Hair Pulling and Emotional Regulation: It’s Complicated

Nail biting or even picking at a scab just a bit too much is something most of us have done. We’ve done it and been able to stop. For some people though, the urge to pull or pick continues and can even become too much to resist. Why does that happen?

Habitual nail biting, hair pulling, and skin picking are collectively referred to as body-focused repetitive behaviors (BFRBs). These recurrent, destructive behaviors directed toward the body are thought to be triggered by some unpleasant emotional state. They’re not uncommon and many people engage in these behaviors from time to time (e.g., nail biting) but do so at subclinical levels that create little or no distress. For others, however, their emotions somehow get misdirected, and the result is destructive body-focused behaviors like chronic, repetitive skin-picking and hair-pulling.

How this process happens is not exactly clear. Take a look at the literature related to hair pulling and other BFRBs and you’re bound to come across a lot of support for the idea that hair pulling, skin picking, nail biting, and other BFRBs are a result of emotional dysregulation (ED). Emotional dysregulation (ED) is the inability to respond to and manage emotions effectively. It involves the repeated use of strategies to regulate emotions that may be effective in the short term but ultimately result in further emotional and physiological distress or contribute to physical, personal, or psychosocial distress.

But is the development of hair pulling as straightforward as poor emotional regulation? New research suggests that, at least for adults, BFRBs like hair pulling may not serve an emotional regulation function but rather be part of a larger response. In a departure from the current popular emotional regulation models, the researchers propose a more integrative approach to the emotional regulation model that considers the role of other factors including childhood trauma and perceived stress (a subjective assessment of how stressful someone considers their situation). The results suggest that understanding hair pulling is a little more complex than you might think.

The Emotional Regulation Model Revisited

A number of models have been proposed to explain hair pulling behavior but most focus on emotional regulation as the basis for the behavior. The most well-known model is the Emotional Regulation (ER) Model. This model proposes that people with trichotillomania (TTM) have a general deficit in ER, meaning that their ability to regulate their emotions is impaired. As a consequence, they engage in hair pulling in an effort to alleviate a negative emotional state. As distress is alleviated, the behavior is reinforced creating a behavior loop of sorts. However, the response doesn’t solve or alleviate the underlying trigger. When the trigger comes again, the response, in this case hair pulling, is the same. Although the hair pulling causes distress, it is maintained by both negative (relief) and positive (stimulation) reinforcement. Over time, what was initially a quick emotional pain reliever becomes a problematic behavior pattern. The hair pulling becomes part of a habitual response pattern that repeats.

The researchers suggest that gaps exist in the current literature and that few studies have explored the relationship between issues such as childhood trauma, perceived stress, emotional dysregulation, and hair-pulling severity. For example, high rates of childhood adversity has been shown to be more prevalent in people with TTM. Higher levels of perceived stress are also linked with hair pulling. This new study sought to assess the ER model by investigating associations between these variables in hair pulling behavior.

The Results

The findings of this study suggest that variables such as childhood trauma/adversity, perceived stress, emotional dysregulation, and symptom severity do indeed contribute to hair pulling but maybe not in the ways previously thought.

Perceived stress was associated with emotion dysregulation in both the TTM group and the control group. Not only was perceived stress significantly higher in the TTM group as compared to the control group, but it was also the only variable in the study that predicted significant variance in emotion dysregulation in the TTM group. However, the association between stress and emotional dysregulation was also present in the control group, and is not unique to people with TTM.

Not unexpectedly, higher rates of childhood trauma, perceived stress and emotional dysregulation were reported in the TTM group. However, emotional dysregulation was not related to hair pulling severity. This finding is a significant departure from previous findings.

Based on the findings, the researchers speculate that childhood trauma, perceived stress and emotional dysregulation may play more of a contributory role in hair pulling. Results also suggest that other factors may play a role in hair pulling including habit formation, disinhibition, and dissociative behaviors.

The Limitations

This is one of the first studies to assess the ER model in this way. The researchers acknowledge that more research is needed and that the study has limitations.

The findings are the result of self-report measures, even though the assessment tools they used are well-established and statistically sound. The majority of the participants were female. This is not unusual but prevents generalization to males. The TTM group was significantly older than the control group but age was not found to be significantly associated with emotional regulation in any of the groups. Sample size was relatively small.

Despite the limitations of the study, it contributes to the literature and provides additional insight into the emotional regulation difficulties in people with TTM by exploring the relationships between emotion dysregulation, childhood trauma, perceived stress, and hair-pulling severity.

The Takeaway

Finding no association between emotional dysregulation and hair pulling severity, along with the fact that perceived stress and emotion dysregulation are not specific to people with TTM suggest that factors other than emotion dysregulation may contribute to hair-pulling. Just how these factors interact remains to be discovered and more research is needed in this area.

Regarding treatment for TTM, the current findings support the need for accurate assessment of possible contributing factors to a person’s hair pulling behavior. Managing stressors and development of constructive emotional regulation strategies may contribute to more positive treatment outcomes.

References

1. Lochner, C., Demetriou, S., Kidd, M., Coetzee, B., & Stein, D. J. (2021). Hair-Pulling Does Not Necessarily Serve an Emotion Regulation Function in Adults With Trichotillomania. Frontiers in psychology, 12, 675468. https://doi.org/10.3389/fpsyg.2021.675468

2. Roberts, S., O'Connor, K., Aardema, F., Bélanger, C., & Courchesne, C. (2016). The role of emotion regulation in body-focused repetitive behaviours. The Cognitive Behaviour Therapist, 9, E7. doi:10.1017/S1754470X16000039

3. Lochner, C., du Toit, P. L., Zungu-Dirwayi, N., Marais, A., van Kradenburg, J., Seedat, S., Niehaus, D. J., & Stein, D. J. (2002). Childhood trauma in obsessive-compulsive disorder, trichotillomania, and controls. Depression and anxiety, 15(2), 66–68. https://doi.org/10.1002/da.10028

4. Grant, J. E., Leppink, E., & Chamberlain, S. (2015). Body focused repetitive behavior disorders and perceived stress: Clinical and cognitive associations. Journal of Obsessive-Compulsive and Related Disorders, 5, 82-86. doi:10.1016/j.jocrd.2015.02.001

5. Shusterman, A., Feld, L., Baer, L., & Keuthen, N. (2009). Affective regulation in trichotillomania: Evidence from a large-scale internet survey. Behaviour Research and Therapy, 47(8), 637-644. doi:10.1016/j.brat.2009.04.004