Affective regulation in trichotillomania: Evidence from a large-scale internet survey
Abstract
Trichotillomania (TTM), a repetitive hair-pulling disorder, is underrepresented in the clinical literature. The current project explores the relationship between affective regulation and disordered hair-pulling. Previous research suggests that cycles of emotional states are correlated with the disorder and may induce, reinforce, or otherwise contribute to hair-pulling behavior. We use anonymous internet survey responses from 1162 self-identified hair-pullers to address four questions about affective regulation in people with TTM: (1) Do hair-pullers experience greater difficulty "snapping out" of affective states than non-pullers? (2) Does difficulty with emotional control correlate with TTM severity? (3) Are subtypes identifiable based on the emotions that trigger hair-pulling behavior? (4) Does difficulty "snapping out" of an emotion predict whether that emotion triggers pulling behavior? The results showed a small-to-moderate relationship between affective regulation and problematic hair-pulling. In addition, individual patterns of emotion regulation were systematically related to emotional cues for hair-pulling as well as overall hair-pulling severity. These findings contribute to an understanding of the phenomenology of TTM and provide empirical support for treatments focused on affect regulation.
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Four subtypes consisting of unique emotional profiles were identified, and cluster membership predicted hair pulling severity.
“Additionally, using latent class analysis, we identified four subtypes consisting of unique emotional profiles and demonstrated that cluster membership predicted hair pulling severity.”
From Dbt-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial (2012) · cites this paper as Shusterman et al., 2009
Hair pullers have more difficulty than normal controls in managing their emotions, with a small to moderate relationship between affective regulation and hair pulling severity.
“Our findings from a large Internet survey of TTM demonstrated that hair pullers had more difficulty than normal controls in managing their emotions, with a small to moderate relationship between affective regulation and hair pulling severity (Shusterman et al., 2009).”
From Dbt-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial (2012) · cites this paper as Shusterman et al., 2009
This finding is consistent with Shusterman et al.'s (2009) argument that more idiographic assessment of ER difficulties is warranted for hair pullers.
“This finding is consistent with Shusterman et al.'s (2009) argument that more idiographic assessment of ER difficulties is warranted for hair pullers.”
From Dbt-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial (2012) · cites this paper as Shusterman et al.'s (2009)
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“, providing stimulation when feeling bored, or relieving tension when stressed or anxious (Shusterman et al., 2009; Duke et al., 2010; Grant et al., 2015; Roberts et al., 2015; Curley et al., 2016).”
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Psychometric Properties of Trichotillomania Severity Measures
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“For instance, emotion and sensory-related variables are often involved in the hair pulling cycle (Badenoch et al., 2020; Roberts et al., 2013; Shusterman et al., 2009; Siwiec & McBride, 2016), and these variables are not assessed on the NIMH-TSS.”
Lungu, A., & Linehan, M. M. (2017) · Elsevier eBooks · doi:10.1016/b978-0-12-803457-6.00018-0 · Cited by 11 · see citing works
The Beliefs in Trichotillomania Scale (Bi TS ): Factor analyses and preliminary validation
Rehm, I. C., Nedeljkovic, M., Moulding, R., & Thomas, A. C. (2019) · British Journal of Clinical Psychology · doi:10.1111/bjc.12219 · Cited by 11 · see citing works
Slikboer, R., Castle, D., Nedeljkovic, M., & Rossell, S. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2017.12.056 · Cited by 9 · see citing works
Snorrason, Í., Kuckertz, J. M., Swisher, V. S., Pendo, K., Rissman, A. J., & Ricketts, E. J. (2023) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2023.102743 · Cited by 9 · see citing works
Clinical Management of Trichotillomania With Bimatoprost
Peabody, T. D., Reitz, S. C., Smith, J., & Teti, B. (2013) · Optometry and Vision Science · doi:10.1097/opx.0b013e318294c158 · Cited by 10 · see citing works
“Automatic pulling might be driven by boredom, whereas focused pulling could be driven by anxiety or tension.(15) Focused hair pulling occurs when the patient is completely absorbed in that single task.”
