Trichotillomania: Boredom and tiredness outpace negative emotions as predictors of hair pulling

People with hair-pulling disorder often cite negative emotions as a trigger, but new research suggests boredom and tiredness may play a more consistent role in preceding the behavior over time. A recent study published in Comprehensive Psychiatry found that while negative feelings accompany the urge to pull hair, they do not reliably predict future pulling episodes. The findings challenge the traditional view that hair pulling serves primarily to regulate emotional distress.

Trichotillomania is a condition where people repeatedly pull out their own hair, resulting in hair loss and psychological distress. It is classified as an obsessive-compulsive related disorder. Historically, clinical models have framed this behavior as a maladaptive coping mechanism. This idea, known as the emotion regulation model, assumes that individuals pull their hair to alleviate negative feelings like tension, anxiety, or sadness.

Studies testing the emotion regulation model have yielded mixed results. It remains debated whether hair pulling serves a general emotion-regulating function or if other factors are at play. Changes in diagnostic guidelines reflect this ongoing scientific uncertainty. Older psychiatric manuals required individuals to feel a sense of tension before pulling and relief afterward to receive a diagnosis. The newest guidelines removed these criteria because many people pull their hair automatically or out of boredom, rather than in response to rising tension.

Most previous research into these patterns has relied on retrospective surveys. These surveys ask participants to recall their emotions and behaviors over past weeks. Human memory is prone to biases, making it difficult to accurately capture fleeting emotional states and momentary urges. Traditional survey designs are not suited to detect subtle, moment-to-moment interactions between internal feelings and physical actions.

To get a more accurate picture, clinical psychologist Christina Gallinat and her colleagues at Heidelberg University Hospital designed a study to track people in real time. They wanted to see exactly how emotional states, the urge to pull, and the actual pulling behavior interact on a daily basis in a natural environment.

The researchers used a technique called ecological momentary assessment. This methodology involves prompting participants on their smartphones multiple times throughout the day to answer brief questions about their current state. The study included 61 adults diagnosed with trichotillomania. Over a ten-day period, the participants received seven daily text messages linking to a short survey.

The survey asked participants to rate their current urge to pull hair on a scale from one to five. It also asked if they had pulled their hair since the last prompt. Participants then rated various emotional states, including negative emotions, positive emotions, boredom, tiredness, and rumination. Rumination refers to a pattern of repetitive, unhelpful thinking about one’s distress or personal problems.

The researchers analyzed the collected data in two distinct ways to capture different timeframes. First, they looked at prospective associations, which involves testing whether a person’s state at one moment predicted their behavior at the next assessment hours later. Second, they looked at concurrent associations, checking which emotions and urges occurred at the exact same time as a pulling episode.

In their prospective analysis of pulling behavior, the researchers found that earlier urges strongly predicted whether a person would pull their hair at the next check-in. Having a prior pulling episode also predicted future episodes, showing that the behavior tends to cluster in specific parts of the day. Among the emotional states, only boredom predicted a subsequent hair-pulling episode. Negative emotions were not statistically significant predictors of future hair pulling.

When analyzing the data concurrently, the researchers observed a slightly different pattern. The intensity of the urge to pull was strongly associated with hair pulling happening at that very moment. Boredom was also linked to a higher likelihood of current pulling. Negative emotions, once again, showed no statistical relationship with the actual occurrence of pulling episodes in the moment.

The researchers then shifted their focus to the urge itself, testing whether earlier emotional states predicted how strong the urge to pull would be at the next assessment. Previous urge intensity was a strong predictor of current urge intensity. Additionally, tiredness predicted an increase in future urges. Negative emotions, boredom, and rumination did not reliably predict later surges in the urge to pull.

Finally, the team looked at what factors accompanied the urge to pull in real time. Here, emotional states showed a distinct relationship. Higher levels of negative emotions, boredom, and rumination were all associated with a stronger current urge to pull hair. Conversely, higher positive emotions were associated with a lower concurrent urge.

The results suggest that while negative emotions can accompany the desire to pull hair, they are not the primary predictors of the behavior over the course of a day. Instead, boredom and tiredness appear to be more reliable indicators of future pulling. This points to an alternative explanation where repetitive behaviors might serve to regulate a person’s level of stimulation. The behavior may act as a way to counteract under-arousal rather than simply soothing emotional distress.

The study features several limitations regarding its timeline that contextually shape these findings. The assessments were spaced up to four hours apart. Human emotions can fluctuate rapidly, and a person might experience a surge of anxiety, pull their hair, and feel relief entirely between the survey prompts. The methodology might miss these brief, rapid changes in emotional states.

The surveys also did not track environmental or social contexts. Factors such as being alone, working at a computer, or sitting in a specific room likely influence both boredom and hair pulling. Without tracking these situational triggers, the exact conditions that accompany the transition from an internal urge to a physical episode remain partially obscured. The findings are also based on a group of volunteers, which means individuals with lower motivation or insight might be underrepresented.

Future studies will need to incorporate shorter time intervals between assessments to capture faster emotional shifts. Including data on a person’s physical surroundings and activities could also help uncover the mechanisms behind the disorder. Such research could eventually guide clinical therapies, helping patients manage environmental triggers and regulate their daily stimulation levels instead of focusing exclusively on emotion regulation.

The study, “Trichotillomania: The interplay between emotional states, urges and hair pulling episodes,” was authored by Christina Gallinat, Maximilian Wilhelm, Markus Moessner, and Stephanie Bauer.