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Emotional regulation cycles in trichotillomania (hair-pulling disorder) across subtypes
Journal of Obsessive-Compulsive and Related Disorders 10 (2016) 84–90
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Journal of Obsessive-Compulsive and Related Disorders journal homepage: www.elsevier.com/locate/jocrd
Emotional regulation cycles in trichotillomania (hair-pulling disorder) across subtypes Sebastian Siwiec n, Dawn Lorraine McBride Faculty of Education, University of Lethbridge, 4401, University Drive, Lethbridge, Alberta, Canada T1K 3M4
art ic l e i nf o
a b s t r a c t
Article history: Received 22 August 2015 Received in revised form 4 May 2016 Accepted 22 June 2016 Available online 23 June 2016
The patterns of emotional regulation involved in trichotillomania (hair-pulling disorder; HPD) were studied across various subtypes of hair pulling. Using the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A), this is the first study to address the regulation of emotions across four specific subtypes of hair pulling. For this study, 427 participants completed an online questionnaire around their hair pulling subtype, severity, and emotions experienced by hair pulling. Participants were divided as either high- or low-focused and either high- or low-automatic. Significant differences between subtypes and severity were reported. Subtypes differed in the severity of the emotions they experienced; individuals with high-focused pulling reported more intense negative emotions, and a greater number of emotions regulated by pulling. Positive emotions–happiness, relief, and calm–were also found to play a significant role in reinforcing hair pulling. For high-focused subtypes, negative emotions before, and after, pulling were associated with greater severity, indicating that altering negative emotions via pulling plays an important role for high-focused subtypes. Clinical and treatment implications, study limitations, and areas of future research are discussed. & 2016 Elsevier Inc. All rights reserved.
Keywords: Trichotillomania Hair-pulling disorder Internet survey Emotional regulation Body-focused repetitive behaviour (BFRB)
1. Introduction Trichotillomania (Hair-Pulling Disorder; HPD) is characterized by the recurrent pulling of one's own hair from any part of one's own body, resulting in hair loss (American Psychiatric Association, 2013). In HPD, hair can be pulled from any area of the body, although the scalp, eyebrows, eyelashes, and pubic hair have been identified as the most frequent sites (Christenson, Mackenzie, & Mitchell, 1991; Lochner, Seedat, & Stein, 2010). A range of social, academic, occupational, physical, and psychological impairments is also experienced by people with HPD. Secrecy, self-stigmatization, shame, and avoidance or impairment of enjoyable social and occupational activities are all routinely reported by people with HPD (Marcks, Woods, & Ridosko, 2005; Soriano et al., 1996; Wetterneck, Woods, Norberg, & Begotka, 2006). Studies using different degrees of strictness in defining HPD have made a precise prevalence rate difficult to settle upon (Duke, Keeley, Geffken et al., 2010). Early studies found the prevalence ranged from 0.6% to 2.5% (Christenson et al., 1991), while larger and more recent community samples endorse a prevalence of 1.2% (Duke, Bodzin, Tavares, Geffken, & Storch, 2009), often with a n Correspondence to: Calgary Counseling Centre #940, 6th Avenue SW Calgary, Alberta, Canada T2P3T1. Tel.: þ 1 4038907472. E-mail addresses: [email protected] (S. Siwiec), [email protected] (D.L. McBride).
http://dx.doi.org/10.1016/j.jocrd.2016.06.003 2211-3649/& 2016 Elsevier Inc. All rights reserved.
higher female presence for the disorder (Chamberlain, Menzies, Sahakian, & Fineberg, 2007; Wetterneck et al., 2006).
2. Pulling styles Over the course of HPD research, a heterogeneous conceptualization of HPD emerged, with individuals reporting two distinct pulling styles. Focused pulling is intentional, goal directed (e.g., looking for a specific hair), or pulling to regulate a negative affective state (e.g., anxiety, stress, etc.). Automatic pulling is defined as pulling that occurs outside of awareness and can occur in the presence of affective states such as boredom (Christenson, Mackenzie, & Mitchell, 1994). Originally it was reported that pure automatic hair pulling occurred in 5–32% of the HPD population, with 15–25% displaying focused-only hair pulling, and 43–80% of individuals displaying a mix of both patterns (Christenson et al., 1994, 1991; du Toit, van Kradenburg, Niehaus, & Stein, 2001). Flessner, Woods, Franklin, Cashin, and Keuthen (2008) who developed the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A), a self-report measure to identify and analyze the unique behaviours of focused and automatic pulling, found pure-automatic and pure-focused hair pulling occurred in less than 0.01% of the HPD population (Flessner & Conelea, 2008; Flessner et al., 2008). Because of this mixed presentation, and the unique characteristics distinguishing focused and automatic
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pulling, it is meaningful understand how these two styles are expressed within the individual and to arrange treatment specifically to address the emotional regulation and awareness deficits of the individual depending on their composite pulling style. Flessner, Busch et al. (2008) reported that an understanding the focused and automatic presentation of individuals may help aid in the response to treatment –improving the decision of the type of therapy to administer and the order the therapy protocol is provided.
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4. Methods 4.1. Subtypes of trichotillomania affect questionnaire (STAQ) A large-scale web survey, the STAQ, composed of two demographics forms and four inventories was compiled to address the research goals. The study sought to reach out to a community sample of nonreferred, self-reported individuals who hair pull. The intention was to capture a large, representative sample size and obtain a comprehensive spectrum of individuals that could not be captured through inpatient clinical research.
3. Emotion regulation Research into therapies for HPD first approached the condition using cognitive behavioural therapy (CBT) and habit reversal training (HRT), which emphasize awareness, self-monitoring, and developing competing responses (Azrin & Nunn, 1973). More recently, studies on therapies for HPD have shifted towards more acceptance and emotion regulation models (Crosby, Dehlin, Mitchell, & Twohig, 2012; Keuthen & Sprich, 2012). This move follows studies that demonstrate HPD serves as a way for individuals to regulate their emotional states (Diefenbach, Tolin, Meunier, & Worhunsky, 2008; Shusterman, Feld, Baer, & Keuthen, 2009). The emotion regulation (ER) model proposes that HPD is initiated by negative emotions and negatively reinforced by the alleviation from these negative affective states. (Roberts, O’Connor, & Bélanger, 2013). In support of this model, Shusterman et al. (2009) found that individuals with HPD had a greater difficulty regulating emotions than did controls. People with HPD have been found to use pulling to regulate a variety of negative affective states including anger, anxiousness, boredom, embarrassment, frustration, guilt, sadness, and tension (Diefenbach, MoutonOdum, & Stanley, 2002; Diefenbach et al., 2008; Duke, Keeley, & Ricketts, 2010; Stanley, Borden, Mouton, & Breckenridge, 1995; Shusterman et al., 2009). In light of findings showing individuals having distinct pulling styles, research is beginning to look at whether some individuals respond more favourably to the behavioural protocols of HRT or the emotional regulation strategies of ER therapies depending on the degree to which individuals pull to avoid, escape, or regulate internal experiences (Crosby et al., 2012; Flessner, Busch et al., 2008). Researchers have yet to explore the relationship between hair pulling style and the role of emotion regulation in HPD. Shusterman et al. (2009) found that individuals differ in what emotional cues they use for pulling, but did not administer the MIST-A to map these emotional patterns onto the degree of focused and automatic pulling that manifests in the individual. Accordingly, the study being reported on proposed three specific research hypotheses to address this unexplored area of research. First, by establishing how the severity of hair pulling maps onto each hair pulling profile. This study hypothesized that the degree to which people use pulling to control how they feel, pull in response to anxiety or sadness, and in the degree of dissociation that occurs – items measured on the MIST-A; will reflect on the MGH-HPS as greater intensity, lower perceived control, greater distress, and overall increased hair pulling severity. Second, people with more focused hair pulling would experience a higher degree of emotional regulation by pulling, expressed as the intensity of change emotional states underwent during the before-during-after pulling cycle. Third, regulating emotions by pulling was hypothesized to create additional negative experiences that reinforced the behaviour. The intention was that by mapping the emotion clusters across hair pulling styles, more intentional and deliberate treatment planning could be developed to be more responsive to the individual.
