Skip to main content

Parental Bonding in Trichotillomania and Skin Picking Disorder



One means of understanding the effect of environmental factors on psychiatric disorders is by examining perceived parenting behavior in the childhood of individuals with trichotillomania and skin picking disorder (i.e. body focused repetitive behaviors (BFRBs)). We hypothesized that adults with BFRBs would show higher scores on dimensions of “care” and “overprotection”. Specifically, we predicted that adults with BFRBs would have parents in the “affectionate constraint” quadrant, based on a combination of high care and high protection scores.


We assessed demographic and clinical differences in 184 adults between the ages of 18 and 65 with Trichotillomania (TTM) (n = 43) and Skin Picking Disorder (SPD) (n = 75), and both (n = 66). The Parental Bonding Instrument (PBI) measured “care” and “overprotection” items. Results from the PBI were compared across groups and with normal control data using independent sample t-tests.


Individuals in the BFRB group had significantly lower maternal and paternal care scores compared to controls. The TTM, SPD, and TTM + SPD (combined) groups all had lower maternal care scores than controls. The TTM + SPD (combined) group had significantly lower paternal care scores and higher maternal protection scores than the normative averages. The most common parenting patterns in subjects with BFRBs were maternal and paternal affectionless control (low care/high protection). From our sample, only 27 % reported optimal maternal parenting and 28 % reported optimal paternal parenting.


These preliminary data suggest that low maternal and paternal care may be associated with BFRBs. However, the nature of this relationship should be further explored, as these results do not necessarily mean that affectionless control parenting leads to a predisposition to BFRBs, and there may in fact be other environmental factors at play. Identifying how individuals perceive familial relationships may provide direction for clinicians in developing tools to address the burden caused by BFRBs.

This is a preview of subscription content, access via your institution.

Availability of Data and Material

Data not available without a data sharing agreement due to confidentiality.


  1. Bohne A, Wilhelm S, Keuthen NJ, Baer L, Jenike MA. Skin picking in German students: Prevalence, phenomenology, and associated characteristics. Behav Moodif. 2002;26(3):320–39.

    Article  Google Scholar 

  2. Teng EJ, Woods DW, Twohig MP, Marcks BA. Body-focused repetitive behavior problems: Prevalence in a nonreferred population and differences in perceived somatic activity. Behavior Modif. 2002;26(3):340–60.

    Article  Google Scholar 

  3. Murphy YE, Flessner CA. Family functioning in paediatric obsessive compulsive and related disorders. Br J Clin Psychol. 2015;54(4):414–34.

    Article  PubMed  Google Scholar 

  4. Reeve EA, Bernstein GA, Christenson GA. Clinical characteristics and psychiatric comorbidity in children with trichotillomania. J Am Acad Child Adol Psychiatr. 1992;31(1):132–8.

    Article  CAS  Google Scholar 

  5. Keuthen NJ, Fama J, Altenburger EM, Allen A, Raff A, Pauls D. Family environment in adolescent trichotillomania. J Obsess Compul Rel Disorders. 2015;2(4):366–74.

    Article  Google Scholar 

  6. Peris TS, Rozenman M, Gonzalez A, Vreeland A, Piacentini J, Tan PZ, Ricketts EJ. Family functioning in pediatric trichotillomania, obsessive compulsive disorder, and healthy comparison youth. Psychiatr Res. 2019;281:112578.

    Article  Google Scholar 

  7. Moore PS, Franklin ME, Keuthen NJ, Flessner CA, Woods DW, Piacentini JA. Family functioning in pediatric trichotillomania. Child Fam Behav Ther. 2009;31(4):255–69.

    Article  Google Scholar 

  8. Grant JE, Chamberlain SR. Personality traits and their clinical associations in trichotillomania and skin picking disorder. BMC Psychiatr. 2021;21(1):1–7.

    Article  Google Scholar 

  9. Hagh-Shenas H, Moradi A, Dehbozorgi G, Farashbandi B, Alishahian F. Trichotillomania-associated personality characteristics. Iran J Med Sci. 2015;29(3):105–8.

    Google Scholar 

  10. Keuthen NJ, Tung ES, Altenburger EM, Blais MA, Pauls DL, Flessner CA. Trichotillomania and personality traits from the five-factor model. Brazil J Psychiatr. 2015;37:317–24.

    Article  Google Scholar 

  11. Takahashi N, Suzuki A, Matsumoto Y, Shirata T, Otani K. Perceived parental affectionless control is associated with high neuroticism. Neuropsychiatr Dis Treat. 2017;13:1111.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Segura-Garcia C, Rania M, Aloi M, Palmieri A, Pellegrino A, Manfrida AP, De Fazio P. Parental bonding in substance and alcohol abusers. Heroin Addict Rel Clin Prob. 2016;18(2):13–20.

