Hair-Pulling & Skin-Picking: Link to Early Trauma & Mental Health

Up to 220,000 Norwegians will experience hair-pulling or skin-picking behaviors that rise to the level of a mental health disorder during their lifetime. These behaviors, characterized by compulsive hair removal resulting in noticeable bald spots or skin picking leading to sores, are often accompanied by significant feelings of shame and embarrassment. “People feel a lot of shame and embarrassment. Not just because there is no hair there, but also because it is self-inflicted,” explains Benjamin Hummelen, project manager from Oslo University Hospital (OUS).

Researchers at the Norwegian University of Science and Technology (NTNU) and OUS, in collaboration with multiple institutions, are working to better understand the underlying mechanisms driving these repetitive behaviors. Their recent work sheds light on the connection between early life experiences, negative thought patterns, and the severity of these disorders.

Multiple Mental Health Connections

It’s well-established that individuals struggling with hair-pulling (trichotillomania) and skin-picking often experience co-occurring mental health conditions, including anxiety, depression, attention-deficit/hyperactivity disorder (ADHD), and obsessive-compulsive disorder (OCD). The new research highlights a particularly strong link between these behaviors and what are known as early maladaptive schemas.

Early maladaptive schemas are deeply ingrained patterns of thoughts and beliefs that develop during childhood, shaping how individuals perceive themselves and the world around them. These schemas can be positive or negative, and are formed through early life experiences. Researchers found a close relationship between these schemas and both the severity and specific type of skin picking or hair pulling. This suggests that therapists may benefit from assessing these negative schemas to gain a deeper understanding of their patients and tailor treatment accordingly.

The findings are published in the journal BMC Psychology.

When Does Repetitive Behavior Become a Disorder?

While many people engage in occasional hair-pulling or skin-picking, it doesn’t necessarily indicate a disorder. The key distinction lies in the impact on daily life. These behaviors become clinically significant when they cause distress and interfere with functioning at work, school, or in social settings.

There are two primary patterns of behavior observed:

• Unconscious Behavior: Some individuals pull their hair or pick at their skin without conscious awareness, often while engaged in other activities like driving or watching television.
• Focused Behavior: Others engage in more deliberate and focused skin picking or hair pulling. This can be a way to cope with negative emotions or boredom, and may even provide a pleasurable sensation.

A Shame-Filled Experience

“For it to be diagnosed, it must be classified as a problem that affects quality of life and ability to function. It must be distressing and affect how you function at work, school, or socially,” explains Torun Grøtte, an associate professor at NTNU’s Department of Psychology in Gjøvik.

The disorders often lead to significant attempts at concealment. Individuals may spend considerable time and effort trying to hide the effects of their behaviors, using hats, wigs, false eyelashes, or makeup to cover bald spots or wounds. “Some people spend several hours a day pulling their hair out or picking at their skin, and they may also spend a lot of time trying to conceal the damage it causes. There is a great deal of shame associated with these disorders,” Grøtte notes.

The Role of Early Maladaptive Schemas

Cognitive theory suggests that schemas – patterns of thoughts, emotions, and physical reactions – develop during childhood and influence our perceptions of ourselves and the world. These schemas can be either positive or negative. Negative schemas, or early maladaptive schemas (EMS), can include beliefs like feeling abandoned or unworthy. These schemas can significantly impact choices and interactions.

Previous research has linked pronounced early maladaptive schemas to more severe symptoms of other mental health disorders, such as obsessive-compulsive disorder, depression, and schizophrenia, and a reduced response to treatment.

The current study aimed to investigate the role of these schemas in hair-pulling and skin-picking disorders. The research involved 283 patients with either hair-pulling, skin-picking, or obsessive-compulsive disorder, and data was collected before the start of treatment.

“This represents one of several academic articles we have planned based on a large treatment project,” Grøtte explains. The project involves treating patients with cognitive behavioral therapy, and will follow them for several years to assess long-term outcomes.

The study confirmed that individuals with more severe symptoms of hair-pulling and skin-picking also exhibited higher levels of early maladaptive schemas. Interestingly, the researchers found relatively few differences in schema profiles between patients with hair-pulling disorder, skin-picking disorder, and obsessive-compulsive disorder.

Patients with hair-pulling disorder were more likely to report feelings of failure, suppression of their own needs, and a sense of being different or not fitting in. Self-sacrifice was a common theme among those with skin-picking disorder, alongside feelings of failure.

Conscious vs. Unconscious Behaviors

The study also revealed differences based on whether the behaviors were deliberate or unconscious. Participants who engaged in focused skin picking or hair pulling had higher levels of early maladaptive schemas, suggesting a stronger connection between these schemas and behaviors used to regulate emotions.

Grøtte and her team plan to continue investigating the relationship between early maladaptive schemas and these disorders, specifically exploring whether individuals with higher schema scores experience poorer treatment outcomes. “Is it the case that people who score high on early maladaptive schemas have poorer treatment outcomes? It would be interesting to find out,” Grøtte said.

The researchers are currently conducting follow-up studies to address this question. “We have a lot of interesting data to look at,” Hummelen added.

The ultimate goal of the project is to raise awareness about hair-pulling and skin-picking disorders in Norway and improve access to effective treatment options. The team is currently testing a new form of cognitive behavioral therapy that combines habit reversal training with acceptance and commitment therapy.