4.2. Participants Recruitment and advertising was done through The TLC Foundation for Body-Focused Repetitive Behaviours (TLC). TLC distributed the survey on their online research page, through an email distributed to thousands of TLC members, and through recurrent posting on the TLC Facebook and Twitter social media pages. 4.3. Inclusion criteria To be included in the study, participants needed to (a) indicate that their hair pulling has resulted in noticeable hair loss or the thinning of hair; (b) report this action causes them mild distress in at least one or more personal, interpersonal, occupational, or academic domains; and (c) indicate that they were at least 18 years of age. To ensure uniformity of inclusion criteria across studies, these criteria were adapted with permission from Dr. Douglas Woods, the main author of the largest trichotillomania study to date–the Trichotillomania Impact Survey (see Woods et al., 2006). Participants were excluded from participation if they endorsed pulling in response to any drug abuse or untreated psychotic condition, or if their pulling was secondary to another medical condition (e.g., dry or itchy skin). 4.4. Survey administration and informed consent The survey was administered online through the Internet survey platform Qualtrics. Surveys were saved anonymously and downloaded by the authors for analysis. Responses were collected between December 2012 and January 2013. Participants accessing the study were provided with the study's rationale and informed both of the voluntary nature of participation and of the ethical approvals for the study granted by the Scientific Advisory Board of the TLC and the Human Research Subjects Committee of the University of Lethbridge. Participants who indicated that they had read and agreed to the terms of consent for participation were provided access to the survey. Upon completing the survey, participants were thanked, debriefed, provided resources to treatment providers, and given a link that later hosted a summary of the findings.
5. Assessments 5.1. Basic demographic form Participants were requested to answer six general demographic questions, including gender, age, ethnicity, and marital status. These questions were asked to gain an understanding of the demographics of participants entering the survey.
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5.2. HPD demographic form The HPD demographic form asked 20 questions to gather descriptive information, including pulling sites, previous diagnosis for HPD, and frequency of pulling. This form included the DSM-5 criteria for HPD, including measuring pulling resulting in hair loss (noticeable or not); distress in social, occupational, or other important areas of functioning; and pulling not due to another general medical condition. Participants needed to endorse these criteria for inclusion in the study. 5.3. Massachusetts general hospital hairpulling scale (MGH-HPS) Participants completed the MGH-HPS (Keuthen et al., 1995). The MGH-HPS is a reliable and valid 7-item, self-report measure to assess the severity of hair pulling (O’Sullivan et al., 1995). Items are rated on a 5-point Likert scale, from 0 to 4, with higher scores indicating higher symptom severity. The MGH-HPS has been shown to be equally sensitive at assessing severity for both focused and automatic hair pulling groups (Flessner & Conelea, 2008), and demonstrates strong internal consistency (Keuthen et al., 1995; Keuthen et al., 2007). The MGH-HPS has undergone a factor analysis to derive a two-factors structure (Keuthen et al., 2007). While a total severity score is created, distinct severity and resistance and control factors have been isolated, with internal consistencies of.832 and.805 respectively (Keuthen et al., 2007).
Table 1 Number and Location of Hair Pulling Sites. Number of sites
Mean
(SD)
Range
Scalp-1 Scalp-5
2.87 4.67
1.88 2.51
1–12 1–16 Most frequent
Hair pulling sites
n
%
N(%)
Scalp Crown Right-temporal Left-temporal Frontal Occipital Totala Eyelashes Eyebrows Pubic hair Moustache Beard Trunk Armpits Arms Legs/Feet Other
279 198 212 218 186 325 203 219 203 13 17 17 64 38 85 31
65.3 46.4 49.6 51.1 43.6 76.1 47.5 51.3 47.5 3.0 4.0 4.0 15.0 8.9 19.9 7.3
133(31.1) 23(5.4) 57(13.3) 27(6.3) 34(8.0) – 74(17.3) 46(10.8) 11(2.6) – 6(1.4) – – 3(.7) 3(.7) 3(.7)
Note. N ¼ 427. Scalp-1 ¼ scalp considered one hair pulling site; Scalp-5 ¼ scalp considered as five separate hair pulling sites. a
Respondents with at least one scalp hair pulling site.
5.4. Milwaukee Inventory for Subtypes of Trichotillomania (MIST-A)
retained for analysis.
The MIST-A measure was developed to formalize the degree to which individuals engage in focused and/or automatic hair pulling (Flessner et al., 2008). Participants completed the 15-item, selfreport measure, which includes items highly correlated with either focused or automatic pulling (Flessner et al., 2008). Items are rated on a 10-point Likert Scale, from 0 to 9, and receive a focused score (ranging from 0 to 90), and an automatic score (ranging from 0 to 45). Higher scores represent a higher dominance of that style's unique behaviours. Using the MIST-A, four hair-pulling profiles were created using a median-split procedure. The four profiles were: high-focused, high-automatic hair pulling (HFHA); highfocused, low-automatic (HFLA), low-focused, high-automatic (LFHA); and low-focused, low-automatic (LFLA).
6.2. Participant demographics The mean age of participants was 33.44-years-old (SD ¼ 12.42), ranging from 18- to 71-years-old. Age of onset ranged from 1- to 51-years-old, with a mean onset of 12.4-years-old (SD ¼6.17). Females accounted for 95.8% of the participants in the survey. Twothirds (66.5%) of the respondents reported having been diagnosed with HPD by a professional, most commonly a psychiatrist or psychologist, while a third (33.5%) reported having never been formally diagnosed with the condition despite reporting the prerequisite criteria. The number, location, and most frequent individual hair pulling sites are presented in Table 1. 6.3. Hair pulling severity across pulling styles
5.5. Hair pulling survey (HPS) The HPS measure was developed to assess affective states play in hair pulling (Stanley et al., 1995). When completing the HPS, participants retrospectively rated the extent to which they experienced each emotion (i.e., anger, anxiousness, boredom, calm, guilt, happiness, indifference, relief, sadness, tension, embarrassment, frustration, indifference) on a 9-point (0 8) Likert scale. Participants rated the experience of each emotion before they engaged in pulling, during pulling, and after they pulled.
6. Results 6.1. Completion rates The survey received 609 responses over the 45 days the online survey was active. Duplicate responses, incomplete surveys, those not meeting the inclusion criteria, or endorsing any of the exclusion criteria, were removed. Of the 609 respondents, 477 completed the study, a response rate of 78%. For not meeting the inclusion or violating any exclusion criteria, 50 (10%) responses were removed from the response pool. A total of 427 surveys were
Scores on the MGH-HPS were analyzed to map the relationship between hair pulling severity and hair pulling profile. Descriptives are presented in Table 2. 6.4. Hair pulling severity An analysis on the role of focused and automatic pulling on TTM severity was performed. Results of the ANOVA revealed a significant main effect for focused pulling F (1, 427) ¼6.632, Table 2 Descriptives for the MGH-HPS. MGH-HPS Severityb Resistance & Controlc Total
HFHA 9.95(3.29) 7.31(2.37)
HFLA 9.06(3.13) 7.90(2.09)
LFHA
LFLA
9.21(3.40) 7.79(2.17)
8.12(3.32) 7.13(2.24)
Totala 9.11(3.34) 7.55(2.23)
17.26(5.01) 16.96(4.48) 17.00(4.86) 15.23(4.68) 16.66(4.81)
Note. N ¼ 427. Means are shown with standard deviations in parentheses. a b c
Mean and standard deviations for the total sample. Questions 1–2, 4, and 7 on the MGH-HPS. Questions 3, 5–6 on the MGH-HPS.
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6.5. Emotional cycles of hair pulling To understand how emotional regulation maps across profiles and to understand what specific emotional experiences are being regulated across profiles, protected ANOVAs were conducted within the four profiles to determine if scores on the HPS significantly changed from before-to-during (BD) pulling, from during-to-after pulling (DA), and from before-after (BA) pulling. To follow up, between-group analyses were performed to identify differences in emotional regulation for specific emotions across the four hair pulling profiles. 6.6. Emotional regulation across the hair pulling cycle Across all profiles, boredom dropped significantly (p o0.001, d ¼0.653) from before-to-during pulling (BD). Nonsignificant DA changes were also reported (p range: 0.209–0.763), suggesting that pulling produces transient drops in boredom only for the duration of engagement in hair pulling. Similarly, calm scores increased across all profiles during pulling (po 0.000, d ¼0.650), and for both high-focused (HF) profiles (HFHA, HFLA), continued to remain high after pulling had stopped (p range: 0.001–0.039). The feeling of relief provided by pulling was also observed, with the trend across all profiles for relief to increase significantly (p o0.000, d ¼1.035) and remain higher after the behaviour had stopped (d ¼0.935). Fig. 1 illustrates the changes in calm, relief, and boredom across the hairpulling cycle. Anxiety regulation was observed, as all profiles showed significant decreases in anxiety
Emotion Intensity
3
2
1
0
Before
During Pulling Cycle Relieved
Calm
After Bored
Fig. 1. Mean change in relieved, calm and bored levels in HFHA across the pulling cycle.
