Characteristics and phenomenology of hair-pulling: An exploration of subtypes☆
Abstract
This study was designed to detail the demographic and phenomenological features of adult chronic hair-pullers. Key possible subtypes were identified a priori. On the basis of the phenomenological data, differences between the following possible subtypes were investigated: hair-pullers with and without DSM-IV trichotillomania (TTM), oral habits, automatic versus focused hair-pulling, positive versus negative affective cues prior to hair-pulling, comorbid self-injurious habits, obsessive-compulsive disorder (OCD), and tics. Forty-seven participants were drawn from an outpatient population of chronic adult hair-pullers. A structured interview that focused on hair-pulling and associated behaviors was administered to participants. Six of the participants (12.8%) were male, and 41 (87.7%) were female. A large number of hair-pullers (63.8%) had comorbid self-injurious habits. A greater proportion of male hair-pullers had comorbid tics when compared with females. Certain subgroups of chronic hair-pullers (e.g., hairpullers with or without automatic/focused hair-pulling, comorbid self-injurious habits, and oral habits) were found to differ on a number of phenomenological and hair-pulling characteristics. However, differences between other possible subgroups (e.g., hair-pullers with or without DSM-IV TTM, comorbid OCD, and negative versus positive affective cues) may reflect greater severity in hair-pulling symptomatology rather than distinct subtypes of chronic hair-pulling. The findings of the present study also indicated that chronic hair-pulling (even in cases where DSM-IV criteria for TTM were not met) has a significant impact on quality of life. The present study provided limited support for the existence of possible subtypes of chronic hair-pulling. Recommendations are made for further investigations into such subtypes.
References (0)
Cited by (119)
The association between trichotillomania symptoms and emotion regulation difficulties: A systematic review and meta-analysis
2024, Journal of Affective DisordersEmotion regulation is postulated to play an important role in Trichotillomania (TTM). Whilst a growing number of studies have examined the relationship between emotion regulation difficulties and TTM symptoms, there have been no attempts to evaluate the overall strength of this association or the quality of the evidence base.
This systematic review and meta-analysis aimed to synthesise findings from studies that have examined the relationship between emotion regulation difficulties and TTM symptoms, to inform future TTM treatment targets. We identified 17 studies that met inclusion criteria. From these studies, 32 correlation coefficients were extracted for meta-analysis. The Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies was used to assess risk of bias amongst the included studies.
There was a moderately sized association between TTM symptoms and ER difficulties, (r adjusted = 0.32, 95 % CI [0.28, 0.37], t = 15.58 (df = 11.86), p < 0.0001) that was moderated by sample size (F(df1 = 1, df2 = 30) = 4.597, b = −0.0001, SE = 0.0001, 95 % CI [−0.0002; 0.0000], p = 0.040) and differences between types of emotion regulation measures (Q(df = 1) = 4.06, p = 0.044).
The data analysed was correlational, therefore causality was unable to be determined. Comorbidities were not able to be examined as a moderator.
This study provided a preliminary integration of the evidence and demonstrated that individuals with higher levels of TTM severity appear to exhibit decreased overall emotion regulation abilities and strategies.
The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings
2023, Behaviour Research and TherapyTrichotillomania is characterized by recurrent pulling out of one's hair, leading to significant hair loss and accompanied by clinically significant distress and/or functional impairment. The current study used data from a randomized controlled trial comparing the effectiveness of acceptance-enhanced behavior therapy (AEBT) to psychoeducation plus supportive therapy (PST; active control) for trichotillomania in an adult sample. The objectives were to examine the moderating and mediating influence of trichotillomania-specific psychological flexibility in treatment for trichotillomania. Participants with lower baseline flexibility performed better in AEBT than PST in terms of greater symptom reduction and quality of life. Lower baseline flexibility also predicted higher likelihood of disorder recovery in AEBT relative to PST. In addition, relative to PST, symptom reduction in AEBT was mediated by psychological flexibility, controlling for anxiety and depression. These findings suggest that psychological flexibility is a relevant process of change in the treatment of trichotillomania. Clinical implications and directions for future research are discussed.
State and trait dissociation in pathological skin picking
2023, European Journal of Trauma and DissociationDissociative experiences like trance or depersonalization may play a prominent role in pathological skin picking (PSP). However, trait and state dissociation and their relation to skin picking have hardly been studied in those with PSP. By means of an anonymous online survey, we recruited 323 adults with PSP defined by Skin Picking Scale-Revised (SPS-R) scores ≥ 7 as well as Skin Picking Impact Scale (SPIS) scores ≥ 7. Participants were administered the Dissociative Experiences Scale-Taxon (DES-T) to determine trait dissociation as well as the modified Peritraumatic Dissociative Experiences Questionnaire (PDEQ) to assess state dissociation during a typical episode of PSP. Sixty-three participants (19.5%) were assigned to the pathological dissociative taxon, that is, were high in trait dissociation. State dissociation during episodes of skin picking was reported by 221 individuals (68.4%) with the feeling of being on “automatic pilot” (49.6%) and alterations in time perception (33.1%) being the most frequent phenomena. Both trait and state dissociation were significantly associated with skin picking-related impairment, but effect sizes were small. Dissociation conceived as trait and state might be an important psychopathological dimension in skin picking. Its systematic detection and recognition may hold therapeutic implications as dissociation is a negative predictor of treatment outcome.