BackgroundBaumeister, A., Schmotz, S., Weidinger, S., & Moritz, S. (2023) · Behavior Therapy · doi:10.1016/j.beth.2023.05.013 · Cited by 8 · see citing works
A brief, residential peer‐support retreat for trichotillomania: A mixed methods evaluation
Slikboer, R., Rehm, I. C., Lam, S., Maloney, A., & Nedeljkovic, M. (2019) · Australian Psychologist · doi:10.1111/ap.12420 · Cited by 8 · see citing works
Arslan, S. C., Çiçek, A. U., Ucuz, İ., & Doğru, H. (2022) · Nordic Journal of Psychiatry · doi:10.1080/08039488.2022.2052179 · Cited by 8 · see citing works
Trichotillomania and Skin-Picking Disorder: Different Kinds of OCD
Grant, J., & Chamberlain, S. (2015) · FOCUS The Journal of Lifelong Learning in Psychiatry · doi:10.1176/appi.focus.130212 · Cited by 9 · see citing works
Affective regulation in trichotillomania before and after self-help interventions.
Weidt, S., Zai, G., Drabe, N., Delsignore, A., Bruehl, A., Klaghofer, R., & Rufer, M. (2016) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2015.12.020 · Cited by 7 · see citing works
Curley, E. E., Tung, E. S., & Keuthen, N. J. (2016) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2016.04.005 · Cited by 8 · see citing works
Emotionsregulation bei psychischen Störungen und in der Psychotherapie
Holl, J., von Oepen, R., & Benecke, C. (2020) · Springer eBooks · doi:10.1007/978-3-662-60280-5_12 · Cited by 7 · see citing works
The Phenomenology of Hair Pulling Urges in Trichotillomania: A Comparative Approach
Madjar, S., & Sripada, C. (2016) · Frontiers in Psychology · doi:10.3389/fpsyg.2016.00199 · Cited by 7 · see citing works
A critical review of the evidence for the equivalence of canine and human compulsions
Walsh, B. (2021) · Applied Animal Behaviour Science · doi:10.1016/j.applanim.2020.105166 · Cited by 10 · see citing works
Mindfulness-Based Cognitive Therapy for Trichotillomania: A Bayesian Case-Control Study
Heeren, A., Busana, C., Coussement, C., & Philippot, P. (2015) · Psychologica Belgica · doi:10.5334/pb.bj · Cited by 5 · see citing works
Trichotillomania: the impact of treatment history on the outcome of an Internet-based intervention
Weidt, S., Bruehl, A., Delsignore, A., Zai, G., Kuenburg, A., Klaghofer, R., & Rufer, M. (2017) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s128592 · Cited by 6 · see citing works
“However, previous TTM online studies have reported similar female predominance in their study sample.(3,16) Whether this reflects TTM as having a higher prevalence in females(1,42) or females with greater information- or help-seeking behavior(43) remains an important but yet unsolved question.”
Forbes, C. N., Tull, M. T., Lavender, J. M., Dixon–Gordon, K. L., & Gratz, K. L. (2022) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-021-09906-y · Cited by 6 · see citing works
“For example, emotion regulation (e.g., obtaining relief from negative affective states, generating positive affective states) has been identified as an expectancy for NSSI (Klonsky, 2007; Nock & Prinstein, 2004; Turner et al., 2012), disordered eating behaviors (Hohlstein et al., 1998), BFRBs (Shusterman et al., 2009;…”
InfluentialKłosowska, J., Prochwicz, K., & Kałużna-Wielobób, A. (2019) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2019.04.001 · Cited by 6 · see citing works
Hair loss related to primary psychiatric disorders
Fettahoğlu, E. Ç. (2014) · TURKDERM · doi:10.4274/turkderm.48.s12 · Cited by 5 · see citing works
Computerized Trans-Diagnostic Dialectical Behavior Therapy Skills Training for Emotion Dysregulation
Lungu, A. (2015) · ResearchWorks at the University of Washington (University of Washington) · Cited by 5 · see citing works
Casas, J. B., Szoke, D. R., & Benuto, L. T. (2020) · Clinical Case Studies · doi:10.1177/1534650120964581 · Cited by 4 · see citing works
“Those who endorsed hair-pulling behaviors in a large online survey were more likely to report difficulty “snapping out” of emotions, including anxiety, guilt, and sadness, than non-pullers (Shusterman et al., 2009).”