4
Emotion Intensity
p ¼0.010, and automatic pulling F (1,427) ¼ 4.112, p o0.05, indicating high-focused and high-automatic pulling present with higher MGH-HPS scores. No significant interaction effect was found between focused and automatic pulling F (1,427) ¼21.438, p ¼0.330. Post-hoc tests found HFHA (p ¼0.003, d ¼0.467), HFLA (p ¼0.009, d¼ 0.348), and LFHA (p ¼0.008, d ¼0.370) profiles reported significantly higher total MGH-HPS scores than the LFLA group. Comparisons between HFHA, HFLA, and LFHA on MGH-HPS Total scores found no significant differences (p range ¼0.644– 0.955). Across factors, the HFHA group had significantly higher severity scores than either the HFLA (p ¼0.046) and LFLA profiles (p o0.001, d¼ 0.609). Both HFLA (p¼ 0.037) and LFHA profiles (p ¼0.016) also reported significantly higher MGH-HPS severity scores than the LFLA group. The HFLA profile experienced significantly higher resistance and control scores than either HFHA (p o0.001) or LFLA (p ¼0.013) groups. The LFHA profile reported significantly higher resistance and control scores than LFLA (p ¼0.033).
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3
2
1
Before
During Pulling Cycle HFHA
After
LFLA
Fig. 2. Mean change in tension levels between HFHA and LFLA across the pulling cycle.
once people began to pull (p range: 0.000–0.002, d ¼ 0.466), and a sustained significant (p o0.000) decrease in anxiety after the behaviour had terminated for HFHA and HFLA participants. Tension levels, as illustrated in Fig. 2, dropped for all profiles both during pulling (p¼ 0.000, d ¼0.374), and after pulling was terminated (p ¼0.000, d ¼ 0.491). Significant BA increases in scores of sadness were found across all profiles (p o0.000, d ¼0.618), corresponding with all profiles showing a significant drop in scores of happiness after pulling. DA pulling across all four profiles (p range: 0.000– 0.004, d¼ 0.414) showed a significant drop in scores of happiness after the individuals stopped hair pulling, while HFLA also showed a significant increase (p ¼0.007, d ¼0.303) in scores of happiness only during pulling. Linear increases in several other negative emotions were reported. Significant increases in guilt and embarrassment from BD (p o0.000, d ¼0.685) and DA (p o0.000, d¼ 0.702) across all four hair pulling profiles were recorded. Frustration showed a linear BA increase (p range: 0.000–0.013, d¼ 0.388), but it was shown to be lowered during pulling for the HFHA profile (p ¼0.008, d ¼0.348). 6.7. Severity of emotional regulation across profiles Kruskal-Wallis tests were conducted for each of the emotions of the HPS. The results indicated significant differences in severity of emotional regulation among the four profiles across emotional states, with the exception of boredom and happiness. The results of this analysis are provided in Table 3. Analysis of the within-groups detected that the HF groups had significantly higher sadness (d¼ 0.629), anxious (d ¼0.608), and anger (d¼ 0.466) scores before pulling than either of the two lowfocused (LF; LFHA, LFLA) profiles (po 0.001), with no significant difference between the LF profiles on these three emotions before, during, or after pulling. Significantly higher levels of anger were also reported during pulling episodes for both HF groups over the LF profiles (po 0.001, d ¼0.261), with the HFHA group also maintaining higher levels of anger. following pulling than the LFLA group (d ¼0.545). The HFHA group reported higher levels of tension before pulling than any of the other three profiles (p o0.001, d ¼0.877) and also showed significant increases in the feeling of relief (d ¼1.128) during pulling compared to the LFHA and LFLA profiles. The feeling of frustration was found to be significantly higher before and after pulling for both HF profiles over the LF profiles, with the HFHA levels being significantly higher than the HFLA profile as well. Guilt and embarrassment showed a similar cycle to frustration, with the HFHA profile having significantly higher levels of guilt and embarrassment before and after pulling than any of the other
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Table 3 Comparisons across hair pulling profiles. Before
During
After
Emotion
n
H
ɑ
n
H
ɑ
n
H
ɑ
Bored Happy Sad Angry Calm Anxious Guilty Tense Relieved Indifferent Frustrated Embarrassed Loneliness
426 409 420 417 411 426 410 425 404 410 418 409 420
5.543 4.739 47.521* 31.776* 6.498 48.762* 18.002* 41.090 2.964 9.188 33.027* 31.550* 35.611*
0.136 0.192 0.000 0.000 0.090 0.000 0.000 0.000 0.397 0.027 0.000 0.000 0.000
414 415 419 413 416 425 419 422 415 411 419 419 419
3.155 5.244 15.485* 11.712* 12.056* 15.790* 9.621 8.774 18.117* 1.804* 8.740 12.409* 27.775*
0.368 0.155 0.001 0.008 0.007 0.001 0.022 0.032 0.000 0.013 0.033 0.006 0.000
415 408 425 417 412 425 423 424 417 405 422 424 417
4.490 2.114 28.539* 17.260* .304 11.310* 25.678* 3.808 7.345 1.410 2.538* 23.750* 4.784*
0.213 0.549 0.000 0.001 0.959 0.010 0.000 0.283 0.062 0.703 0.000 0.000 0.000
Note. df ¼3 *
p r 0.0167
three groups (d ¼ 0.413–0.558). Lastly, the feeling of loneliness was significantly higher than the other three groups for the HFHA before pulling, with the HFLA profile having higher scores before pulling than the LFLA group (p¼ 0.003). Additionally, the HFHA profile had higher levels of loneliness after pulling than the other three profiles.
7. Discussion The current study looked at the affective cycles maintaining hair pulling across profiles. Three objectives were developed: (a) to understand differences in severity across hair pulling profiles, (b) to understand the role that emotion regulation plays across profiles, and (c) to understand what negative emotions are produced when individuals with HPD engage in hair pulling. 7.1. Severity across profiles Mapping MGH-HPS onto each hair pulling profile identified that for total scores on the MGH-HPS, three profiles–HFHA, HFLA, and LFHA–had significantly higher mean hair pulling severity than LFLA. Extending the research of Flessner and Conelea (2008), these results show that individuals who had more hair pulling behaviours⎯either focused or automatic⎯had more severe hair pulling than those reporting fewer focused or automatic behaviours. The lack of a statistically significant main effect between focused and automatic pulling supports earlier studies that found both focused and automatic hair pulling behaviours shared equivalent severity (Flessner & Conelea, 2008). Results of the MGH-HPS also found that the HFHA profile had more severe hair pulling urges, greater frequency to pull, frequency of urges, and overall distress. In addition, both HFLA and LFHA groups also reported experiencing a higher intensity of hair pulling urges, pulling frequency, and distress than the LFLA group. Participants in the HFLA and LFHA groups reported having more difficulty resisting both the urge to pull and in controlling their hair pulling behaviour than the those in the LFLA group, suggesting a relationship between the amount of focused or automatic behaviours an individual has, and the greater difficulty in controlling, monitoring, and resisting hair pulling. The relationship of this effect, whether severity influences pulling style or pulling style influences severity, should be a topic for emerging research.
