Why some people can’t stop pulling out their hair or picking their skin

Up to 220,000 Norwegians will, at some point in their lives, pick at their skin or pull out their hair to such an extent that it qualifies as a mental health disorder.

They pull out their hair until bald spots appear, or pick at their skin until it becomes sore.

“People feel a lot of shame and embarrassment. Not just because there's no hair there, but also because it's self-inflicted,” says Benjamin Hummelen. He is a specialist in psychiatry at Oslo University Hospital (OUS).

Researchers at NTNU and OUS have collaborated with several other institutions in Norway and abroad to take a closer look at some of the mechanisms that may underlie frequent and repetitive hair pulling and skin picking.

Multiple mental health disorders

Research shows that many who struggle with hair pulling and skin picking also suffer from other mental health disorders such as anxiety, depression, ADHD, and obsessive-compulsive disorder (OCD).

The researchers have now found that there is a close link between so-called early maladaptive schemas and both the severity and type of skin picking or hair pulling.

Therapists can therefore benefit from assessing these negative schemas in order to better understand their patients.

Schemas are developed at an early age

According to cognitive theory, all people develop various patterns of thoughts, emotions, and physical reactions during childhood. These influence how they view themselves and the world around them.

These schemas can be positive or negative, and they are shaped by experiences early in life. An example of a negative schema, or early maladaptive schema, is the belief that people will abandon you or not be there for you.

Early maladaptive schemas can influence the choices you make and the way you interact with the world and other people.

“Elevated levels of early maladaptive schemas are found in most patients with mental health disorders. Cognitive theory regards early maladaptive schemas as a kind of common denominator in mental health problems,” says Torun Grøtte.

She is an associate professor at NTNU'S Department of Psychology.

When does hair pulling and skin picking become a disorder?

Even though the repeated skin picking or hair pulling is self-inflicted, it does not mean that it is a deliberate action.

It is a behaviour that is difficult to stop.

There are two different patterns that characterise the behaviour:

• Some people pull out their hair or pick at their skin without even being aware of it, completely unconsciously. They often do it while concentrating on something else, such as driving or watching a TV show.

• The other pattern is more focused and deliberate skin picking and hair pulling. The act itself can alleviate negative emotions or boredom, and it can also produce a pleasurable feeling.

Most people pull their hair or pick at their skin occasionally, without it being a problem.

A disorder associated with shame

Grøtte explains that the behaviour is only diagnosed as a disorder when it significantly affects a person's quality of life and ability to function.

"It must be distressing and affect how you function at work, school, or socially,” she says.

Some people spend several hours a day pulling their hair out or picking at their skin, and they may also spend a lot of time trying to conceal the damage it causes.

"They may use hats, wigs, or false eyelashes to conceal bald spots, or apply makeup to cover wounds and scars. There is a great deal of shame associated with these disorders,” says Grøtte.

Aimed to get a better understanding

Previous research has shown that people with strong early maladaptive schemas also tend to exhibit more severe symptoms of various mental health disorders, such as OCD, depression, and schizophrenia. They also tend to respond less well to treatment.

The researchers aimed to gain a better understanding of the role early maladaptive schemas play in hair-pulling and skin-picking disorders.

The 283 patients in the study had either hair-pulling, skin-picking, or obsessive-compulsive disorder. They were asked to complete a survey before they began treatment.

Throughout the project, these patients receive a form of cognitive behavioural therapy. The researchers will follow the patients throughout treatment and also for several years afterwards.

Often felt like failures

The study found that patients who had both severe and multiple symptoms of hair-pulling and skin-picking disorders also had high levels of early maladaptive schemas.

The researchers were not surprised by this. What they did not expect, however, was that there would be so few differences between patients with hair-pulling disorder, skin-picking disorder, and obsessive-compulsive disorder.

The researchers also found that patients with hair-pulling disorder more often felt like failures, suppressed their own needs, felt different from others and that they did not fit in.

Self-sacrifice was common in patients with skin-picking disorder, and they too often felt like failures.

Differences in conscious and unconscious behaviours

Another interesting finding was that there were differences between patients who picked at their skin or pulled out their hair deliberately and those who did it unconsciously.

Participants who picked or pulled in a focused manner had higher levels of early maladaptive schemas. This may suggest that the link is particularly strong among people who use these behaviours to cope with negative emotions, according to Grøtte.

She explains that the researchers plan to continue studying the correlation between early maladaptive schemas and hair-pulling and skin-picking disorders.

“Is it the case that people who score high on early maladaptive schemas have poorer treatment outcomes? It would be interesting to find out,” says Grøtte.

The researchers are already well underway with the follow-up studies.

“We have a lot of interesting data to look at,” says Hummelen.

Reference:

Flagstad et al. Early maladaptive schemas in trichotillomania and skin-picking disorder: their relationships with symptom severity and subtypes, BMC Psychology, 2025. DOI: 10.1186/s40359-025-03096-y

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