Affective correlates of trichotillomania

Abstract

Affective correlates of hair pulling were investigated in a sample of 44 participants diagnosed with trichotillomania (TM). Participants completed the Hair Pulling Survey on which they rated the intensity of ten different affective states across three different phases of hair pulling (before, during and after). Repeated measures analysis of variance was used to examine the change of emotional experience across the hair pulling cycle. Results indicated significant decreases in boredom, anxiety and tension, and significant increases in guilt relief, sadness and anger across time (p<0.005). The role of co-existent anxiety and mood disorders also was examined using repeated measures analysis of variance. Results of these analyses indicated that patients with and without co-existent disorders differed only on patterns of anger across time, and therefore do not support affective subtypes of TM patients based on co-existent diagnosis. Implications of these findings for conceptualization and treatment of TM are discussed.

Introduction

Trichotillomania (TM), or repetitive hair pulling, is a potentially severe disorder that requires increased attention from researchers (Diefenbach et al., 2000, Stein and Christenson, 1999). Although the prevalence of TM in the general population is still unknown, surveys of college students indicate that as many as 15.3% of participants endorse noncosmetic hair pulling (Stanley, Borden, Bell, & Wagner, 1994), with 2.5% reporting clinically significant hair pulling (Christenson, Pyle, & Mitchell, 1991). Although it is not clear how these figures generalize to the population at large, the data imply that TM is not rare, as was once believed. In addition, TM can be associated with significant problems such as avoidance of pleasurable activities (Christenson and Mansueto, 1999, Stemberger et al., 2000) as well as personal distress and interpersonal conflicts (Stemberger et al., 2000, Soriano et al., 1996). These data highlight the need for additional research to assist in the identification and treatment of TM.

The emotional experience associated with hair pulling is one important topic that requires additional research. Current diagnostic criteria for TM require an increased sense of tension immediately before or while trying to resist hair pulling, and feelings of pleasure, gratification or relief associated with pulling hair (American Psychiatric Association, 1994). However, research suggests that these affective criteria may be overly restrictive, given that 17–23% of hair pullers do not report these experiences when pulling (Christenson et al., 1991, Schlosser et al., 1994). In addition, research suggests that a variety of affective states that are not included in the diagnostic criteria for TM may be associated with hair pulling. For example, situations commonly associated with negative affective states such as anxiety, anger and embarrassment often serve as cues for hair pulling (Christenson, Ristvedt, & Mackenzie, 1993). In addition, Mansueto (1990) has noted that hair pulling is associated with various negative affective states besides tension, such as boredom, anger, depression and frustration. In a comprehensive behavioral model of TM (Mansueto, Stemberger, Thomas, & Golomb 1997), affective experience was identified as an important maintaining factor of hair pulling, serving as both a stimulus cue and reinforcer of the behavior. However, the affective component of this model has not been tested directly with TM patients.

In one study, change in affective experience across the hair pulling cycle was investigated in a sample of nonclinical hair pullers using the Hair Pulling Survey (HPS; Stanley, Borden, Mouton, & Breckenridge 1995). The HPS is a self-report measure that assesses affective states experienced before, during, and after hair pulling. Results of this study indicated that hair pulling was associated with decreases in tension, boredom, sadness and anger. It is important to note, however, that changes in affect occurred only from pre to post, and not from pre to during hair pulling. Therefore, the relationship between emotional states before and after hair pulling actually may be more salient to the phenomenology of TM than changes from before one pulls to the time while one pulls, as current diagnostic criteria imply. However, replication of these data with a clinical sample is necessary before implications for the diagnosis and treatment of TM can be drawn.

Research has shown that co-existent diagnoses are common in TM, with lifetime prevalence rates of Axis I disorders ranging as high as 82% Christenson et al., (1991). Anxiety and mood disorders are the most common co-existent disorders for TM patients (Christenson, 1995), and given the nature of these conditions, such co-existent pathology may influence the affective experience of TM patients. Therefore, the role of co-existent anxiety and mood disorders on affective correlates of hair pulling also was investigated. This issue is important to explore, given that differences in affective experiences by co-existent diagnosis might indicate the presence of subtypes of TM and suggest the need for different treatment approaches by subtype.

The goal of the current study was to examine affective experiences associated with hair pulling in a sample of patients diagnosed with TM. This study addressed both the range of affect reported by patients with TM and the self-reported patterns of change for these affective states across the hair pulling cycle. In addition, the role of co-existent anxiety and mood disorders on affective ratings was examined. Investigation of these issues will provide a clearer understanding of the affective experiences of patients diagnosed with TM and will have important implications for both conceptualization and treatment of the disorder.