7.2. Emotional cycles This study found hair pulling produced a significant linear decrease from pre- to post-pulling in boredom, with no significant differences in the magnitude of the drop across profiles, a finding consistent with previous research (Diefenbach et al., 2002; Duke et al., 2009; Duke, Keeley, & Ricketts, 2010). This supports boredom serving as a stimulus cue across profiles and that because pulling is an effective downward regulator of boredom, pulling can become negatively reinforced across time (Diefenbach et al., 2002). Underarousal has been hypothesized to serve as the cue that initiates hair pulling in individuals with more automatic pulling, and this study found that this might also be operating in focused hair pulling (Penzel, 2003; Shusterman et al., 2009). All profiles showed significant decreases in anxiety and tension while pulling, with HF profiles reporting the highest pre-pulling levels of both emotions. All four groups use hair pulling to lower the negative arousal states of tension and anxiety, but this regulation is pronounced for individuals who pull intentionally to reduce these emotional states. For LFHA individuals, lowered anxiety and tension remain contingent on continuing to pull and return to pre-pulling levels once the behaviour stops. The other three profiles, HFHA, HFLA, and LFLA, did not follow this trend. Their levels of anxiety dropped significantly once they stopped pulling, suggesting that for these profiles, hair pulling is an effective downward regulator of anxiety. One explanation is that because individuals with focused hair pulling are more goal-focused toward alleviating tension and anxiety by pulling, their decreases can be more stable following the cessation of pulling. Tension showed a different trend with the HFHA, HFLA, and LFHA profiles, showing a stable post-pulling decrease once the behaviour had stopped. Increases during pulling for calm and relief indicate that while hair pulling regulates down negative emotions like boredom, anxiety, and tension, it also increases the experiences of pleasurable emotions (Mansueto, Stemberger, Thomas, & Golomb, 1997). While participants in all four profiles report feeling more calm once they began to pull, both LF profiles return to pre-pulling levels as soon as they stop the behaviours, while the HF profiles maintained an elevated feeling of calm even after pulling. Participants in all four profiles report feeling relieved after they had stopped the behaviour. This shows that relief obtained through pulling is a more stable and enduring state than the sense of calm, which presents as a more short-lived emotional state for automatic pulling. This emphasizes the value of hair pulling as an effective, but
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maladaptive, strategy people with HPD use to control emotional states. 7.3. Creation of negative affect The current study also identified an intensification of several key emotional experiences that varied across the four hair pulling groups. HF profile members reported feeling sadder before beginning to pull than members of either the LFHA or LFLA profiles. There was a trend for HF participants to show decreasing sadness scores during pulling, while participants with LFHA and LFLA profiles reported progressive increases in sadness across the pulling cycle. This suggests hair pulling may serve a regulatory function for HF profiles, but not for LF profiles. However, once pulling stopped, participants in all four profiles reported feeling significantly sadder than before they began pulling, with HFHA reporting the most severe scores, followed sequentially by HFLA, LFHA, and LFLA profiles. All groups reported feeling angrier after pulling, but there were differences in the magnitude of this increase. Both HF profiles had significantly higher anger scores prior to pulling than either the LFHA and LFLA profiles. What is unique about the HFHA profile is that anger is significantly lowered during hair pulling, suggesting that for this profile, pulling serves to regulate down feelings of anger. Guilt associated with pulling was also found to increase across the entire hair pulling cycle, a finding consistent with the early work of Diefenbach et al. (2002). The HFHA profile reported experiencing higher pre- and post-pulling feelings of guilt than any of the other three profiles. Because HFHA individuals have the most intentional and unconscious hair-pulling behaviours, higher levels of guilt may be attributed to the powerlessness of needing to pull, as well as the inability to stop, resist, or predict when hair pulling will occur next. Frustration increased from pre- to post-pulling, and it became significantly higher as the individual continued to pull. Although levels of frustration are higher post-pulling, HFHA individuals also used hair pulling as a way to emotionally regulate frustration down–a pattern not identified in previous research. Results showed HFHA individuals experienced higher levels of embarrassment before and after pulling than any of the other profiles, and both HF styles experienced more embarrassment surrounding their condition than the LF profiles. One explanation proposed by Christenson, Ristvedt, and Mackenzie (1993) is that when someone feels embarrassed, it may serve as a cue to begin hair pulling, and this cue is more prominent for HF hair pulling as a result of the tendency in this subtype for pulling to serve a more prominent role in emotional regulation. Following pulling, embarrassment may shift from an external event (i.e., something happened that caused the individual to feel embarrassed) to an internal experience, as one has to face the effects of his or her pulling (Neal-Barnett, Ward-Brown, Mitchell, & Krownapple, 2000).
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followed by HFLA, LFHA, and finally, LFLA. Discrete differences among profiles were reported. High-focused profiles regulate sadness significantly more than LF profiles. Differences in anger showed that for HF profiles, hair pulling emotionally regulates anger down for these individuals, while for LF individuals, needing to pull enabled them to remain calm and control tension and anxiety. Guilt, frustration, and embarrassment were found across all four profiles, although with increased severity for HF profiles, highlighting an important need to attend to these emotions that characterize the way individuals perceive and react to themselves because of hair pulling. Treatments not only should target the regulative nature of hair pulling for individuals, but also address the self-perception of individuals experiencing embarrassment, frustration, anger, and guilt. Future treatments should consider the pleasurable nature HPD has for individuals and develop alternative, pleasurable, self-soothing responses the individual can use when the desire for pulling is triggered in order to respond to the need for people with HPD to have effective and accessible strategies to emotionally regulate. The study has limitations. First, this study inferred that significant changes in emotional experiences from before- to duringpulling represented an attempt⎯conscious or not⎯to emotionally regulate distressing negative emotions. Future studies may also want to include a formalized emotional regulation measure to strengthen the conclusion that changes on the HPS reflect difficulties in emotional regulation. Second, because the study was conducted online, there was no clinical means of validating and confirming a trichotillomania diagnosis for respondents. This selfselected sample may also differ from a more ethnic or male-represented sample, or from inpatient, clinical populations. Additionally, the HPS measure was retrospective measure; asking people to reflect on their recent pulling episodes and the affective states they can recall experiencing rather than collecting this data in-vivo. Future research should explore the stability of hair pulling profiles across time. Understanding whether a natural oscillation exists with hair pulling profiles as a product of time or treatment could allow health professionals to adjust their approach dynamically to target the specific factors that characterize each of the four profiles. Another direction for research is the role of stimulus regulation (Penzel, 2003) and how tactile, visual, and oral stimulation provided by pulling may play roles in hair pulling and severity by attempting to return the body to a state of homeostatic arousal. Because up to 70% of individuals report some form of hair pulling ritual (Lochner et al., 2010) or oral habit (du Toit et al., 2001), differences in the expression of these behaviours could shed further light on the severity across hair pulling profiles.
Acknowledgements The authors acknowledge the contribution of the TLC Foundation for Body-Focused Repetitive Behaviors for hosting and distributing the surveys used in this study.
8. Conclusions References This study helps to fill the gap identified in previous studies in understanding the specific emotions and states of individuals with HPD. The results revealed a complex pattern of emotional cycles among those individuals. While important differences existed among the profiles, a general conclusion is that individuals who endorse high-focused hair pulling show higher amplitude cycles (i.e., larger changes across time) than LF profiles, with moderate to large effect sizes achieved across emotions. Those with a HFHA profile experience the highest amplitude emotional cycles,
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jpsychores.2006.12.003. Keuthen, N. J., O’Sullivan, R. L., Ricciardi, J. N., Shera, D., Savage, C. R., Borgmann, A. S., … Baer, L. (1995). The Massachusetts General Hospital (MGH) Hairpulling Scale: 1. Development and factor analyses. Psychotherapy and Psychosomatics, 64, 141–145. Retrieved from: 〈http://www.karger.com/Journal/Issue/251613〉. Lochner, C., Seedat, S., & Stein, D. J. (2010). Chronic hair-pulling: Phenomenologybased subtypes. Journal of Anxiety Disorders, 24, 196–202. http://dx.doi.org/ 10.1016/j.janxdis.2009.10.008. Mansueto, C. S., Stemberger, R. M. T., Thomas, A. M., & Golomb, R. G. (1997). Trichotillomania: A comprehensive behavioral model. Clinical Psychology Review, 17, 567–577. http://dx.doi.org/10.1016/s0272-7358(97)00028-7. Marcks, B. A., Woods, D. W., & Ridosko, J. L. (2005). The effects of trichotillomania disclosure on peer perceptions and social acceptability. Body Image, 2, 299–306. http://dx.doi.org/10.1016/j.bodyim.2005.05.003. Neal-Barnett, A. M., Ward-Brown, B. J., Mitchell, M., & Krownapple, M. (2000). Hairpulling in African Americans–Only your hairdresser knows for sure: An exploratory study. Cultural Diversity Ethnic Minority Psychology, 6, 352–362. http: //dx.doi.org/10.1037/1099–9809.6.4.352. O’Sullivan, R. L., Keuthen, N. J., Hayday, C. F., Ricciardi, J. N., Buttolph, M. L., Jenike, M. A., et al. (1995). The Massachusetts General Hospital (MGH) Hairpulling Scale: 2. Reliability and validity. Psychotherapy and Psychosomatics, 64, 146–148. Retrieved from: 〈http://www.karger.com/Journal/Issue/251613〉. Penzel, F. (2003). The hair-pulling problem: A complete guide to trichotillomania. New York, NY: Oxford University Press. Roberts, S., O’Connor, K., & Bélanger, C. (2013). Emotion regulation and other psychological models for body-focused repetitive behaviors. Clinical Psychology Review, 33, 745–762. http://dx.doi.org/10.1016/j.cpr.2013.05.004. Shusterman, A., Feld, L., Baer, L., & Keuthen, N. (2009). Affective regulation in trichotillomania: Evidence from a large-scale internet survey. Behaviour Research and Therapy, 47, 637–644. http://dx.doi.org/10.1016/j.brat.2009.04.004. Soriano, J. L., O’Sullivan, R. L., Baer, L., Phillips, K. A., McNally, R. J., & Jenike, M. A. (1996). Trichotillomania and self-esteem: A survey of 62 female hair pullers. Journal of Clinical Psychiatry, 57, 77–82. Stanley, M. A., Borden, J. W., Mouton, S. G., & Breckenridge, J. K. (1995). Nonclinical hair-pulling: Affective correlates and comparison with clinical samples. Behaviour Research and Therapy, 33, 179–186. http://dx.doi.org/10.1016/0005–7967 (94)E0018-E. du Toit, P. L., van Kradenburg, J., Niehaus, D. J. H., & Stein, D. J. (2001). Characteristics and phenomenology of hair-pulling: An exploration of subtypes. Comprehensive Psychiatry, 42, 247–256. http://dx.doi.org/10.1053/comp.2001.23134. Wetterneck, C. T., Woods, D. W., Norberg, M. M., & Begotka, A. M. (2006). The social and economic impact of trichotillomania: Results from two nonreferred samples. Behavioral Interventions, 21, 97–109. http://dx.doi.org/10.1002/bin.211. Woods, D. W., Flessner, C. A., Franklin, M. E., Keuthen, N. J., Goodwin, R. D., Stein, D. J., et al. (2006). The trichotillomania impact project (TIP): Exploring phenomenology, functional impairment, and treatment utilization. Journal of Clinical Psychiatry, 67, 1877–1888. http://dx.doi.org/10.4088/JCP.v67n1207.
