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Trichotillomania: impact on psychosocial functioning and quality of life
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Behaviour Research and Therapy 43 (2005) 869–884 www.elsevier.com/locate/brat
Trichotillomania: impact on psychosocial functioning and quality of life$ Gretchen J. Diefenbach, David F. Tolin, Scott Hannan, Johanna Crocetto, Patrick Worhunsky Anxiety Disorders Center, Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA Received 27 December 2003; received in revised form 22 April 2004; accepted 21 June 2004
Abstract This study explored the impact of hair pulling on psychosocial functioning for patients diagnosed with trichotillomania (TTM; n ¼ 28). TTM patients were compared to age and gender-matched groups of psychiatric patients without TTM (n ¼ 28) and nonpsychiatric control volunteers (NC, n ¼ 28) on measures of psychological distress, functioning/quality of life, and self-esteem. Results indicated that TTM patients reported more severe psychosocial impairments than did NC volunteers; however, these differences were mediated by differences in level of depression. Regression analyses indicated significant relationships between some measures of psychosocial functioning and severity of hair pulling, independent of level of depression. Finally, an interview of the impact of hair pulling on 6 domains of daily functioning (negative affect/negative self-evaluations, grooming, recreational activities, social interaction, work/housework productivity, and physical health) indicated common and wide-ranging impairments for both lifetime and current (i.e., past week) ratings. These results highlight the importance of promoting and improving resources for the clinical care of TTM patients, and provide some directions for clinicians to enhance assessment of interference caused by TTM. r 2004 Elsevier Ltd. All rights reserved. Keywords: Trichotillomania; Hair pulling; Quality of life
$
This research was funded by grants from Hartford Hospital (Grants 126073 and 126082) to the first author. These data were presented at the national meeting of the Association for Advancement of Behavior Therapy, November 2003, Boston, MA. Corresponding author. +Tel.: +1-860-545-7685; fax: +1-860-545-7156. E-mail address: [email protected] (G.J. Diefenbach). 0005-7967/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2004.06.010
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1. Introduction Trichotillomania (TTM) is an impulse control disorder characterized by repetitive hair pulling resulting in noticeable hair loss. The exact prevalence of TTM is unknown; however, estimates from university surveys suggest that 1.5% of males and 3.4% of females endorse clinically significant hair pulling, with .6% endorsing all diagnostic criteria of TTM (Christenson, Pyle, & Mitchell, 1991). The prevalence of nonclinical hair pulling behaviors range even higher, up to 15.3%, in university surveys (Stanley, Borden, Bell, & Wagner, 1994). Although hair pulling was once considered benign, TTM has recently gained recognition as a distressing and impairing psychiatric condition (Diefenbach, Reitman, & Williamson, 2000). However, research is only beginning to outline the psychosocial impairments associated with TTM. The goal of the current study was to examine the impact of TTM on psychosocial functioning and quality of life. Most previous research has categorized impairments associated with TTM based on patient interviews, chart reviews, or descriptive questionnaires (e.g., Casati, Toner, & Yu, 2000; du Toit, van Kradenburg, Niehaus, & Stein, 2001; Seedat & Stein, 1998; Stemberger, Thomas, Mansueto, & Carter, 2000). From these data, several different domains of impaired quality of life have been reported. First, research suggests consequences on psychological distress and lowered self-esteem (du Toit et al., 2001; Seedat & Stein, 1998; Soriano et al., 1996; Stemberger et al., 2000). Similarly, patients with TTM commonly report negative self-referencing emotions such as guilt and shame, as well as frustrations with being unable to control hair pulling (Casati et al., 2000; du Toit et al., 2001; Stemberger et al., 2000). Hair pulling can also negatively impact social functioning. For example, individuals with TTM will often attempt to conceal hair loss through extra time and expense grooming (e.g., special hair styles or make-up) or avoidance of recreational activities (e.g., du Toit et al., 2001; Stemberger et al., 2000). The quality of interpersonal relationships can also be affected by increased arguments or decreased sexual intimacy (Stemberger et al., 2000). In addition, patients report that hair pulling can be socially isolating, by keeping hair pulling a secret from even close friends and family. Preliminary data also suggest impact on occupational functioning, such as missed work days or lowered