What lies beneath hair-pulling and skin-picking behaviours? The position of early maladaptive schemas

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 generally fully outdoors 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 perhaps 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 “unhealthy habits” (Mackay, 2023). Folks often describe two totally different experiences of pulling or selecting:

• centered episodes, a deliberate, aware behaviour and
• automated episodes, when it occurs with out them noticing, nearly 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 reminiscences, feelings and beliefs about ourselves and different folks. EMSs develop when vital wants will not be met in childhood and may turn into highly effective inner messages that affect how we handle troublesome emotions (Bishop et al., 2021; Ke & Barlas, 2018). EMSs have been linked to greater symptom severity in a number of psychological well being circumstances (Dostal and Pilkington, 2023), however we don’t know if these identical 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/selecting 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 have been ladies (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 have been totally assessed or accessible, which restricted how a lot they might modify for these variations within the analyses.

EMSs was measured by the Younger Schema Questionnaire–Brief Kind, alongside validated self-report measures of pulling/selecting severity and subtypes (automated and centered). Clinicians additionally accomplished a score of total sickness severity utilizing the Medical International Impression Severity scale (CGI-S) for the TTM and SPD teams.

The authors then used ANCOVA to match schema scores between teams (controlling for age and sickness period) and correlational analyses to discover relationships between schemas and symptom severity or pulling/selecting fashion.

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 1 dysfunction.
• The OCD group didn’t present greater or decrease schema ranges than the TTM or SPD teams, though some variations had been anticipated based mostly on earlier analysis.

Schemas have been linked with symptom severity

• There have been small to average associations between EMSs and pulling or selecting severity.
• For TTM, greater scores on a number of schemas (together with failure and social isolation) have been linked with extra extreme pulling on self-report and clinician rankings. Which means 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 have been related to larger selecting severity. This means that individuals who maintain these beliefs additionally are inclined to report extra extreme selecting, though the examine can not clarify why these patterns happen.

Targeted pulling/selecting confirmed the strongest hyperlinks to schemas

• Schemas have been extra strongly linked to centered pulling and selecting; the kind of behaviours folks do deliberately or in response to emotional states.
• In TTM, centered pulling was considerably associated to 9 totally different schemas, whereas automated pulling confirmed nearly no significant associations.
• The same sample appeared in SPD: centered selecting was linked to schemas corresponding to abandonment and distrust, however automated selecting was not.
• Which means focused-driven pulling and selecting appears to be extra tied to folks’s underlying beliefs, whereas automated behaviours confirmed no such sample on this examine.

People who’s pulling and selecting behaviours tended to be pushed by their feelings had greater ranges of early maladaptive schemas.

Conclusion

The authors conclude that EMSs (early maladaptive schemas) are frequent throughout Hair Pulling (Trichotillomania – TTM), Pores and skin-Choosing Dysfunction (SPD) and Obsessive Compulsive Dysfunction (OCD), supporting their transdiagnostic relevance.

In addition they recommend that schemas could deepen our understanding of why some folks pull or choose 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 recommend that early maladaptive schemas are frequent throughout hair-pulling, skin-picking and OCD, supporting their position as a shared, transdiagnostic characteristic of those circumstances.

Strengths and limitations

This examine makes a priceless contribution to an space the place high-quality analysis is scarce. It attracts on one of many largest scientific samples of TTM and SPD so far, and it contains an OCD comparability group. That is useful as a result of bigger samples enable 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 enhance our belief that the findings they reported are actual, slightly than ensuing from likelihood or poor measurement.

Nevertheless, there are a number of limitations. One vital methodological omission is the absence of an influence calculation. Though the general pattern seems giant, with out figuring out 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 bounds of the pattern measurement and analytical design.

The examine was additionally cross-sectional, which means all knowledge have been collected at a single time level. This makes it unattainable to find out causality: we can not know whether or not sure schemas contribute to extra extreme pulling and selecting, or whether or not years of fighting a BFRB form how folks see themselves and others. Longitudinal designs are wanted to know directionality.

An additional limitation is the dearth of gender range within the pattern, with most individuals being ladies. Inhabitants research present that these circumstances have an effect on folks 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 lots of lacking details about melancholy and nervousness. Due to this, the researchers couldn’t modify for these circumstances of their principal analyses. This issues as a result of the teams differed of their charges of melancholy, so among the “no distinction” findings could mirror unmeasured comorbidities slightly than true similarity.

Lastly, some clinically vital experiences weren’t captured. For instance, many people describe “trance-like” pulling or selecting (Mayerson et al., 2025), which doesn’t map neatly onto the centered versus automated distinction used within the examine. It stays unclear how these dissociative or absorbed states relate to schemas, and this hole limits the examine’s capability to completely symbolize the lived expertise of TTM and SPD.

Many people who hair-pull or skin-pick describe being in a “trance”, coming into an altered state of consciousness that makes the behaviour really feel all-consuming. The sort of expertise was not accounted for throughout the examine.

Implications for observe

This examine presents an vital reminder that circumstances like TTM and SPD will not be merely “unhealthy habits”. The associations between centered pulling or selecting and deeper perception patterns recommend that folks 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 selecting does for the individual in moments of misery. Schema-informed formulations could assist folks perceive why urges really feel overwhelming at sure occasions, why they fluctuate and why behavioural expertise alone are generally 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 fundamental data on the degree of colleges, GPs, and frontline psychological well being employees might cut back disgrace and velocity up entry to specialist care. For companies, the examine indicators the significance of assessing comorbidities corresponding to melancholy and nervousness, which can work together with schemas and form the expertise of pulling and selecting. As a result of the examine couldn’t modify for these attributable to lacking knowledge, future scientific work ought to routinely display screen for and tackle them.

For researchers, these findings increase 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
• May schemas assist clarify why some folks transfer between automated and centered pulling throughout their lives?

Enhancing fundamental 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 velocity up entry to help.

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 melancholy 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). Eager about feeling: Utilizing trait emotional intelligence in understanding the associations between early maladaptive schemas and coping kinds. Psychology and Psychotherapy: Concept, 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 nervousness and depressive symptomology. JCPP Advances, e70041. https://doi.org/10.1002/jcv2.70041

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