Contents lists available at ScienceDirect
Journal of Obsessive-Compulsive and Related Disorders journal homepage: www.elsevier.com/locate/jocrd
Emotional regulation cycles in trichotillomania (hair-pulling disorder) across subtypes Sebastian Siwiec n, Dawn Lorraine McBride Faculty of Education, University of Lethbridge, 4401, University Drive, Lethbridge, Alberta, Canada T1K 3M4
art ic l e i nf o
a b s t r a c t
Article history: Received 22 August 2015 Received in revised form 4 May 2016 Accepted 22 June 2016 Available online 23 June 2016
The patterns of emotional regulation involved in trichotillomania (hair-pulling disorder; HPD) were studied across various subtypes of hair pulling. Using the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A), this is the first study to address the regulation of emotions across four specific subtypes of hair pulling. For this study, 427 participants completed an online questionnaire around their hair pulling subtype, severity, and emotions experienced by hair pulling. Participants were divided as either high- or low-focused and either high- or low-automatic. Significant differences between subtypes and severity were reported. Subtypes differed in the severity of the emotions they experienced; individuals with high-focused pulling reported more intense negative emotions, and a greater number of emotions regulated by pulling. Positive emotions–happiness, relief, and calm–were also found to play a significant role in reinforcing hair pulling. For high-focused subtypes, negative emotions before, and after, pulling were associated with greater severity, indicating that altering negative emotions via pulling plays an important role for high-focused subtypes. Clinical and treatment implications, study limitations, and areas of future research are discussed. & 2016 Elsevier Inc. All rights reserved.
Keywords: Trichotillomania Hair-pulling disorder Internet survey Emotional regulation Body-focused repetitive behaviour (BFRB)
1. Introduction Trichotillomania (Hair-Pulling Disorder; HPD) is characterized by the recurrent pulling of one's own hair from any part of one's own body, resulting in hair loss (American Psychiatric Association, 2013). In HPD, hair can be pulled from any area of the body, although the scalp, eyebrows, eyelashes, and pubic hair have been identified as the most frequent sites (Christenson, Mackenzie, & Mitchell, 1991; Lochner, Seedat, & Stein, 2010). A range of social, academic, occupational, physical, and psychological impairments is also experienced by people with HPD. Secrecy, self-stigmatization, shame, and avoidance or impairment of enjoyable social and occupational activities are all routinely reported by people with HPD (Marcks, Woods, & Ridosko, 2005; Soriano et al., 1996; Wetterneck, Woods, Norberg, & Begotka, 2006). Studies using different degrees of strictness in defining HPD have made a precise prevalence rate difficult to settle upon (Duke, Keeley, Geffken et al., 2010). Early studies found the prevalence ranged from 0.6% to 2.5% (Christenson et al., 1991), while larger and more recent community samples endorse a prevalence of 1.2% (Duke, Bodzin, Tavares, Geffken, & Storch, 2009), often with a n Correspondence to: Calgary Counseling Centre #940, 6th Avenue SW Calgary, Alberta, Canada T2P3T1. Tel.: þ 1 4038907472. E-mail addresses: [email protected] (S. Siwiec), [email protected] (D.L. McBride).
http://dx.doi.org/10.1016/j.jocrd.2016.06.003 2211-3649/& 2016 Elsevier Inc. All rights reserved.
higher female presence for the disorder (Chamberlain, Menzies, Sahakian, & Fineberg, 2007; Wetterneck et al., 2006).
2. Pulling styles Over the course of HPD research, a heterogeneous conceptualization of HPD emerged, with individuals reporting two distinct pulling styles. Focused pulling is intentional, goal directed (e.g., looking for a specific hair), or pulling to regulate a negative affective state (e.g., anxiety, stress, etc.). Automatic pulling is defined as pulling that occurs outside of awareness and can occur in the presence of affective states such as boredom (Christenson, Mackenzie, & Mitchell, 1994). Originally it was reported that pure automatic hair pulling occurred in 5–32% of the HPD population, with 15–25% displaying focused-only hair pulling, and 43–80% of individuals displaying a mix of both patterns (Christenson et al., 1994, 1991; du Toit, van Kradenburg, Niehaus, & Stein, 2001). Flessner, Woods, Franklin, Cashin, and Keuthen (2008) who developed the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A), a self-report measure to identify and analyze the unique behaviours of focused and automatic pulling, found pure-automatic and pure-focused hair pulling occurred in less than 0.01% of the HPD population (Flessner & Conelea, 2008; Flessner et al., 2008). Because of this mixed presentation, and the unique characteristics distinguishing focused and automatic
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pulling, it is meaningful understand how these two styles are expressed within the individual and to arrange treatment specifically to address the emotional regulation and awareness deficits of the individual depending on their composite pulling style. Flessner, Busch et al. (2008) reported that an understanding the focused and automatic presentation of individuals may help aid in the response to treatment –improving the decision of the type of therapy to administer and the order the therapy protocol is provided.
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4. Methods 4.1. Subtypes of trichotillomania affect questionnaire (STAQ) A large-scale web survey, the STAQ, composed of two demographics forms and four inventories was compiled to address the research goals. The study sought to reach out to a community sample of nonreferred, self-reported individuals who hair pull. The intention was to capture a large, representative sample size and obtain a comprehensive spectrum of individuals that could not be captured through inpatient clinical research.