BackgroundTrichotillomania: Therapist Guide
Twohig, M. P., & Woods, D. W. (2023) · doi:10.1093/med-psych/9780197670309.001.0001 · Cited by 4 · see citing works
El tratamiento psicológico de la tricotolomanía: un estudio de caso
Sarmiento, T., Guillén, V., & Sánchez, J. M. (2016) · Revista de Psicopatología y Psicología Clínica · doi:10.5944/rppc.vol.21.num.1.2016.16374 · Cited by 4 · see citing works
“…la conducta, evitando en muchas ocasiones incluso el tratamiento, por vergüenza (Diefenbach, Tolin, Hannan, Crocetto y Worhunsky, 2005; Shusterman, Feld, Baer y Keuthen, 2009), o por la creencia de que no se puede hacer nada para tratar el problema (Shusterman et al., 2009; Walsh y McDougle, 2001).”
BackgroundSwisher, V. S., Ricketts, E. J., Peris, T. S., Jones, G. M., Dunning, E. E., Valle, S., Cavic, E., Löchner, C., Stein, D. J., Dougherty, D. D., et al. (2025) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2025.10.037 · Cited by 3 · see citing works
Exploring pharmacological treatment for trichotillomania: do we need better education?
Krajewski, P., Zirpel, H., Saceda-Corralo, D., Thaçi, D., & Szepietowski, J. (2024) · International Journal of Dermatology · doi:10.1111/ijd.17269 · Cited by 3 · see citing works
“14 On the other hand, on the basis that boredom may be a trigger to pulling, authors hypothesize that it helps to modulate negative emotions caused by an unwillingness to relax and feelings of perfectionism.”
Azizi, S., Farshi, M. G., Poursharifi, H., & Farazmand, S. (2017) · Practice in Clinical Psychology · doi:10.18869/acadpub.jpcp.5.2.123 · Cited by 4 · see citing works
“In addition, stressful situations which are associated with unpleasant emotions usually stimulates hair pulling behavior which reflects maladap- tive coping style (Shusterman et al., 2009; Teng, Woods, Twohig, & Marcks, 2002; Diefenbach et al., 2008).”
BackgroundSlikboer, R., Nedeljkovic, M., Castle, D., & Rossell, S. (2018) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2018.06.007 · Cited by 3 · see citing works
Domínguez, Z. E. M. (2012) · Acción Psicológica · doi:10.5944/ap.9.2.4111 · Cited by 3 · see citing works
Trichotillomania: Identification and Treatment
McDonald, K. (2012) · Journal of Counseling & Development · doi:10.1002/j.1556-6676.2012.00053.x · Cited by 4 · see citing works
Body‐Focused Repetitive Behavior
Conelea, C. A., Frank, H., & Walther, M. R. (2017) · doi:10.1002/9781118877142.ch21 · Cited by 3 · see citing works
Usmani, A., Szkutak, A., & Keuthen, N. J. (2023) · Current clinical psychiatry · doi:10.1007/978-3-031-29368-9_12 · Cited by 2 · see citing works
Rehm, I. C., Moulding, R., & Nedeljkovic, M. (2024) · Australian Psychologist · doi:10.1080/00050067.2024.2376881 · Cited by 2 · see citing works
“Research into the affective cues and correlates of hair pulling behaviours (e.g., Diefenbach et al., 2002; Shusterman et al., 2009) influenced the development of habit reversal therapy (HRT) protocols, since “enhanced” through the incorporation of acceptance and commitment therapy (ACT; e.g.,…”
Psychiatric Conditions and Touch
Cascio, C. (2016) · Springer eBooks · doi:10.1007/978-1-4939-6418-5_23 · Cited by 2 · see citing works
Mouton-Odum, S., & Houghton, D. (2018) · Bulletin of the Menninger Clinic · doi:10.1521/bumc.2018.82.4.288 · Cited by 1 · see citing works
Review of Psychotherapeutic Approaches for OCD and Related Disorders
Mathes, B. M., Kirk, N. P. V., & Elias, J. A. (2015) · Current Treatment Options in Psychiatry · doi:10.1007/s40501-015-0052-7 · Cited by 2 · see citing works
Lisi, D., Wood‐Ross, C., Regev, R., Laposa, J. M., & Rector, N. A. (2024) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2024.2408381 · Cited by 1 · see citing works
“…have been found in those with BDD, TTM, and EXC presentations (Arnold et al., 1998; Blakey et al., 2016; Buhlmann et al., 2008; Gupta et al., 1996; Shusterman et al., 2009); however, perfectionistic beliefs have been inconsistently associated with hoarding symptoms (see Taylor et al., 2010) or…”
Kınay, D., Aydın, E. P., Kasar, N., & Guney, O. (2026) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.70350 · Cited by 1 · see citing works
Dixon, M. M. (2016) · J. Willard Marriott Library · doi:10.26053/0h-6086-d8g0 · Cited by 1 · see citing works
Postpartum-onset and childhood sexual trauma in a patient with skin picking disorder: a case report
Memiş, Ç. Ö., Kurt, M., Doğan, B., Sevinçok, D., & Sevinçok, L. (2017) · Psychiatry and Clinical Psychopharmacology · doi:10.1080/24750573.2017.1311468 · Cited by 1 · see citing works
“Stress, anxiety, boredom, feelings of tiredness or anger have been found to be possible triggers for SPD [4,5].”
