Imagine your teenage self and everything you had to navigate: growing independence, changing physiology, and strong emotions, just to name a few. Think of the shame that can often be felt as part of this and how intense this can feel for 14-year-old you. Now, add to this the fact that you have trichotillomania, also known as hairpulling disorder. Not only are you navigating the typical challenges of adolescence, but you have also started to compulsively pull your hair.
Trichotillomania is a body-focused repetitive behaviour (BFRB) that involves the compulsive pulling of one’s own hair and typically emerges in early adolescence (Christensen et al., 2023). Approximately 1% of adolescents have clinically diagnosable trichotillomania, with much higher numbers estimated for hairpulling behaviours within the general population (Grzesiak et al., 2017; Moreno-Amador et al., 2023). Depression and anxiety commonly co-occur with trichotillomania, with estimates of comorbidity ranging from ~10-40% (Grant et al., 2020; Lochner et al., 2019). It is currently unclear what psychological mechanisms underpin the relationship between trichotillomania, depression, and anxiety. The most common explanations are emotion regulation (Roberts et al., 2013) and the comprehensive behavioural model (ComB) of hairpulling (Mansueto et al., 1997). Within both models, negative emotions and self-evaluation are key. Not only are negative self-evaluative emotions integral to the onset and maintenance of hairpulling, but they have also been linked to both depression and anxiety. One such negative emotion is shame.
Shame is characterised by the experience of self-conscious and self-condemning emotions through which an individual scrutinises and negatively evaluates themselves, as well as their behaviour (Noble et al., 2017). Shame is a commonly reported feeling among hairpullers and has been linked to greater symptom severity, as well as depression and anxiety. Yet despite the link between shame and symptom severity, and the key role of adolescence in the onset and maintenance of hairpulling, there has been little to no research examining the role of shame in adolescent hairpullers. This is where Mayerson et al. (2025) come in.
Hairpulling often begins in early adolescence, with estimates that 1% of adolescents have clinically diagnosable hairpulling disorder. This statistic is much higher for hairpulling behaviours generally.
Methods
To learn more about the phenomenology of hairpulling in adolescents and to explore the role of shame in adolescent hairpulling and cooccurring depression and anxiety, Mayerson and colleagues (2025) employed a cross-sectional survey design. They recruited a community-based sample via social media, BFRB forums and charity websites. Participants completed five online questionnaires, the first of which was created by the authors specifically for this study. The authors chose to create their own measure of hairpulling phenomenology, drawing from their own lived experience and views from hairpullers reflected in qualitative studies. The particular focus of this was to establish the prevalence of ‘trance’ pulling, different from previously documented ‘automatic’ pulling, a commonly researched but disputed subtype of trichotillomania. The remaining questionnaires were established measures of hairpulling severity in children, shame, depression and anxiety.
Results
One-hundred and twenty-eight participants completed the survey, aged between 13-18 (M = 16.8, SD = 1.3), with 78.9% identifying as female and 50% identifying as white. Most participants were from the UK (43.8%), followed by North America (33.6%).
The phenomenology of hairpulling in adolescents
Adolescents most frequently pulled from their scalp (75%), followed by the pubic area (57%), with most participants reporting pulling from multiple sites (80.5%). In terms of pulling style, approximately half reported ‘usually’ or ‘always’ pulling without realising and over three-quarters ‘usually’ or ‘always’ specifically searched out hairs with a particular feeling to pull. For post-pulling rituals, over three-quarters at least ‘usually’ looked at the hair or root afterwards and two-thirds either ‘usually’ or ‘often’ rubbed the hair or root afterwards.
A unique aspect to this research was exploring the trance-like nature of hairpulling, which is a core feature of trichotillomania. In this sample, 88% reported pulling in a trance at least ‘some of the time’ and 61.8% reported that they experienced this ‘usually’ or ‘always’. This makes trance-pulling more prevalent than several other commonly discussed hairpulling features and one of the most frequent phenomenological experiences reported.
The mediating role of shame
Regression and mediation analyses found that:
- Shame (r = 0.339), depression (r = 0.355), and anxiety (r = 0.266) all significantly positively correlated with hairpulling symptom severity in adolescents
- Shame significantly positively correlated with anxiety (r = 0.472) and depression (r = 0.620)
- Shame partially mediated the relationship between hairpulling severity and depression
- Shame fully mediated the relationship between hairpulling severity and anxiety
These findings demonstrate that higher levels of hairpulling severity are associated with higher levels of shame and depression, and that shame partially mediates the relationship between depression and symptom severity. This suggests that shame explains some of the relationship between how severe hairpulling is and how severe depression is in adolescents – but not all. This is in contrast to findings in relation to anxiety, where shame fully explained the relationship between anxiety and hairpulling severity.