occupational goals (Keuthen et al., 2002; Seedat & Stein, 1998). Finally, hair pulling can impact physical health. For example, physical damage from pulling (e.g., scarring) (e.g., O’Sullivan, Keuthen, Jenike, & Gumley, 1996), avoidance of medical care, or in some rare instances medical complications from trichophagia (eating hair) (Bouwer & Stein, 1998; du Toit et al., 2001) can occur. These studies suggest that TTM may be associated with functional impairment and decreased quality of life. However, most previous investigations are limited by the absence of data from standardized and psychometrically validated quality-of-life measures. Such data would provide a clearer indication of the degree of impairment (not just presence or absence of various problems) and would allow for comparisons of TTM patients to other groups of individuals. To date, only one preliminary investigation has used standardized quality-of-life measures to demonstrate that patients with TTM report impaired quality of life in comparison with published norms, and these impairments were attributed to coexistent depression (Keuthen et al., 2002). However, this study was limited by the absence of a matched comparison group of participants without TTM. The goal of the current study was to extend previous research by comparing TTM patients with gender- and age-matched comparison groups on several measures of quality of life. Two comparison groups were included: a psychiatric control (PC) group and a nonpsychiatic control
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(NC) group. The PC group was comprised of patients with anxiety and mood disorders, but without TTM. The NC group was comprised of community volunteers with no psychiatric diagnoses or history of psychiatric treatment. Three categories of measures were administered: psychological distress (i.e., anxiety, depression), psychosocial functioning/life satisfaction, and self-esteem. It was predicted that patients with TTM and patients in the PC group would report more psychological distress, more severe functional disability, lower life satisfaction, and lower self-esteem than would the volunteers in the NC group. In addition, the relationship between hair pulling symptoms and outcome measures was explored using regression analyses. It was predicted that hair pulling symptoms would be associated with higher psychological distress, lower functional disability, lower life satisfaction, and lower self-esteem. Finally, a qualitative interview was administered to patients with TTM to identify specific ways in which hair pulling impacts daily life within 6 domains: negative affect/negative self-evaluations, grooming, recreational activities, social interaction, work/housework productivity, and physical health.
2. Method 2.1. Participants Three groups of participants were included in this study: TTM participants, PC, and nonpsychiatric control participants (NC). TTM participants included 28 adults recruited for participation in a TTM treatment outcome study (Diefenbach, Tolin, Maltby, Hannan, & Crocetto, 2003). All participants were assigned a primary diagnosis of TTM based on administration of the Trichotillomania Diagnostic Interview (TDI, Rothbaum & Ninan, 1994). As is customary in TTM research, diagnosis was based on DSM-IV criteria (American Psychiatric Association, 1994) with or without the endorsement of increasing and decreasing tension associated with pulling (criteria B and C).1 Comorbid diagnoses were assessed through administration of the Structured Clinical Interview for DSM-IV (SCID, First, Spitzer, Gibbon, & Williams, 1995). Comorbid disorders in the TTM group included major depression or dysthymic disorder (n ¼ 6; 21.4%), specific phobia (n ¼ 5; 17.9%), pain disorder (n ¼ 3; 10.7%), social phobia (n ¼ 3; 10.7%), and posttraumatic stress disorder, hypochondriasis, panic disorder, and anxiety disorder NOS (n ¼ 1; 3.6% each). Two comparison groups comprised of participants matched for age (75 years) and gender to the TTM participants were included in this study. First, a PC group was comprised of 28 patients who sought treatment at an anxiety outpatient clinic associated with a large private hospital. All procedures were completed by the PC group within the context of their regular clinic intake appointment. Participants in the PC group were diagnosed using the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV, Brown, DiNardo, & Barlow, 1994). Principal Axis I diagnoses for participants in the PC group included obsessive–compulsive disorder (n ¼ 8; 28.6%), generalized anxiety disorder (n ¼ 7; 25.0%), panic disorder with or without agoraphobia (n ¼ 5; 1
Endorsement of these criteria was not required as they have been found to exclude participants with clinically significant hair pulling (Christenson, MacKenzie, & Mitchell, 1991). In the current sample 53.6% (n ¼ 15) endorsed full diagnostic criteria.
