NEO-FFI personality clusters in trichotillomania
Introduction
Limited success has been reported to date for existing treatment interventions for trichotillomania (TTM). One might argue that current treatment approaches fail to adequately tailor treatment strategies to varying symptom presentations in different pullers. Furthermore, there has been little investigation of personality variables in TTM. The examination of personality prototypes in hair pullers may elucidate phenotypes that advance our knowledge of etiology and promote the development of more effective treatments for differing presentations of TTM.
Our group has previously explored personality traits in TTM including their predictive validity for TTM diagnosis, hair pulling (HP) severity and control, and HP style (Keuthen et al., 2015). Scores on the NEO-Five Factory Inventory (FFI; Costa and McCrae, 1992) domain of neuroticism predicted TTM case vs. control status with every 1-point increase in neuroticism scores resulting in a 10% greater chance of TTM diagnosis. Higher neuroticism was associated with both greater pulling severity and less pulling control. Higher openness and lower agreeableness were also associated with greater pulling severity. Higher neuroticism and lower openness were associated with greater focused pulling while none of the NEO-FFI domains predicted automatic pulling.
The current study extends our previous research by examining personality prototypes or profiles in hair pullers, rather than isolated personality dimensions. Our prior trait analyses failed to shed light on the dynamic organization of multiple personality traits within the individual. Identification of personality patterns provides a multivariate picture of personality and illuminates how traits co-occur within the individual. It is arguably the case that identification of personality prototypes in hair pulling may be more useful in identifying genetic and environmental etiologies and in predicting disorder presentation, course and treatment outcome, than trait dimensions alone.
Asendorpf et al. (2001) previously identified a three-prototype model of personality consisting of undercontrollers (characterized by high scores in neuroticism and low scores in agreeableness and conscientiousness), overcontrollers (characterized by high scores in neuroticism and low scores in extraversion and openness to experience) and a resilient type (characterized by below average scores in neuroticism and above average scores in all other NEO-FFI dimensions). Thus, the undercontrollers have limited control over impulses and display externalizing tendencies. The overcontrollers display excessive modulation of impulses and internalizing or avoidance tendencies. Finally, those with the resilient prototype exhibit social and cognitive flexibility that allows them to optimally adapt to life challenges. These prototypes have been replicable in different populations and at different development stages. There is an extensive literature that has explored these prototypes in psychiatric (e.g., Mueller et al., 2010, Sanchez-Guarnido et al., 2015) and medical (e.g., Berry et al., 2007) populations. Mueller et al. (2010) performed a cluster analysis of NEO-FFI scales in compulsive buying, an impulse control disorder purportedly on a spectrum with TTM. Two personality clusters were identified. One cluster was similar to the undercontrolled prototype while a second cluster shared features of both the resilient and overcontrolled cluster.
It is also of note that earlier research (Flessner et al., 2008) reported two common styles of pulling. The automatic style is characterized by unaware pulling, often while engaged in sedentary activities. The focused style is associated with uncomfortable affect or sensations and pulling occurs with greater awareness. This latter style of pulling shares some features with the undercontrolled personality prototype while the automatic style of pulling, in contrast, does not appear similar to any of the personality prototypes. Given that Mueller and colleagues identified two personality clusters in another obsessive-compulsive spectrum disorder, we hypothesized that there would similarly be two personality clusters in TTM.
Section snippets
Participants
Participants were 164 adult hair pullers between the ages of 18 and 65 who had participated in two consecutive TTM studies at Massachusetts General Hospital between 2006 and 2012. All subjects either met criteria for DSM-IV-TR TTM or chronic HP (all TTM criteria satisfied except tension before pulling or when attempting to resist, formerly criterion B, and/or pleasure, relief, or gratification when pulling, formerly criterion C). Additionally, participants did not have lifetime diagnoses of
Results
Latent class cluster analysis was first performed using MCLUST to identify existing personality prototypes within the participants. The best solution for each number of clusters (1 through 9) regardless of shape and volume were identified. The BIC values as well as the log-likelihood and AIC values that were manually calculated using the appropriate formulas can be seen in Table 1. The BIC values for all solutions (including all shapes, volumes, and number of clusters) are graphed in Fig. 1. In
Discussion
Our investigation into the personality traits of individuals suffering from TTM has identified two prototypes. The first prototype contains individuals who have greater neuroticism but less extraversion, agreeableness, and conscientiousness than those in the second prototype. While these conceptions of the nature and personality of two clusters of hair pullers are compelling, they require replication in future studies. It is also unclear if these results in our largely Caucasian study would
Disclosures
Nancy Keuthen and Christopher Flessner are members of the scientific advisory board of the Trichotillomania Learning Center. Nancy Keuthen is also a member of the scientific advisory board of the International Obsessive Compulsive Disorder Foundation and receives royalties from New Harbinger, Inc. She also has equity interest in Johnson & Johnson, Merck & Co., Inc., Pfizer, Inc., and Procter & Gamble Co. The other authors report no conflicts of interest.
Acknowledgments
We gratefully recognize financial support for this project from the Trichotillomania Learning Center, Inc. (TLC) and its BFRB Precision Medicine Initiative, as well as the Greater Kansas City Foundation. We also wish to express gratitude to Saraj Mothi for his statistical consultation and Amanda Falcon, Miriam Frank, and Zachary Madison who performed data input and cleaning.
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These authors are co-first authors as they contributed equally to this work.