When Mia was 14, she finally typed the question she’d been too scared to ask: “Why can’t I stop pulling my hair?”
The internet gave her a word she had never heard before: trichotillomania, which is a body-focused repetitive behaviour (BFRB). An NHS page described it as a “habit”, but it didn’t feel like one to Mia. It felt like something deeper, heavier and sometimes completely outside her awareness. When she built up the courage to speak to her school counsellor, they frowned and said, “I don’t know what that is, but maybe try a stress ball?” This story is fictional but based on the lived realities of many with trichotillomania (hair-pulling disorder).
Trichotillomania (TTM) and skin-picking disorder (SPD) are not rare, yet they remain misunderstood, minimised, or dismissed as “bad habits” (Mackay, 2023). People usually describe two different experiences of pulling or picking:
- focused episodes, a deliberate, conscious behaviour and
- automatic episodes, when it happens without them noticing, almost like being on autopilot (Grant & Chamberlain, 2021).
Researchers are beginning to explore what drives these behaviours.
One area of focus is early maladaptive schemas (EMSs). Schemas are made up of memories, emotions and beliefs about ourselves and other people. EMSs develop when important needs are not met in childhood and can become powerful internal messages that influence how we manage difficult feelings (Bishop et al., 2021; Ke & Barlas, 2018). EMSs have been linked to higher symptom severity in several mental health conditions (Dostal and Pilkington, 2023), but we don’t know if these same patterns are also relevant for TTM or SPD.
This is explored by Flagstad and colleagues (2025), who investigate the relationship between EMSs and symptom severity and pulling/picking styles in TTM and SPD, as well as how this compares to obsessive compulsive disorder (OCD).
Hair-pulling and skin-picking disorders affect 2-4% of the population, yet are under-researched, under-recognised and under-treated.
Methods
This was a cross-sectional study using baseline (pre-treatment) data from 283 treatment-seeking adults in Norway with a diagnosis of TTM (n = 120), SPD (n = 75) or OCD (n = 88), the majority of whom were women (84.76%). There were some significant differences between the groups, including age, sex, employment status. The researchers also noted that not all comorbidities were fully assessed or available, which limited how much they could adjust for these differences in the analyses.
EMSs was measured through the Young Schema Questionnaire–Short Form, alongside validated self-report measures of pulling/picking severity and subtypes (automatic and focused). Clinicians also completed a rating of overall illness severity using the Clinical Global Impression Severity scale (CGI-S) for the TTM and SPD groups.
The authors then used ANCOVA to compare schema scores between groups (controlling for age and illness duration) and correlational analyses to explore relationships between schemas and symptom severity or pulling/picking style.
Results
No group differences in schema levels
- Across TTM, SPD and OCD, there were no significant differences in EMSs, with all three groups showing similarly elevated levels.
- This indicates that elevated levels of EMSs are transdiagnostic and not specific to one disorder.
- The OCD group did not show higher or lower schema levels than the TTM or SPD groups, even though some differences had been expected based on earlier research.
Schemas were linked with symptom severity
- There were small to moderate associations between EMSs and pulling or picking severity.
- For TTM, higher scores on several schemas (including failure and social isolation) were linked with more severe pulling on self-report and clinician ratings. This means that people who endorsed beliefs like “I’m not good enough,” tended to experience more intense or distressing pulling urges.
- For SPD, the pattern was weaker but still present: schemas such as shame and abandonment were associated with greater picking severity. This suggests that people who hold these beliefs also tend to report more severe picking, although the study cannot explain why these patterns occur.
Focused pulling/picking showed the strongest links to schemas
- Schemas were more strongly connected to focused pulling and picking; the type of behaviours people do intentionally or in response to emotional states.
- In TTM, focused pulling was significantly related to nine different schemas, while automatic pulling showed almost no meaningful associations.
- A similar pattern appeared in SPD: focused picking was linked to schemas such as abandonment and mistrust, but automatic picking was not.
- This means that focused-driven pulling and picking seems to be more tied to people’s underlying beliefs, while automatic behaviours showed no such pattern in this study.
Individuals who’s pulling and picking behaviours tended to be driven by their emotions had higher levels of early maladaptive schemas.
Conclusion
The authors conclude that EMSs (early maladaptive schemas) are common across Hair Pulling (Trichotillomania – TTM), Skin-Picking Disorder (SPD) and Obsessive Compulsive Disorder (OCD), supporting their transdiagnostic relevance.
They also suggest that schemas may deepen our understanding of why some people pull or pick in more emotionally-driven, focused ways. They argue that assessing schemas in clinical settings may help clinicians develop a fuller picture of patients’ experiences, including underlying behavioural drivers, which may aid the tailoring of interventions.
This study provides preliminary evidence to suggest that early maladaptive schemas are common across hair-pulling, skin-picking and OCD, supporting their role as a shared, transdiagnostic feature of these conditions.
Strengths and limitations
This study makes a valuable contribution to an area where high-quality research is scarce. It draws on one of the largest clinical samples of TTM and SPD to date, and it includes an OCD comparison group. This is beneficial because larger samples allow more accurate estimates of schema patterns, and the OCD group provides a meaningful benchmark for testing whether these patterns are shared across disorders. The researchers used validated and widely recognised measures, and their statistical approach was careful, with appropriate checks for normality and adjustments for multiple comparisons. This helps increase our trust that the findings they reported are real, rather than resulting from chance or poor measurement.