3. Emotion regulation Research into therapies for HPD first approached the condition using cognitive behavioural therapy (CBT) and habit reversal training (HRT), which emphasize awareness, self-monitoring, and developing competing responses (Azrin & Nunn, 1973). More recently, studies on therapies for HPD have shifted towards more acceptance and emotion regulation models (Crosby, Dehlin, Mitchell, & Twohig, 2012; Keuthen & Sprich, 2012). This move follows studies that demonstrate HPD serves as a way for individuals to regulate their emotional states (Diefenbach, Tolin, Meunier, & Worhunsky, 2008; Shusterman, Feld, Baer, & Keuthen, 2009). The emotion regulation (ER) model proposes that HPD is initiated by negative emotions and negatively reinforced by the alleviation from these negative affective states. (Roberts, O’Connor, & Bélanger, 2013). In support of this model, Shusterman et al. (2009) found that individuals with HPD had a greater difficulty regulating emotions than did controls. People with HPD have been found to use pulling to regulate a variety of negative affective states including anger, anxiousness, boredom, embarrassment, frustration, guilt, sadness, and tension (Diefenbach, MoutonOdum, & Stanley, 2002; Diefenbach et al., 2008; Duke, Keeley, & Ricketts, 2010; Stanley, Borden, Mouton, & Breckenridge, 1995; Shusterman et al., 2009). In light of findings showing individuals having distinct pulling styles, research is beginning to look at whether some individuals respond more favourably to the behavioural protocols of HRT or the emotional regulation strategies of ER therapies depending on the degree to which individuals pull to avoid, escape, or regulate internal experiences (Crosby et al., 2012; Flessner, Busch et al., 2008). Researchers have yet to explore the relationship between hair pulling style and the role of emotion regulation in HPD. Shusterman et al. (2009) found that individuals differ in what emotional cues they use for pulling, but did not administer the MIST-A to map these emotional patterns onto the degree of focused and automatic pulling that manifests in the individual. Accordingly, the study being reported on proposed three specific research hypotheses to address this unexplored area of research. First, by establishing how the severity of hair pulling maps onto each hair pulling profile. This study hypothesized that the degree to which people use pulling to control how they feel, pull in response to anxiety or sadness, and in the degree of dissociation that occurs – items measured on the MIST-A; will reflect on the MGH-HPS as greater intensity, lower perceived control, greater distress, and overall increased hair pulling severity. Second, people with more focused hair pulling would experience a higher degree of emotional regulation by pulling, expressed as the intensity of change emotional states underwent during the before-during-after pulling cycle. Third, regulating emotions by pulling was hypothesized to create additional negative experiences that reinforced the behaviour. The intention was that by mapping the emotion clusters across hair pulling styles, more intentional and deliberate treatment planning could be developed to be more responsive to the individual.
4.2. Participants Recruitment and advertising was done through The TLC Foundation for Body-Focused Repetitive Behaviours (TLC). TLC distributed the survey on their online research page, through an email distributed to thousands of TLC members, and through recurrent posting on the TLC Facebook and Twitter social media pages. 4.3. Inclusion criteria To be included in the study, participants needed to (a) indicate that their hair pulling has resulted in noticeable hair loss or the thinning of hair; (b) report this action causes them mild distress in at least one or more personal, interpersonal, occupational, or academic domains; and (c) indicate that they were at least 18 years of age. To ensure uniformity of inclusion criteria across studies, these criteria were adapted with permission from Dr. Douglas Woods, the main author of the largest trichotillomania study to date–the Trichotillomania Impact Survey (see Woods et al., 2006). Participants were excluded from participation if they endorsed pulling in response to any drug abuse or untreated psychotic condition, or if their pulling was secondary to another medical condition (e.g., dry or itchy skin). 4.4. Survey administration and informed consent The survey was administered online through the Internet survey platform Qualtrics. Surveys were saved anonymously and downloaded by the authors for analysis. Responses were collected between December 2012 and January 2013. Participants accessing the study were provided with the study's rationale and informed both of the voluntary nature of participation and of the ethical approvals for the study granted by the Scientific Advisory Board of the TLC and the Human Research Subjects Committee of the University of Lethbridge. Participants who indicated that they had read and agreed to the terms of consent for participation were provided access to the survey. Upon completing the survey, participants were thanked, debriefed, provided resources to treatment providers, and given a link that later hosted a summary of the findings.
5. Assessments 5.1. Basic demographic form Participants were requested to answer six general demographic questions, including gender, age, ethnicity, and marital status. These questions were asked to gain an understanding of the demographics of participants entering the survey.
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5.2. HPD demographic form The HPD demographic form asked 20 questions to gather descriptive information, including pulling sites, previous diagnosis for HPD, and frequency of pulling. This form included the DSM-5 criteria for HPD, including measuring pulling resulting in hair loss (noticeable or not); distress in social, occupational, or other important areas of functioning; and pulling not due to another general medical condition. Participants needed to endorse these criteria for inclusion in the study. 5.3. Massachusetts general hospital hairpulling scale (MGH-HPS) Participants completed the MGH-HPS (Keuthen et al., 1995). The MGH-HPS is a reliable and valid 7-item, self-report measure to assess the severity of hair pulling (O’Sullivan et al., 1995). Items are rated on a 5-point Likert scale, from 0 to 4, with higher scores indicating higher symptom severity. The MGH-HPS has been shown to be equally sensitive at assessing severity for both focused and automatic hair pulling groups (Flessner & Conelea, 2008), and demonstrates strong internal consistency (Keuthen et al., 1995; Keuthen et al., 2007). The MGH-HPS has undergone a factor analysis to derive a two-factors structure (Keuthen et al., 2007). While a total severity score is created, distinct severity and resistance and control factors have been isolated, with internal consistencies of.832 and.805 respectively (Keuthen et al., 2007).
Table 1 Number and Location of Hair Pulling Sites. Number of sites
Mean
(SD)
Range
Scalp-1 Scalp-5
2.87 4.67
1.88 2.51
1–12 1–16 Most frequent
Hair pulling sites
n
%
N(%)
Scalp Crown Right-temporal Left-temporal Frontal Occipital Totala Eyelashes Eyebrows Pubic hair Moustache Beard Trunk Armpits Arms Legs/Feet Other
279 198 212 218 186 325 203 219 203 13 17 17 64 38 85 31
65.3 46.4 49.6 51.1 43.6 76.1 47.5 51.3 47.5 3.0 4.0 4.0 15.0 8.9 19.9 7.3
133(31.1) 23(5.4) 57(13.3) 27(6.3) 34(8.0) – 74(17.3) 46(10.8) 11(2.6) – 6(1.4) – – 3(.7) 3(.7) 3(.7)
Note. N ¼ 427. Scalp-1 ¼ scalp considered one hair pulling site; Scalp-5 ¼ scalp considered as five separate hair pulling sites. a
Respondents with at least one scalp hair pulling site.
5.4. Milwaukee Inventory for Subtypes of Trichotillomania (MIST-A)
retained for analysis.
The MIST-A measure was developed to formalize the degree to which individuals engage in focused and/or automatic hair pulling (Flessner et al., 2008). Participants completed the 15-item, selfreport measure, which includes items highly correlated with either focused or automatic pulling (Flessner et al., 2008). Items are rated on a 10-point Likert Scale, from 0 to 9, and receive a focused score (ranging from 0 to 90), and an automatic score (ranging from 0 to 45). Higher scores represent a higher dominance of that style's unique behaviours. Using the MIST-A, four hair-pulling profiles were created using a median-split procedure. The four profiles were: high-focused, high-automatic hair pulling (HFHA); highfocused, low-automatic (HFLA), low-focused, high-automatic (LFHA); and low-focused, low-automatic (LFLA).
6.2. Participant demographics The mean age of participants was 33.44-years-old (SD ¼ 12.42), ranging from 18- to 71-years-old. Age of onset ranged from 1- to 51-years-old, with a mean onset of 12.4-years-old (SD ¼6.17). Females accounted for 95.8% of the participants in the survey. Twothirds (66.5%) of the respondents reported having been diagnosed with HPD by a professional, most commonly a psychiatrist or psychologist, while a third (33.5%) reported having never been formally diagnosed with the condition despite reporting the prerequisite criteria. The number, location, and most frequent individual hair pulling sites are presented in Table 1. 6.3. Hair pulling severity across pulling styles
5.5. Hair pulling survey (HPS) The HPS measure was developed to assess affective states play in hair pulling (Stanley et al., 1995). When completing the HPS, participants retrospectively rated the extent to which they experienced each emotion (i.e., anger, anxiousness, boredom, calm, guilt, happiness, indifference, relief, sadness, tension, embarrassment, frustration, indifference) on a 9-point (0 8) Likert scale. Participants rated the experience of each emotion before they engaged in pulling, during pulling, and after they pulled.