88% of participants reported hairpulling in a trance-like state, with a further 61.8% reporting that they usually or always hairpulled in this way.
Conclusions
Mayerson et al. (2025) found that in adolescents, shame appears to play a role in the relationship between hairpulling and co-occurring anxiety and depression. The partial mediation for depression indicates that shame is important but other mechanisms are likely also involved. Interestingly, however, the full mediation between anxiety and hairpulling severity implies that this relationship can be explained by feelings of shame.
Furthermore, findings from this study suggest that the phenomenology of hairpulling in adolescents is highly comparable to that of adult hairpulling. Importantly, the authors also found compelling evidence for trance-pulling in adolescents, distinct from low awareness or ‘automatic’ pulling, suggesting the commonly described ‘subtypes’ (‘automatic’ vs ‘focused’ pulling) of trichotillomania may not be accurate classifications of the condition.
In this study, shame fully mediated the relationship between anxiety and hairpulling severity in adolescents, but only partially mediated the relationship between depression and hairpulling severity.
Strengths and limitations
There are several strengths to this study, most notably that it provides novel research in a largely under researched area. By examining hairpulling phenomenology and the psychological role of shame in adolescents, a population notably absent from much of the existing BFRB literature, the study makes a valuable contribution to research on trichotillomania. A further strength is the use of lived experience to guide the research. Using qualitative data and the lived experience of the research team adds to the ecological validity of this study, helping to build our understanding of hairpulling from the perspective of those that actually pull their hair, rather than from scientists looking to explain behaviour they see but do not feel. In such an under researched area it is vital to draw on the lived experience of individuals with trichotillomania to deepen our understanding of the condition in a meaningful way.
However, the strength of this research is also a potential limitation. The introduction of a novel hairpulling phenomenology questionnaire allowed the authors to access experiences, such as trance-pulling, that are not well captured by existing measures. However, without psychometric validation, these findings are best understood as descriptive rather than definitive. The prominence of trance-pulling in the results is theoretically intriguing, but its interpretation is necessarily provisional. To address this future research could aim to test the construct validity and internal reliability of the new scale.
One final point to consider is how the recruitment process may have shaped the sample. The retained sample was recruited predominantly via Reddit and Instagram, largely through BFRB‑specific online communities and influencer‑linked content. This suggests that the findings may disproportionately reflect the experiences of adolescents already engaged with hairpulling‑related online spaces, who may have higher severity symptoms and/or have more awareness of their own hairpulling. Future research could aim to recruit a wider sample from the general population as it is likely that prevalence of hairpulling behaviours in the general adolescent population are higher but also on a greater scale from encapsulating individuals with low severity that are unaware of their pulling as a condition.
A strength and a limitation of this research is the introduction of a novel hairpulling phenomenology measure. By designing it based on lived experience, it likely more accurately represents the experiences of those with trichotillomania. Conversely, its novelty means it hasn’t been psychometrically tested.
Implications for practice
Returning to that imagined 14‑year‑old version of yourself, the findings of this study feel particularly meaningful. This research suggests that for many adolescents who hairpull, shame is not simply an unfortunate by‑product of the behaviour, but a psychologically active process that may shape emotional distress and co‑occurring anxiety and depression. For that young person, this matters.
In practice, these findings invite a shift in emphasis for treatment of trichotillomania in adolescents. Currently, interventions for adolescent hairpulling have often prioritise behavioural control (e.g., habit reversal training), becoming more aware of pulling, interrupting the behaviour, and learning competing responses (Rahman et al., 2017). While these strategies can be helpful, this evidence suggests that focusing on behaviour alone risks overlooking the emotional processes that may sustain distress. If shame plays a central role in how hairpulling feels and how it connects to broader mental health difficulties, then interventions that explicitly address shame, self‑criticism, and self‑evaluation may be crucial. This may include greater integration of compassion‑focused, acceptance‑based, or emotion‑regulation approaches alongside behavioural work. Indeed, there are some early signs of research that shows some efficacy to taking such an approach with adult trichotillomania (Ong et al., 2023) and thus would warrant further exploration.