However, there are several limitations. One important methodological omission is the absence of a power calculation. Although the overall sample appears large, without knowing whether the study was adequately powered, we cannot be sure whether the similarities between groups reflect genuine psychological overlap or the limits of the sample size and analytical design.
The study was also cross-sectional, meaning all data were collected at a single time point. This makes it impossible to determine causality: we cannot know whether certain schemas contribute to more severe pulling and picking, or whether years of struggling with a BFRB shape how people see themselves and others. Longitudinal designs are needed to understand directionality.
A further limitation is the lack of gender diversity in the sample, with most participants being women. Population studies show that these conditions affect people of all genders (Grant et al., 2020), so the underrepresentation of men in this study limits the generalisability of these findings.
The handling of missing data introduces further uncertainty. Almost a third of the original sample did not complete the schema questionnaire and there was a lot of missing information about depression and anxiety. Because of this, the researchers could not adjust for these conditions in their main analyses. This matters because the groups differed in their rates of depression, so some of the “no difference” findings may reflect unmeasured comorbidities rather than true similarity.
Finally, some clinically important experiences were not captured. For example, many individuals describe “trance-like” pulling or picking (Mayerson et al., 2025), which does not map neatly onto the focused versus automatic distinction used in the study. It remains unclear how these dissociative or absorbed states relate to schemas, and this gap limits the study’s ability to fully represent the lived experience of TTM and SPD.
Many individuals who hair-pull or skin-pick describe being in a “trance”, entering an altered state of consciousness that makes the behaviour feel all-consuming. This type of experience was not accounted for within the study.
Implications for practice
This study offers an important reminder that conditions like TTM and SPD are not simply “bad habits”. The associations between focused pulling or picking and deeper belief patterns suggest that people may be using these behaviours to manage intense emotions, shame or fears of abandonment. For clinicians, this means going beyond surface behaviours and asking what the pulling or picking does for the person in moments of distress. Schema-informed formulations may help people understand why urges feel overwhelming at certain times, why they fluctuate and why behavioural skills alone are sometimes not enough (Haaland et al., 2011).
Many people, like Mia in the opening story, still encounter professionals who have never heard of these disorders. Improving basic knowledge at the level of schools, GPs, and frontline mental health workers could reduce shame and speed up access to specialist care. For services, the study signals the importance of assessing comorbidities such as depression and anxiety, which may interact with schemas and shape the experience of pulling and picking. Because the study could not adjust for these due to missing data, future clinical work should routinely screen for and address them.
For researchers, these findings raise new questions:
- Do schema-focused interventions improve outcomes when added to behavioural treatments like Habit Reversal Therapy?
- How do trance-like or dissociative pulling episodes fit into this picture? and
- Could schemas help explain why some people move between automatic and focused pulling across their lives?
Improving basic knowledge of hair-pulling and skin-picking in schools, primary care, and frontline mental health care is a vital first step to begin reducing the shame associated with body-focused repetitive behaviours, and speed up access to support.
Statement of interests
Laura Lee – None.
Edited by
Dr Nina Higson-Sweeney.
Links
Primary paper
Ella Flagstad, Benjamin Hummelen, Erna Moen, Toril Dammen, Åshild Haaland, Tor Sunde, Bjarne Hansen, Diana Strand Johnsen, Douglas Woods, Torun Grøtte (2025). Early maladaptive schemas in trichotillomania and skin-picking disorder: Their relationships with symptom severity and subtypes. BMC Psychology, 13, 789. https://doi.org/10.1186/s40359-025-03096-y
Other references
Bishop, A., Younan, R., Low, J., & Pilkington, P. D. (2022). Early maladaptive schemas and depression in adulthood: A systematic review and meta‐analysis. Clinical Psychology & Psychotherapy, 29(1), 111-130. https://doi.org/10.1002/cpp.2630
Grant, J. E., & Chamberlain, S. R. (2021). Automatic and focused hair pulling in trichotillomania: Valid and useful subtypes? Psychiatry Research, 306, 114269. https://doi.org/10.1016/j.psychres.2021.114269
Grant, J. E., Dougherty, D. D., & Chamberlain, S. R. (2020). Prevalence, gender correlates, and co-morbidity of trichotillomania. Psychiatry Research, 288, 112948. https://doi.org/10.1016/j.psychres.2020.112948
Haaland, A. T., Vogel, P. A., Launes, G., Haaland, V. Ø., Hansen, B., Solem, S., & Himle, J. A. (2011). The role of early maladaptive schemas in predicting exposure and response prevention outcome for obsessive-compulsive disorder. Behaviour Research and Therapy, 49(11), 781–788. https://doi.org/10.1016/j.brat.2011.08.007
Ke, T., & Barlas, J. (2020). Thinking about feeling: Using trait emotional intelligence in understanding the associations between early maladaptive schemas and coping styles. Psychology and Psychotherapy: Theory, Research and Practice, 93(1), 1-20. https://doi.org/10.1111/papt.12202
Mackay, C. E. (2023). Trichotillomania: a perspective synthesised from neuroscience and lived experience. BMJ Mental Health, 26(1). https://doi.org/10.1136/bmjment-2023-300795
Mayerson, T. F., Waite, P., & Mackay, C. (2025). The mediating role of shame in the relationship between adolescent hairpulling and co-occurring anxiety and depressive symptomology. JCPP Advances, e70041. https://doi.org/10.1002/jcv2.70041
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