6. Results 6.1. Completion rates The survey received 609 responses over the 45 days the online survey was active. Duplicate responses, incomplete surveys, those not meeting the inclusion criteria, or endorsing any of the exclusion criteria, were removed. Of the 609 respondents, 477 completed the study, a response rate of 78%. For not meeting the inclusion or violating any exclusion criteria, 50 (10%) responses were removed from the response pool. A total of 427 surveys were
Scores on the MGH-HPS were analyzed to map the relationship between hair pulling severity and hair pulling profile. Descriptives are presented in Table 2. 6.4. Hair pulling severity An analysis on the role of focused and automatic pulling on TTM severity was performed. Results of the ANOVA revealed a significant main effect for focused pulling F (1, 427) ¼6.632, Table 2 Descriptives for the MGH-HPS. MGH-HPS Severityb Resistance & Controlc Total
HFHA 9.95(3.29) 7.31(2.37)
HFLA 9.06(3.13) 7.90(2.09)
LFHA
LFLA
9.21(3.40) 7.79(2.17)
8.12(3.32) 7.13(2.24)
Totala 9.11(3.34) 7.55(2.23)
17.26(5.01) 16.96(4.48) 17.00(4.86) 15.23(4.68) 16.66(4.81)
Note. N ¼ 427. Means are shown with standard deviations in parentheses. a b c
Mean and standard deviations for the total sample. Questions 1–2, 4, and 7 on the MGH-HPS. Questions 3, 5–6 on the MGH-HPS.
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6.5. Emotional cycles of hair pulling To understand how emotional regulation maps across profiles and to understand what specific emotional experiences are being regulated across profiles, protected ANOVAs were conducted within the four profiles to determine if scores on the HPS significantly changed from before-to-during (BD) pulling, from during-to-after pulling (DA), and from before-after (BA) pulling. To follow up, between-group analyses were performed to identify differences in emotional regulation for specific emotions across the four hair pulling profiles. 6.6. Emotional regulation across the hair pulling cycle Across all profiles, boredom dropped significantly (p o0.001, d ¼0.653) from before-to-during pulling (BD). Nonsignificant DA changes were also reported (p range: 0.209–0.763), suggesting that pulling produces transient drops in boredom only for the duration of engagement in hair pulling. Similarly, calm scores increased across all profiles during pulling (po 0.000, d ¼0.650), and for both high-focused (HF) profiles (HFHA, HFLA), continued to remain high after pulling had stopped (p range: 0.001–0.039). The feeling of relief provided by pulling was also observed, with the trend across all profiles for relief to increase significantly (p o0.000, d ¼1.035) and remain higher after the behaviour had stopped (d ¼0.935). Fig. 1 illustrates the changes in calm, relief, and boredom across the hairpulling cycle. Anxiety regulation was observed, as all profiles showed significant decreases in anxiety
Emotion Intensity
3
2
1
0
Before
During Pulling Cycle Relieved
Calm
After Bored
Fig. 1. Mean change in relieved, calm and bored levels in HFHA across the pulling cycle.
4
Emotion Intensity
p ¼0.010, and automatic pulling F (1,427) ¼ 4.112, p o0.05, indicating high-focused and high-automatic pulling present with higher MGH-HPS scores. No significant interaction effect was found between focused and automatic pulling F (1,427) ¼21.438, p ¼0.330. Post-hoc tests found HFHA (p ¼0.003, d ¼0.467), HFLA (p ¼0.009, d¼ 0.348), and LFHA (p ¼0.008, d ¼0.370) profiles reported significantly higher total MGH-HPS scores than the LFLA group. Comparisons between HFHA, HFLA, and LFHA on MGH-HPS Total scores found no significant differences (p range ¼0.644– 0.955). Across factors, the HFHA group had significantly higher severity scores than either the HFLA (p ¼0.046) and LFLA profiles (p o0.001, d¼ 0.609). Both HFLA (p¼ 0.037) and LFHA profiles (p ¼0.016) also reported significantly higher MGH-HPS severity scores than the LFLA group. The HFLA profile experienced significantly higher resistance and control scores than either HFHA (p o0.001) or LFLA (p ¼0.013) groups. The LFHA profile reported significantly higher resistance and control scores than LFLA (p ¼0.033).
87
3
2
1
Before
During Pulling Cycle HFHA
After
LFLA
Fig. 2. Mean change in tension levels between HFHA and LFLA across the pulling cycle.
once people began to pull (p range: 0.000–0.002, d ¼ 0.466), and a sustained significant (p o0.000) decrease in anxiety after the behaviour had terminated for HFHA and HFLA participants. Tension levels, as illustrated in Fig. 2, dropped for all profiles both during pulling (p¼ 0.000, d ¼0.374), and after pulling was terminated (p ¼0.000, d ¼ 0.491). Significant BA increases in scores of sadness were found across all profiles (p o0.000, d ¼0.618), corresponding with all profiles showing a significant drop in scores of happiness after pulling. DA pulling across all four profiles (p range: 0.000– 0.004, d¼ 0.414) showed a significant drop in scores of happiness after the individuals stopped hair pulling, while HFLA also showed a significant increase (p ¼0.007, d ¼0.303) in scores of happiness only during pulling. Linear increases in several other negative emotions were reported. Significant increases in guilt and embarrassment from BD (p o0.000, d ¼0.685) and DA (p o0.000, d¼ 0.702) across all four hair pulling profiles were recorded. Frustration showed a linear BA increase (p range: 0.000–0.013, d¼ 0.388), but it was shown to be lowered during pulling for the HFHA profile (p ¼0.008, d ¼0.348). 6.7. Severity of emotional regulation across profiles Kruskal-Wallis tests were conducted for each of the emotions of the HPS. The results indicated significant differences in severity of emotional regulation among the four profiles across emotional states, with the exception of boredom and happiness. The results of this analysis are provided in Table 3. Analysis of the within-groups detected that the HF groups had significantly higher sadness (d¼ 0.629), anxious (d ¼0.608), and anger (d¼ 0.466) scores before pulling than either of the two lowfocused (LF; LFHA, LFLA) profiles (po 0.001), with no significant difference between the LF profiles on these three emotions before, during, or after pulling. Significantly higher levels of anger were also reported during pulling episodes for both HF groups over the LF profiles (po 0.001, d ¼0.261), with the HFHA group also maintaining higher levels of anger. following pulling than the LFLA group (d ¼0.545). The HFHA group reported higher levels of tension before pulling than any of the other three profiles (p o0.001, d ¼0.877) and also showed significant increases in the feeling of relief (d ¼1.128) during pulling compared to the LFHA and LFLA profiles. The feeling of frustration was found to be significantly higher before and after pulling for both HF profiles over the LF profiles, with the HFHA levels being significantly higher than the HFLA profile as well. Guilt and embarrassment showed a similar cycle to frustration, with the HFHA profile having significantly higher levels of guilt and embarrassment before and after pulling than any of the other
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Table 3 Comparisons across hair pulling profiles. Before
During
After
Emotion
n
H
ɑ
n
H
ɑ
n
H
ɑ
Bored Happy Sad Angry Calm Anxious Guilty Tense Relieved Indifferent Frustrated Embarrassed Loneliness
426 409 420 417 411 426 410 425 404 410 418 409 420
5.543 4.739 47.521* 31.776* 6.498 48.762* 18.002* 41.090 2.964 9.188 33.027* 31.550* 35.611*
0.136 0.192 0.000 0.000 0.090 0.000 0.000 0.000 0.397 0.027 0.000 0.000 0.000
414 415 419 413 416 425 419 422 415 411 419 419 419
3.155 5.244 15.485* 11.712* 12.056* 15.790* 9.621 8.774 18.117* 1.804* 8.740 12.409* 27.775*
0.368 0.155 0.001 0.008 0.007 0.001 0.022 0.032 0.000 0.013 0.033 0.006 0.000
415 408 425 417 412 425 423 424 417 405 422 424 417
4.490 2.114 28.539* 17.260* .304 11.310* 25.678* 3.808 7.345 1.410 2.538* 23.750* 4.784*
0.213 0.549 0.000 0.001 0.959 0.010 0.000 0.283 0.062 0.703 0.000 0.000 0.000
Note. df ¼3 *
p r 0.0167
three groups (d ¼ 0.413–0.558). Lastly, the feeling of loneliness was significantly higher than the other three groups for the HFHA before pulling, with the HFLA profile having higher scores before pulling than the LFLA group (p¼ 0.003). Additionally, the HFHA profile had higher levels of loneliness after pulling than the other three profiles.
