Decision Making and Trichotillomania: What’s the Connection?

Dr. Dawn Ferrara
Oct 31st, 2021

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Decisions…we all make them. Sometimes we’re fully aware of the decisions we make. We think them through and choose our actions. Other times, though, we seem to be running on autopilot, and we just seem to end up where we are. Sometimes that works out just fine. Other times, we’re left wondering, “Why did I do that?” “What was I thinking?” Even when we’re not fully aware of our decisions, we make them a million times a day.

What do decisions have to do with hair pulling? Quite a lot actually.

If you or a loved one lives with a body-focused repetitive behaviors (BFRBs) like hair pulling, you’ve probably had the experience of someone asking why you do it and can’t you just stop? It’s frustrating for sure and there isn’t always a good answer. Hair pulling is complex and there are layers of reasons why it happens.

Researchers have found that people with BFRBs like trichotillomania (TTM) and skin picking disorder (SPD) have differences in the way they process information. Neuropsychological studies have found that people with hair pulling or skin picking disorders have structural differences in their brains compared to people that don’t have one of these disorders. People with TTM and SPD also show differences in their cognitive functions. People with TTM show impairments in inhibitory control, spatial working memory, divided attention, visuospatial learning, and immediate visual memory. Studies into skin picking are more limited but people with SPD tend to have an impaired stop-signal inhibitory control that makes it hard for them to stop picking at their skin. In other words, people with SPD also have a harder time controlling their behavior or knowing when to stop (greater impairment of inhibitory control), as compared to people with HPD. These differences don’t mean that people with BFRBs are somehow “broken”. It simply means that their brains seem to be structurally different and process information in ways that may make them more susceptible to developing a BFRB.

So, what does all of this neurocognitive information have to do with hair pulling and decision making? Researchers think quite a bit.

One area of cognitive functioning that has not been well-studied is that of decision making. Decision making is a key part of behavior and a necessary part of behavior change. Given what we know about the structural and cognitive differences in people with a hair pulling or skin picking disorder, it seems logical that decision making would be an area to be considered. There has been some research related to decision making in people with TTM, but virtually none with people with skin picking disorder. A new study seeks to take a deeper look at the relationship between decision making, TTM, and SPD.

Understanding Decision Making

When describing decision making, cognitive researchers generally categorize decision making as either decision making under risk or decision making under uncertain situations.

Decision making under risk involves giving the person information about the outcomes of a task and the reward-punishment risks. The information is straightforward, and the person knows the likely outcomes and risk/reward.

Decision making under uncertain situations means that the person is given information that implies possible outcomes, so the reward-punishment risk is unclear. How a person interprets these types of tasks is highly dependent on how their brain processes and interpret information. These processes are thought to be related to both the brain’s structure and function.

Decision-making under uncertain situations has not been previously studied in patients with TTM or SPD. Decision-making under uncertain situations is strongly associated with specific areas of the brain. Given what is known about structural brain and neurocognitive differences in people with TTM and SPD, further study seems prudent.

The Study

Researchers sought to explore decision making in people with TTM and SPD. A secondary objective was to explore possible differences between automatic and focused-type patterns of pulling/picking. A third objective was to assess the relationship between decision making and impulsivity. The study used an established gambling-style decision making measurement tool that included decision making under uncertain situations.

The study found that people with TTM have poor decision-making performance when compared with people who do not have TTM. Decision making performance under uncertainty for people with SPD was similar to people without SPD.

People with TTM tended to make more risky decision choices. They were more sensitive to immediate reward and their choices resulted in more losses. They tended to opt for the immediate reward without thinking about later consequences. This fits with TTM pulling behavior patterns. People with SPD and the control group tended to avoid risk more often.

Regarding focused vs. automatic styles, people who identified with the focused type of picking/pulling tended to show impairments in decision making. These findings are compatible with the focused type of behavior. A focused style is more deliberate and targeted. There is awareness of the behavior but continue anyway. Subjects in the focused-type group knew they were making risky choices and did so anyway.  

Interestingly, impulsivity was not found to be related to the decision-making performance of participants with either TTM or SPD. This finding suggests that attention does not affect decision-making performance.

What the Results Mean for TTM

In short, the results shed light on the “why” of TTM and SPD. The results of this study support previous findings that suggest decision-making, especially under uncertain situations, is impaired in people with TTM. These impairments may be related to being more prone to risk-taking and not learning from feedback. Difficulties with emotional regulation in the TTM group may have contributed to poor decision making behaviors.  

These results suggest that while neural circuitry is important to consider, it is also important to address the cognitive factors that play a role in decision making. Assessing decision making in clinical evaluation may lend additional information that can translate into more individualized treatment planning. Treatments should include both behavioral and cognitive elements to address behavioral change as well as aspects of emotional regulation and decision making.

Researchers have only touched the surface of how brain structure and neurocognitive functioning influence behaviors. Much more work needs to be done but each new piece of information brings researchers one step closer to finding treatments that can alleviate symptoms and improve quality of life.



1. Chamberlain, S. R., Blackwell, A. D., Fineberg, N. A., Robbins, T. W., & Sahakian, B. J. (2005). The neuropsychology of obsessive compulsive disorder: The importance of failures in cognitive and behavioural inhibition as candidate endophenotypic markers. Neuroscience & Biobehavioral Reviews, 29(3), 399–419. 10.1016/j.neubiorev.2004.11.006

2. 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.

3. Demirci, H., Aydın, E. P., Kenar, J. G., Özer, Ö. A., & Karamustafalıoğlu, K. O. (2021). Decision-making performance in trichotillomania and skin picking disorder. Journal of Obsessive-Compulsive and Related Disorders31, 100688.

4. Clark, L., Cools, R., & Robbins, T. (2004). The neuropsychology of ventral prefrontal cortex: Decision-making and reversal learning. Brain and Cognition55(1), 41-53.


Dr. Dawn Ferrara


With over 25 years of clinical practice, Dawn brings experience, education and a passion for educating others about mental health issues to her writing. She holds a Master’s Degree in Marriage and Family Counseling, a Doctorate in Psychology and is a Board-Certified Telemental Health Provider. Practicing as a Licensed Professional Counselor and Licensed Marriage and Family Therapist, Dawn worked with teens and adults, specializing in anxiety disorders, work-life issues, and family therapy. Living in Hurricane Alley, she also has a special interest and training in disaster and critical incident response. She now writes full-time, exclusively in the mental health area, and provides consulting services for other mental health professionals. When she’s not working, you’ll find her in the gym or walking her Black Lab, Riley.

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