Emotional Experiences During Hair Pulling: New Research Insights

Dr. Dawn Ferrara
Jan 3rd, 2022

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When it comes to Trichotillomania (TTM), not all hair pulling is the same. While hair pulling is the dominant feature of TTM, research has revealed that the presentation of TTM is quite heterogenous. Research has found that there are distinct sub-types of TTM. These sub-types were identified as:

  • Subtype 1: Sensory-sensitive Pullers
  • Subtype 2: Low Awareness Pullers
  • Subtype 3: Impulsive/Perfectionist Pullers

Each of these subtypes has a unique set of clinical profile and constellation of symptoms that can be used to shape treatment approaches.

The ritual of hair pulling also differs between individuals. The pulling can be more automatic or more focused and intentional. Automatic pulling occurs when the person doesn’t realize that they’re pulling. The pulling often occurs while the person is engaged in activities such as reading or watching TV. With focused pulling, the person is responding to an overt urge to pull. There is a buildup on tension that is relieved by the act of pulling.

While this sub-typing is helpful diagnostically, it doesn’t really explain the underlying emotional motivations and the individual experiences of pulling. How one person experiences their pulling may be completely different from someone else with the same diagnosis. If there are sub-types of pulling behaviors, are there emotional dimensions that influence pulling behavior as well? One of the challenges of research into trich has been gathering information about individual hair pulling episodes and how these are experienced by the person in the moment. A new study takes a closer look at hair pulling and the role that emotions may play in pulling behavior.

Why Do Emotions Matter?

Cognitive Behavioral Therapy (CBT) and related therapies have been the predominant approach to treating hair pulling. CBT is based on the premise that how we think, how we feel, and how we behave influence each other. What behavior gets reinforced in that dynamic depends on the thoughts and feelings that are associated with the behavior.

While CBT and other related therapies have been successful in symptom reduction for many people, not everyone finds relief. Treatment gains are not always lasting. For some, treatment is not very effective at all.

CBT relies on a reinforcement model for behavior change, meaning that there is an emotional/motivational component that reinforces the desired behavior. It is unclear exactly why or how individual differences influence the effectiveness of treatment. From a cognitive-behavioral perspective, it is reasonable to consider whether there are different reinforcement patterns among people with TTM that may affect their response to treatment.

What Did the Study Find?

The study sought to take a closer look at sub-types of hair pulling to determine whether there might be sub-classes with differing emotional patterns associated with hair pulling. They collected data from over a thousand participants in an online treatment group for TTM that utilized a CBT-based program. Part of the program allowed participants to record certain information when they experienced hair pulling episodes, including emotions before and after the episode.

The results revealed that there are differences in the emotional response and reinforcement patterns among people who pull. Analysis of the data revealed that participant responses could be divided into six groups. Four of the groups showed the reinforcement patterns commonly associated with TTM, including the emotional relief associated with hair-pulling along with emotions such as shame or frustration. These groups differed primarily in their frequency of emotional activation. Together, they accounted for 73.2% of the participants.

The remaining two groups revealed some unexpected results. The fifth group (7.8% of the participants) showed little reinforcement in response to hair-pulling. They reported high emotional arousal but the emotions they experienced showed little change following a hair-pulling episode. Participants in this group reported more specific or extreme behaviors such as eating hair (trichophagia)  and pulling during the night.

The sixth group showed very little emotional activation during a hair pulling episode, leaving little opportunity for emotional reinforcement following the episode. They accounted for 18.9% of participants. It was suggested that co-occurring depression might be contributing to the low level of emotional arousal.

There were also some commonalities across the groups. All six groups reported increases in feelings of guilt following a pulling episode. However, there was little reduction in feelings of anxiety. While anxiety often co-occurs with TTM, this finding suggests that hair pulling employs an emotional process separate from the anxiety.  All six groups also reported feelings of satisfaction after pulling which is commonly seen in treatment settings.

What Does This Mean for Treatment?

This study builds on what was previously known about subtypes of hair pulling behavior and takes a closer look at the emotional underpinnings of hair pulling and reinforcement of the behavior. These findings suggest that there are significant differences between types of hair pulling as well as sub-groups whose emotional patterns don’t fit the current thinking about TTM and how it is reinforced. A substantial number of people (27% in this study) seem to have symptoms and reinforcement patterns that don’t conform to the current conceptualization of TTM. As such, they may not respond as well to conventional treatment.

Given the differences in reinforcement patterns, approaches that rely on traditional reinforcement models may not address the individual dynamics of TTM in some people. Treatment may provide incomplete symptom reduction or, for some, no relief. A treatment approach tailored to a person’s specific clinical profile and patterns may be more beneficial. Individualized care allows the person to heal and grow in the way that is the best fit for them.

Findings from this study speak to the need to understand and consider individual differences and emotional patterns for people with TTM. A considerable number of people may not “fit” the traditional model. They may need adjustments to their treatment plan that better address their unique emotional patterns and needs, as well as common co-occurring issues such as depression or insomnia. Individualized treatment creates a better fit and increases the chances for a successful outcome.

This research adds to the current understanding of hair pulling behavior. Better understanding brings hope for the development of more effective treatment methods and more successful treatment outcomes.



1. Grant, J. E., Peris, T. S., Ricketts, E. J., Lochner, C., Steins, D. J., Chamberlain, S. R., … Keuthin, N. J. (2020). Identifying subtypes of trichotillomania (hair pulling disorder) and excoriation (skin picking) disorder using mixture modeling in a multicenter sample. Journal of Psychiatric Research, in press. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0022395620310578?via%3Dihub

2. Myers, M. M. (2021). Latent Class Analysis of Emotions Experienced During Compulsive Hair-Pulling Episodes [Unpublished master's thesis]. Texas State University.https://digital.library.txstate.edu/bitstream/handle/10877/13506/MYERS-THESIS-2021.pdf?sequence=1


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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