Trichotillomania: The interplay between emotional states, urges and hair pulling episodes

Background Trichotillomania (TTM) is a body-focused repetitive behavior disorder characterized by recurrent hair pulling and psychosocial impairment. Although theoretical models emphasize emotion regulation as a key mechanism in TTM, the precise relationship between emotional states, urge intensity, and hair pulling behavior remains unclear. Objective This study examined the momentary interplay between affective states, urge intensity, and hair pulling episodes in daily life using Ecological Momentary Assessment (EMA). Methods Sixty-one Individuals diagnosed with TTM reported seven times daily for ten days on their hair-pulling behavior, urge intensity and current emotional states, resulting in 2557 data points with 702 reported hair-pulling episodes. Multilevel analyses were used to assess concurrent and prospective associations, with “prospective” referring to predictions of the subsequent assessment. Results Urge intensity was a robust predictor of hair pulling episodes, both concurrently and prospectively. Previous pulling episodes predicted subsequent episodes indicating some temporal stability over the course of the day. Boredom prospectively predicted hair pulling episodes, while tiredness prospectively predicted urge intensity. Negative affect and rumination were associated with stronger concurrent urges but did not predict subsequent urges or episodes. However, positive and negative affect were associated with the concurrent urge intensity. Conclusions Findings highlight the central role of urge intensity and boredom in the short-term emergence of hair pulling behavior. The results challenge models that focus primarily on emotional dysregulation and call for a more differentiated perspective on urge and behavior. Future etiological models should incorporate broader contextual, cognitive and sensory factors to better capture the mechanisms underlying TTM.