Examining the effects of caffeine consumption on the severity of body-focused repetitive behaviors
2022, Psychiatry Research CommunicationsCaffeine has long been discussed in communities of individuals with body-focused repetitive behaviors (BFRBs), a group of compulsive disorders including trichotillomania (TTM) and skin picking disorder (SPD), as a potential trigger for worsening symptoms. While the anxiogenic effects of caffeine have been well characterized, findings from studies on disorders related to BFRBs have yielded mixed results. This study aimed to examine the effect of caffeine consumption on BFRB symptom severity. Subjects reported their caffeine consumption in the past week and completed measures related to BFRB severity and other clinical outcomes. Participants who reported moderate daily caffeine use (150–300 mg) had significantly lower scores on severity scales compared to subjects who reported low (<150 mg) or high (>300 mg) daily caffeine use. The results of this analysis indicate that moderate caffeine consumption is associated with less severe BFRB symptoms. It is possible that moderate caffeine use increases alertness in adults with BFRBs who pull or pick subconsciously, without triggering anxiety-induced BFRBs. Prospective clinical trials should be conducted to provide clearer insight into the effect of caffeine and other psychostimulants on BFRBs.
Significance of family history in understanding and subtyping trichotillomania
2022, Comprehensive PsychiatryThe existence of subtypes of trichotillomania (TTM) have long been hypothesized, and recent studies have further elucidated characteristic subtypes of TTM and possible ramifications of subtyping for treatment. In clinical applications of subtyping for treatment of TTM, family history (FH) of psychiatric disorders in patients may serve as a tool to differentiate disorder presentations and inform care. We compared prevalence of psychiatric illnesses in first-degree relatives of participants with TTM and healthy controls, respectively, in a large sample, and examined associations between those psychiatric disorders that were significantly different in the FH between groups and measures of disability, severity, and neuropsychological constructs.
We compared FHs of 152 participants (mean age = 29.9) with TTM and 71 healthy controls (mean age = 29.6), utilizing chi-squared tests to determine which psychiatric illnesses were more prevalent in FHs of participants with TTM. We then used two-tailed t-tests to compare TTM participants with those more prevalent FHs to participants without those FHs on measures of disorder severity, disability, and neuropsychological constructs.
Obsessive-compulsive disorder (OCD), TTM, skin picking disorder (SPD), and major depressive disorder (MDD) were significantly more frequent in first-degree relatives (p < 0.0033) of TTM participants than those of healthy controls. TTM participants with a FH of OCD scored significantly higher on measures of impulsivity and lower on measures of distress tolerance. Those with FH of TTM, SPD, and MDD did not differ significantly across measured variables.
OCD, TTM, SPD, and MDD are more prevalent in the FHs of people with TTM, as compared to healthy controls. TTM participants with a family history of OCD may be more likely to demonstrate decreased distress tolerance and increased impulsivity. In all, as understanding of TTM subtypes develops, the FH may prove a useful tool in delineating subtypes and informing care.
Automatic and focused hair pulling in trichotillomania: Valid and useful subtypes?
2021, Psychiatry ResearchPrior work suggested that trichotillomania may have four subtypes based on the extent to which pulling is automatic or focused in nature. 238 adults with trichotillomania undertook clinical and cognitive assessments and were assigned into four subtypes based on k-means clustering of Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A) scores. We examined whether a cluster solution was apparent using conventional metrics. Based on prior literature, we then force-fitted a four subtype model (low-low, low-high, high-low, high-high). Subtypes were compared and validity of the MIST-A subtyping approach was evaluated. A cluster solution did not converge based on conventional metrics. Following force-fitting, subtypes did not differ on demographic variables, age at symptom onset, nor duration of illness. The high-focused high-automatic subtype had worse symptom severity than other subtypes. Co-morbid depression was more common in the low-focused low-automatic and high-focused low-automatic subtypes. This study suggests that MIST-A subtypes may not be valid or clinically useful based on several issues. First, k-means models indicated that the MIST-A data did not generate any cluster solutions. Second, when a forced cluster solution was fitted, the subtypes did not differ on the vast majority of measures. Third, force-fitting four subtypes yielded findings that were logically inconsistent (e.g. worse quality of life in one group, but higher rates of comorbid anxiety/depression in others). Overall, we suggest that both focused and automatic pulling may characterize the same pulling episode, or certainly the same person across episodes. Thus they may be clinically relevant variables, but not forming coherent subtypes.
- ☆
Supported by the Medical Research Council of South Africa.