The findings also highlight the importance of how clinicians talk about hairpulling with young people. Framing hairpulling purely as something to be “stopped” or “controlled” may inadvertently reinforce shame, particularly for adolescents who experience pulling as trance‑like and difficult to interrupt. Normalising the emotional context of hairpulling, acknowledging the loss of control many young people report, and creating space to discuss shame openly may already represent a meaningful shift in practice.
The study also opens important avenues for future research. Longitudinal work is needed to understand how shame, hairpulling, anxiety, and depression influence one another over time, and whether reducing shame through therapeutic intervention reduces hairpulling severity for adolescents. Further development and validation of measures capturing phenomenological experiences such as trance-pulling would also allow these experiences to be integrated more fully into theory and treatment.
For that younger imagined self, this research offers something quietly powerful: a reframing. Hairpulling is not simply a bad habit or a failure of control, but an experience embedded in emotion, vulnerability, and self‑evaluation. Recognising this does not immediately solve the problem, but it does offer a more compassionate and potentially more effective place to begin.
Interventions for trichotillomania in adolescents could focus on reducing shame rather than focusing solely on the behaviour of hairpulling, which risks overlooking the underlying emotional processes behind a greatly misunderstood condition.
Statement of interests
Courtney Taylor Browne Luka has no conflicts of interest to declare.
Edited by
Dr Nina Higson-Sweeney.
Links
Primary paper
Talia Mayerson, Clare Mackay, & Polly Waite. (2024). 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
Other references
Christensen, R. E., Tan, I., & Jafferany, M. (2023). Recent advances in trichotillomania: A narrative review. Acta Dermatovenerologica Alpina, Pannonica, Et Adriatica, 32(4), 151–157.
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
Grzesiak, M., Reich, A., Szepietowski, J. C., Hadryś, T., & Pacan, P. (2017). Trichotillomania Among Young Adults: Prevalence and Comorbidity. Acta Dermato-Venereologica, 97(4), Article 4. https://doi.org/10.2340/00015555-2565
Lochner, C., Keuthen, N. J., Curley, E. E., Tung, E. S., Redden, S. A., Ricketts, E. J., Bauer, C. C., Woods, D. W., Grant, J. E., & Stein, D. J. (2019). Comorbidity in trichotillomania (hair-pulling disorder): A cluster analytical approach. Brain and Behavior, 9(12), e01456. https://doi.org/10.1002/brb3.1456
Mansueto, C. S., Townsley Stemberger, R. M., McCombs Thomas, A., & Goldfinger Golomb, R. (1997). Trichotillomania: A comprehensive behavioral model. Clinical Psychology Review, 17(5), 567–577. https://doi.org/10.1016/S0272-7358(97)00028-7
Moreno-Amador, B., Cervin, M., Falcó, R., Marzo, J. C., & Piqueras, J. A. (2023). Body-dysmorphic, hoarding, hair-pulling, and skin-picking symptoms in a large sample of adolescents. Current Psychology, 42(28), 24542–24553. https://doi.org/10.1007/s12144-022-03477-1
Noble, C. M., Gnilka, P. B., Ashby, J. S., & McLaulin, S. E. (2017). Perfectionism, Shame, and Trichotillomania Symptoms in Clinical and Nonclinical Samples. Journal of Mental Health Counseling, 39(4), 335–350. https://doi.org/10.17744/mehc.39.4.05
Ong, C. W., Woods, D. W., Franklin, M. E., Saunders, S. M., Neal-Barnett, A. M., Compton, S. N., & Twohig, M. P. (2023). The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings. Behaviour Research and Therapy, 164, 104302. https://doi.org/10.1016/j.brat.2023.104302
Rahman, O., McGuire, J., Storch, E. A., & Lewin, A. B. (2017). Preliminary Randomized Controlled Trial of Habit Reversal Training for Treatment of Hair Pulling in Youth. Journal of Child and Adolescent Psychopharmacology, 27(2), 132–139. https://doi.org/10.1089/cap.2016.0085
Roberts, S., O’Connor, K., & Bélanger, C. (2013). Emotion regulation and other psychological models for body-focused repetitive behaviors. Clinical Psychology Review, 33(6), 745–762. https://doi.org/10.1016/j.cpr.2013.05.004