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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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“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
In the citing paper
“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
In the citing paper
“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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“Both hair pulling and skin pickingmodulate affective states as well as providing pleasurable stimulation, and it appears that affective experiences play an important role inmaintaining and possibly causing these problems (Shusterman et al., 2009; Snorrason et al., 2010).”
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“Also, research suggests that boredom plays a role in TTM (e.g. Diefenbach, Mouton-Odum, & Stanley, 2002; Diefenbach et al., 2008; Shusterman et al., 2009) and experimental manipulation of boredom has been shown to increase the frequency of both skin picking and nail biting in individuals prone to…”
BackgroundDbt-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial
Keuthen, N. J., Rothbaum, B. O., Fama, J., Altenburger, E., Falkenstein, M. J., Sprich, S. E., Kearns, M., Meunier, S., Jenike, M. A., & Welch, S. S. (2012) · Journal of Behavioral Addictions · doi:10.1556/jba.1.2012.003 · Cited by 124
“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).”
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“In our own research,([8]) we reported a correlation between problematic hair pulling and affective regulation with predicted relationships between affective pulling triggers, problematic emotion regulation, and pulling severity.”
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Keuthen, N. J., Rothbaum, B. O., Welch, S. S., Taylor, C., Falkenstein, M., Heekin, M., Jordan, C. A., Timpano, K., Meunier, S., Fama, J., et al. (2010) · Depression and Anxiety · doi:10.1002/da.20732 · Cited by 81
“More recently, Shusterman et al.([21]) conducted a large-scale Internet survey of self-identified hair pullers to examine the potential contribution of affective regulation in TTM.”
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Emotion regulation in individuals with and without trichotillomania
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Movement decoupling: A self-help intervention for the treatment of trichotillomania.
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“Feelings of embarrassment and shame can also result in avoidance of professional treatment such as CBT (Diefenbach, Tolin, Hannan, Crocetto, & Worhunsky, 2005; Shusterman et al., 2009).”
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The relationship of psychological trauma with trichotillomania and skin picking
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“Personality allegedly plays a role in the development of TTM and SP.(14) Emotionality and emotional regulation difficulties, reward dependence and harm avoidance, have been reported among the personality traits in both disorders.”
BackgroundInfluentialSensory over-responsivity in trichotillomania (hair-pulling disorder)
Falkenstein, M. J., Conelea, C. A., Garner, L. E., & Haaga, D. A. F. (2017) · Psychiatry Research · doi:10.1016/j.psychres.2017.11.034 · Cited by 44
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“…hair pulling (Diefenbach et al., 2002, Diefenbach et al., 2008), and several studies have linked hair pulling to maladaptive emotion regulation strategies (Begotka et al., 2004, Houghton et al., 2014, Norberg et al., 2007, Roberts et al., 2015, Roberts et al., 2013, Shusterman et al., 2009).”
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Hair‐pulling disorder (Trichotillomania): Etiopathogenesis, diagnosis and treatment in a nutshell
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“Explanatory models of psychology suggest that hair-pulling may regulate emotional or stressful states as well as it provides temporary relief from negative emotions and this may lead to a reinforcement of the same hair-pulling behavior.(22-24) Greater difficulties in emotional regulation are a common background for al…”
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“Automatic SP behaviors could have the role of coping strategies for anxiety through reward dependence and harm avoidance mechanisms for people with avoidant personality, as highlighted by other authors.(18) Given this potential role, it could be expected that psychotherapeutic work targeting avoidant personality trait…”
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Houazene, S., Leclerc, J. B., O’Connor, K. P., & Aardema, F. (2021) · Behaviour Research and Therapy · doi:10.1016/j.brat.2021.103804 · Cited by 31
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“Similarly, previous research on TTM has demonstrated an emotion regulation function of hair pulling behavior (Diefenbach et al., 2008; Shusterman et al., 2009).”
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“Episodes of BFRBs are hypothesized to result from a drive to stop experiencing a given affective state, and a lack of alternative methods for coping (Shusterman et al. 2009) (Fig.”
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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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“Multiple studies monitoring emotion regulation in individuals with trichotillomania have demonstrated that these individuals struggle to regulate various emotional states when compared to controls (15).”
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Houazene, S., Aardema, F., Leclerc, J. B., & O’Connor, K. P. (2020) · Behaviour Change · doi:10.1017/bec.2020.16 · Cited by 14
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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.”
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“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.”
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“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 7
“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
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“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
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“…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
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
“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
“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
Domínguez, Z. E. M. (2012) · Acción Psicológica · doi:10.5944/ap.9.2.4111 · Cited by 3
Trichotillomania: Identification and Treatment
McDonald, K. (2012) · Journal of Counseling & Development · doi:10.1002/j.1556-6676.2012.00053.x · Cited by 4
Body‐Focused Repetitive Behavior
Conelea, C. A., Frank, H., & Walther, M. R. (2017) · doi:10.1002/9781118877142.ch21 · Cited by 3
Usmani, A., Szkutak, A., & Keuthen, N. J. (2023) · Current clinical psychiatry · doi:10.1007/978-3-031-29368-9_12 · Cited by 2
Rehm, I. C., Moulding, R., & Nedeljkovic, M. (2024) · Australian Psychologist · doi:10.1080/00050067.2024.2376881 · Cited by 3
“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. J. (2016) · Springer eBooks · doi:10.1007/978-1-4939-6418-5_23 · Cited by 2
Mouton‐Odum, S., & Houghton, D. C. (2018) · Bulletin of the Menninger Clinic · doi:10.1521/bumc.2018.82.4.288 · Cited by 2
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
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
“…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
Dixon, M. M. (2016) · J. Willard Marriott Library · doi:10.26053/0h-6086-d8g0 · Cited by 1
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
“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
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
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
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
Çoban, M. C. (2021) · Turk Turizm Arastirmalari Dergisi · doi:10.26677/tr1010.2021.901 · Cited by 1
Green, S. (2009) · International Journal of Orofacial Myology · doi:10.52010/ijom.2009.35.1.5 · Cited by 1
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
Emotion Regulation in the Obsessive‐Compulsive Spectrum Disorders
Napolitano, L. A. (2017) · Wiley eBooks · doi:10.1002/9781118890233.ch64 · Cited by 1
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
Keuthen, N., & Usmani, A. (2016) · Springer eBooks · doi:10.1007/978-1-4939-2605-3_9 · Cited by 2
Dombrowski, S. C., Gischlar, K. L., Mrazik, M., & Gordon, J. (2011) · Springer eBooks · doi:10.1007/978-1-4419-9970-2_7
Body-Focused Repetitive Behaviors
Grant, J. E., & Chamberlain, S. R. (2018) · Cambridge University Press eBooks · doi:10.1017/9781108164313.029
Metadata
- 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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