assessing schemas in scientific settings could assist clinicians develop a fuller image of sufferers’ experiences, together with underlying behavioural drivers, which can assist the tailoring of interventions.
This examine supplies preliminary proof to counsel that early maladaptive schemas are widespread throughout hair-pulling, skin-picking and OCD, supporting their position as a shared, transdiagnostic function of those situations.
Strengths and limitations
This examine makes a useful contribution to an space the place high-quality analysis is scarce. It attracts on one of many largest scientific samples of TTM and SPD to this point, and it contains an OCD comparability group. That is helpful as a result of bigger samples permit 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 extensively 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, fairly than ensuing from probability or poor measurement.
Nevertheless, there are a number of limitations. One essential methodological omission is the absence of an influence calculation. Though the general pattern seems massive, with out understanding whether or not the examine was adequately powered, we can’t be positive whether or not the similarities between teams mirror real psychological overlap or the boundaries of the pattern measurement and analytical design.
The examine was additionally cross-sectional, that means all knowledge had been collected at a single time level. This makes it inconceivable to find out causality: we can’t know whether or not sure schemas contribute to extra extreme pulling and choosing, 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 range within the pattern, with most individuals being girls. Inhabitants research present that these situations have an effect on individuals of all genders (Grant et al., 2020), so the underrepresentation of males on this examine limits the generalisability of those findings.
The dealing with of lacking knowledge introduces additional uncertainty. Nearly a 3rd of the unique pattern didn’t full the schema questionnaire and there was loads of lacking details about despair and anxiousness. Due to this, the researchers couldn’t modify for these situations of their major analyses. This issues as a result of the teams differed of their charges of despair, so among the “no distinction” findings could mirror unmeasured comorbidities fairly than true similarity.
Lastly, some clinically essential experiences weren’t captured. For instance, many people describe “trance-like” pulling or choosing (Mayerson et al., 2025), which doesn’t map neatly onto the centered versus computerized distinction used within the examine. It stays unclear how these dissociative or absorbed states relate to schemas, and this hole limits the examine’s potential to totally symbolize 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. Any such expertise was not accounted for throughout the examine.
Implications for apply
This examine gives an essential reminder that situations like TTM and SPD will not be merely “dangerous habits”. The associations between centered pulling or choosing and deeper perception patterns counsel 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 choosing does for the individual in moments of misery. Schema-informed formulations could assist individuals perceive why urges really feel overwhelming at sure occasions, why they fluctuate and why behavioural abilities 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. Enhancing primary data on the stage of faculties, GPs, and frontline psychological well being staff may scale back disgrace and pace up entry to specialist care. For providers, the examine alerts the significance of assessing comorbidities corresponding to despair and anxiousness, which can work together with schemas and form the expertise of pulling and choosing. As a result of the examine couldn’t modify for these on account of lacking knowledge, future scientific work ought to routinely display for and deal with them.
For researchers, these findings elevate new questions:
- Do schema-focused interventions enhance outcomes when added to behavioural therapies 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?
Enhancing primary data of hair-pulling and skin-picking in colleges, main care, and frontline psychological well being care is an important first step to start decreasing the disgrace related to body-focused repetitive behaviours, and pace up entry to assist.
Assertion of pursuits
Laura Lee – None.
Edited by
Dr Nina Higson-Sweeney.
Hyperlinks
Main 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 despair in maturity: A scientific overview and meta‐evaluation. Medical Psychology & Psychotherapy, 29(1), 111-130. https://doi.org/10.1002/cpp.2630
Grant, J. E., & Chamberlain, S. R. (2021). Computerized 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 position 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). Excited about feeling: Utilizing trait emotional intelligence in understanding the associations between early maladaptive schemas and coping kinds. Psychology and Psychotherapy: Idea, 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 position 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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