    Google Scholar 

  13. Villalta L, Arévalo R, Valdepérez A, Pascual JC, de los Cobos JP. Parental bonding in subjects with pathological gambling disorder compared with healthy controls. Psychiatr Q. 2015;86(1):61–7.

    Article  PubMed  Google Scholar 

  14. Grant JE, Kim SW. Parental bonding in pathological gambling disorder. Psychiatr Q. 2002;73(3):239–47. PMID: 12143085.

  15. Grant JE, Kim SW. Temperament and early environmental influences in kleptomania. Compr Psychiatry. 2002;43(3):223–8. PMID: 11994842.

  16. Yoshida T, Taga C, Matsumoto Y, Fukui K. Paternal overprotection in obsessive-compulsive disorder and depression with obsessive traits. Psychiatry Clin Neurosci. 2005;59(5):533–8. PMID: 16194254.

  17. Wilcox HC, Grados M, Samuels J, Riddle MA, Bienvenu OJ 3rd, Pinto A, Cullen B, Wang Y, Shugart YY, Liang KY, Nestadt G. The association between parental bonding and obsessive compulsive disorder in offspring at high familial risk. J Affect Disord. 2008;111(1):31–9. 2008 Mar 4. PMID: 18299151.

  18. Vogel PA, Stiles TC, Nordahl HM. Recollections of parent-child relationships in OCD out-patients compared to depressed out-patients and healthy controls. Acta Psychiatr Scand. 1997;96(6):469–74. PMID: 9421344.

  19. Myhr G, Sookman D, Pinard G. Attachment security and parental bonding in adults with obsessive-compulsive disorder: a comparison with depressed out-patients and healthy controls. Acta Psychiatr Scand. 2004;109(6):447–56. PMID: 15117290.

  20. Keuthen NJ, O’Sullivan RL, Ricciardi JN, Shera D, Savage CR, Borgmann AS, Jenike MA, Baer L. The Massachusetts General Hospital (MGH) Hairpulling Scale: 1. development and factor analyses. Psychother Psychosom. 1995;64(3–4):141–5. PMID: 8657844.

  21. Snorrason I, Olafsson RP, Flessner CA, Keuthen NJ, Franklin ME, Woods DW. The skin picking scale-revised: factor structure and psychometric properties. J Obsess Compuls Rel Disord. 2012;1(2):133–7.

    Article  Google Scholar 

  22. Parker G. The Parental Bonding Instrument: psychometric properties reviewed. Psychiatr Dev. 1989;7(4):317–35. PMID: 2487899.

  23. Parker G. Reported parental characteristics of agoraphobics and social phobics. Br J Psychiatry. 1979;135:555–60. PMID: 534811.

  24. Parker G. Parental overprotection: A risk factor in psychosocial development. Incorporated: Grune & Stratton; 1983.

    Google Scholar 

  25. Wilhelm K, Niven H, Parker G, Hadzi-Pavlovic D. The stability of the Parental Bonding Instrument over a 20-year period. Psychol Med. 2005;35(3):387–93. PMID: 15841874.

  26. Grant JE, Dougherty DD, Chamberlain SR. Prevalence, gender correlates, and co-morbidity of trichotillomania. Psychiatry Res. 2020;288:112948. Epub 2020 Apr 18. PMID: 32334275; PMCID: PMC7212053.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


My gratitude and appreciation to Sam Chamberlain for advising on statistical analyses and to Allen Terman for assisting in the preparation of this manuscript.


This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations



SV designed the study, analyzed the data, and drafted the manuscript. EC contributed to the literature review. JG designed the study and drafted the manuscript. All authors edited the manuscript.

Corresponding author

Correspondence to Jon E. Grant JD, MD, MPH.

Ethics declarations

Conflict of Interest

Ms. Valle and Ms. Chesivoir report no financial relationships with commercial interests. Dr. Grant has received research grants from the TLC Foundation for Body-Focused Repetitive Behaviors, Otsuka, Biohaven, Promentis, and Avanir Pharmaceuticals. He receives yearly compensation for acting as editor-in-chief of the Journal of Gambling Studies and has received royalties from Oxford University Press, American Psychiatric Publishing, Inc., Norton Press, and McGraw Hill.

Ethics Approval/Consent to Participate

Participants were provided with an oral consent form and were instructed to check a box to confirm their interest in completing the survey. Survey responders were compensated for their time. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human subjects/patients were approved by the University of Chicago Institutional Review Board.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Valle, S., Chesivoir, E. & Grant, J.E. Parental Bonding in Trichotillomania and Skin Picking Disorder. Psychiatr Q 93, 409–418 (2022).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Trichotillomania
  • Skin picking
  • Parental bonding
  • Development