BackgroundDevelopment of a measure of cognitions and beliefs in trichotillomania
Rehm, I. C. (2016) · Swinburne figshare (Swinburne University of Technology) · doi:10.25916/sut.26269711 · Cited by 1 · see citing works
Body-focused repetitive behaviours are associated with being a ‘creature of habit’
Dodds, C., & Windget, D. (2020) · Journal of Behavioral and Cognitive Therapy · doi:10.1016/j.jbct.2020.03.013 · Cited by 1 · see citing works
Filling the void: boredom’s associations with hoarding symptom severity
Weiss, E. R., Todman, M., & Roane, D. M. (2024) · Discover Psychology · doi:10.1007/s44202-024-00145-2 · Cited by 1 · see citing works
New Wave Therapies for Pediatric OCD
Bergman, R. L., & Rozenman, M. S. (2019) · Cambridge University Press eBooks · doi:10.1017/9781108235655.025 · Cited by 1 · see citing works
Çoban, M. C. (2021) · Turk Turizm Arastirmalari Dergisi · doi:10.26677/tr1010.2021.901 · Cited by 1 · see citing works
Green, S. (2009) · International Journal of Orofacial Myology · doi:10.52010/ijom.2009.35.1.5 · Cited by 1 · see citing works
Mechanisms of Treatments for Trichotillomania (Hair Pulling Disorder)
Brennan, E., Francazio, S., Murphy, Y. E., & Flessner, C. (2017) · doi:10.1002/9781118877142.ch20 · Cited by 1 · see citing works
Emotion Regulation in the Obsessive‐Compulsive Spectrum Disorders
Napolitano, L. A. (2017) · Wiley eBooks · doi:10.1002/9781118890233.ch64 · Cited by 1 · see citing works
Developing and Evaluating a Situated Assessment Instrument for Trichotillomania: The SAM² TAIPreprint
Lūka, C. T. B., Hendry, K., Dutriaux, L., Stevenson, J. L., & Barsalou, L. W. (2023) · doi:10.31234/osf.io/v6qna · Cited by 1 · see citing works
Keuthen, N., & Usmani, A. (2016) · Springer eBooks · doi:10.1007/978-1-4939-2605-3_9 · Cited by 2 · see citing works
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Body-Focused Repetitive Behaviors
Grant, J., & Chamberlain, S. (2019) · A Transdiagnostic Approach to Obsessions, Compulsions and Related Phenomena · doi:10.1017/9781108164313.029
- Authors
- Shusterman, A., Feld, L., Baer, L., & Keuthen, N.
- Affiliations
- Wesleyan University (US)
- Massachusetts General Hospital (US)
- Corresponding author
- Shusterman, Anna
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2009-08
- Volume
- 47
- Issue
- 8
- Pages
- 637-644
- ISSN
- 0005-7967 (ISSN-L)
- OpenAlex
- W2053285253
- Cited by
- 127
- References
- 34
- Citations by year
- 2026: 3 · 2025: 1 · 2024: 4 · 2023: 27 · 2022: 3 · 2021: 6 · 2020: 10 · 2019: 6 · 2018: 5 · 2017: 14 · 2016: 13 · 2015: 13 · 2014: 4 · 2013: 3 · 2012: 6
- FWCI
- 5.30
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Keywords
- trichotillomania, emotion regulation, emotional triggers, symptom severity
- MeSH terms
- Adolescent, Adult, Affect, Aged, Aged, 80 and over, Female, Health Surveys, Humans, Male, Middle Aged, Surveys and Questionnaires, Trichotillomania, Internet
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