7. Discussion The current study looked at the affective cycles maintaining hair pulling across profiles. Three objectives were developed: (a) to understand differences in severity across hair pulling profiles, (b) to understand the role that emotion regulation plays across profiles, and (c) to understand what negative emotions are produced when individuals with HPD engage in hair pulling. 7.1. Severity across profiles Mapping MGH-HPS onto each hair pulling profile identified that for total scores on the MGH-HPS, three profiles–HFHA, HFLA, and LFHA–had significantly higher mean hair pulling severity than LFLA. Extending the research of Flessner and Conelea (2008), these results show that individuals who had more hair pulling behaviours⎯either focused or automatic⎯had more severe hair pulling than those reporting fewer focused or automatic behaviours. The lack of a statistically significant main effect between focused and automatic pulling supports earlier studies that found both focused and automatic hair pulling behaviours shared equivalent severity (Flessner & Conelea, 2008). Results of the MGH-HPS also found that the HFHA profile had more severe hair pulling urges, greater frequency to pull, frequency of urges, and overall distress. In addition, both HFLA and LFHA groups also reported experiencing a higher intensity of hair pulling urges, pulling frequency, and distress than the LFLA group. Participants in the HFLA and LFHA groups reported having more difficulty resisting both the urge to pull and in controlling their hair pulling behaviour than the those in the LFLA group, suggesting a relationship between the amount of focused or automatic behaviours an individual has, and the greater difficulty in controlling, monitoring, and resisting hair pulling. The relationship of this effect, whether severity influences pulling style or pulling style influences severity, should be a topic for emerging research.
7.2. Emotional cycles This study found hair pulling produced a significant linear decrease from pre- to post-pulling in boredom, with no significant differences in the magnitude of the drop across profiles, a finding consistent with previous research (Diefenbach et al., 2002; Duke et al., 2009; Duke, Keeley, & Ricketts, 2010). This supports boredom serving as a stimulus cue across profiles and that because pulling is an effective downward regulator of boredom, pulling can become negatively reinforced across time (Diefenbach et al., 2002). Underarousal has been hypothesized to serve as the cue that initiates hair pulling in individuals with more automatic pulling, and this study found that this might also be operating in focused hair pulling (Penzel, 2003; Shusterman et al., 2009). All profiles showed significant decreases in anxiety and tension while pulling, with HF profiles reporting the highest pre-pulling levels of both emotions. All four groups use hair pulling to lower the negative arousal states of tension and anxiety, but this regulation is pronounced for individuals who pull intentionally to reduce these emotional states. For LFHA individuals, lowered anxiety and tension remain contingent on continuing to pull and return to pre-pulling levels once the behaviour stops. The other three profiles, HFHA, HFLA, and LFLA, did not follow this trend. Their levels of anxiety dropped significantly once they stopped pulling, suggesting that for these profiles, hair pulling is an effective downward regulator of anxiety. One explanation is that because individuals with focused hair pulling are more goal-focused toward alleviating tension and anxiety by pulling, their decreases can be more stable following the cessation of pulling. Tension showed a different trend with the HFHA, HFLA, and LFHA profiles, showing a stable post-pulling decrease once the behaviour had stopped. Increases during pulling for calm and relief indicate that while hair pulling regulates down negative emotions like boredom, anxiety, and tension, it also increases the experiences of pleasurable emotions (Mansueto, Stemberger, Thomas, & Golomb, 1997). While participants in all four profiles report feeling more calm once they began to pull, both LF profiles return to pre-pulling levels as soon as they stop the behaviours, while the HF profiles maintained an elevated feeling of calm even after pulling. Participants in all four profiles report feeling relieved after they had stopped the behaviour. This shows that relief obtained through pulling is a more stable and enduring state than the sense of calm, which presents as a more short-lived emotional state for automatic pulling. This emphasizes the value of hair pulling as an effective, but
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maladaptive, strategy people with HPD use to control emotional states. 7.3. Creation of negative affect The current study also identified an intensification of several key emotional experiences that varied across the four hair pulling groups. HF profile members reported feeling sadder before beginning to pull than members of either the LFHA or LFLA profiles. There was a trend for HF participants to show decreasing sadness scores during pulling, while participants with LFHA and LFLA profiles reported progressive increases in sadness across the pulling cycle. This suggests hair pulling may serve a regulatory function for HF profiles, but not for LF profiles. However, once pulling stopped, participants in all four profiles reported feeling significantly sadder than before they began pulling, with HFHA reporting the most severe scores, followed sequentially by HFLA, LFHA, and LFLA profiles. All groups reported feeling angrier after pulling, but there were differences in the magnitude of this increase. Both HF profiles had significantly higher anger scores prior to pulling than either the LFHA and LFLA profiles. What is unique about the HFHA profile is that anger is significantly lowered during hair pulling, suggesting that for this profile, pulling serves to regulate down feelings of anger. Guilt associated with pulling was also found to increase across the entire hair pulling cycle, a finding consistent with the early work of Diefenbach et al. (2002). The HFHA profile reported experiencing higher pre- and post-pulling feelings of guilt than any of the other three profiles. Because HFHA individuals have the most intentional and unconscious hair-pulling behaviours, higher levels of guilt may be attributed to the powerlessness of needing to pull, as well as the inability to stop, resist, or predict when hair pulling will occur next. Frustration increased from pre- to post-pulling, and it became significantly higher as the individual continued to pull. Although levels of frustration are higher post-pulling, HFHA individuals also used hair pulling as a way to emotionally regulate frustration down–a pattern not identified in previous research. Results showed HFHA individuals experienced higher levels of embarrassment before and after pulling than any of the other profiles, and both HF styles experienced more embarrassment surrounding their condition than the LF profiles. One explanation proposed by Christenson, Ristvedt, and Mackenzie (1993) is that when someone feels embarrassed, it may serve as a cue to begin hair pulling, and this cue is more prominent for HF hair pulling as a result of the tendency in this subtype for pulling to serve a more prominent role in emotional regulation. Following pulling, embarrassment may shift from an external event (i.e., something happened that caused the individual to feel embarrassed) to an internal experience, as one has to face the effects of his or her pulling (Neal-Barnett, Ward-Brown, Mitchell, & Krownapple, 2000).
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followed by HFLA, LFHA, and finally, LFLA. Discrete differences among profiles were reported. High-focused profiles regulate sadness significantly more than LF profiles. Differences in anger showed that for HF profiles, hair pulling emotionally regulates anger down for these individuals, while for LF individuals, needing to pull enabled them to remain calm and control tension and anxiety. Guilt, frustration, and embarrassment were found across all four profiles, although with increased severity for HF profiles, highlighting an important need to attend to these emotions that characterize the way individuals perceive and react to themselves because of hair pulling. Treatments not only should target the regulative nature of hair pulling for individuals, but also address the self-perception of individuals experiencing embarrassment, frustration, anger, and guilt. Future treatments should consider the pleasurable nature HPD has for individuals and develop alternative, pleasurable, self-soothing responses the individual can use when the desire for pulling is triggered in order to respond to the need for people with HPD to have effective and accessible strategies to emotionally regulate. The study has limitations. First, this study inferred that significant changes in emotional experiences from before- to duringpulling represented an attempt⎯conscious or not⎯to emotionally regulate distressing negative emotions. Future studies may also want to include a formalized emotional regulation measure to strengthen the conclusion that changes on the HPS reflect difficulties in emotional regulation. Second, because the study was conducted online, there was no clinical means of validating and confirming a trichotillomania diagnosis for respondents. This selfselected sample may also differ from a more ethnic or male-represented sample, or from inpatient, clinical populations. Additionally, the HPS measure was retrospective measure; asking people to reflect on their recent pulling episodes and the affective states they can recall experiencing rather than collecting this data in-vivo. Future research should explore the stability of hair pulling profiles across time. Understanding whether a natural oscillation exists with hair pulling profiles as a product of time or treatment could allow health professionals to adjust their approach dynamically to target the specific factors that characterize each of the four profiles. Another direction for research is the role of stimulus regulation (Penzel, 2003) and how tactile, visual, and oral stimulation provided by pulling may play roles in hair pulling and severity by attempting to return the body to a state of homeostatic arousal. Because up to 70% of individuals report some form of hair pulling ritual (Lochner et al., 2010) or oral habit (du Toit et al., 2001), differences in the expression of these behaviours could shed further light on the severity across hair pulling profiles.
Acknowledgements The authors acknowledge the contribution of the TLC Foundation for Body-Focused Repetitive Behaviors for hosting and distributing the surveys used in this study.
8. Conclusions References This study helps to fill the gap identified in previous studies in understanding the specific emotions and states of individuals with HPD. The results revealed a complex pattern of emotional cycles among those individuals. While important differences existed among the profiles, a general conclusion is that individuals who endorse high-focused hair pulling show higher amplitude cycles (i.e., larger changes across time) than LF profiles, with moderate to large effect sizes achieved across emotions. Those with a HFHA profile experience the highest amplitude emotional cycles,
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