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17.9%), major depressive disorder (n ¼ 3; 10.7%), specific phobia (n ¼ 2; 7.1%), posttraumatic stress disorder (n ¼ 1; 3.6%), social phobia (n ¼ 1; 3.6%), and anxiety disorder NOS (n ¼ 1; 3.6%). Second, a NC group was comprised of 28 volunteers who were recruited through a hospital-wide e-mail distribution. Community volunteers were free from psychiatric disorders as evidenced by TDI and SCID interviews, and denied history of psychiatric treatment. 2.2. Measures 2.2.1. TTM measures Massachusetts General Hospital Hair Pulling Scale (MGH-HPS). The Massachusetts General Hospital Hair Pulling Scale (Keuthen et al., 1995) is a 7-item self-report measure of hair pulling symptoms. Items assess frequency, intensity, controllability, resistance, and distress from pulling. The MGH-HPS has demonstrated strong internal consistency, test–retest reliability, convergent validity with clinician-rated hair pulling scales, and divergent validity with measures of anxiety and depression (Keuthen et al., 1995; O’Sullivan et al., 1995). Similar psychometric properties of the MGH-HPS were found in analyses with data from the TTM sample of the current study (Crocetto, Diefenbach, Tolin, & Maltby, 2003). However, in this latter study, the MGH-HPS did not correlate with ratings of hair loss severity (r ¼ :10; p=ns). Therefore, a measure of hair loss severity also was included in the current study to complement the MGH-HPS. 2.2.1.1. Alopecia Rating. A measure of hair loss severity was rated using a 7-point Likert scale with the following anchors: 1=no evidence of hair pulling to 7=large bald spots that are difficult to conceal. The Alopecia Rating was administered by trained psychologists examining all readily visible areas of hair loss (e.g., scalp, eyebrows, arms). In one case, the alopecia rating was adminstered as a self-report, given that this participant pulled solely from the pubic region. This scale has demonstrated good interrater agreement in previous treatment outcome research when rating photographs of alopecia (Tolin, Franklin, Diefenbach, & Gross, 2002), as well as the current sample of TTM patients (rs ¼ :93) (Crocetto et al., 2003). 2.2.1.2. Trichotillomania Interference Checklist. The Trichotillomania Interference Checklist is an interview developed for the present study to obtain descriptive information regarding the presence or absence of 36 different areas of TTM interference. Interference items were grouped into 6 different categories: negative affect/negative self-evaluations (e.g., low self-esteem), grooming (e.g., fix hair style a certain way), recreational activities (e.g., avoid swimming), social interaction (e.g., arguments with loved ones), work/housework productivity (e.g., late for work and other appointments), and physical health (e.g., skin infections). For each item participants endorse whether or not hair pulling had ‘‘ever’’ caused them these problems and whether or not they had these problems ‘‘within the past week.’’ Reliability of item categorization was excellent (Kappa=.97) as obtained by asking a second clinician with extensive experience in TTM to rate each item into the 6 categories. 2.2.2. Anxiety and depression measures 2.2.2.1. Beck Depression Inventory-II (BDI-II). The BDI-II (Beck, Steer, & Brown, 1996) is a widely used self-report measure of depression containing 21 items of common depressive
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symptoms rated on a 4-point severity scale. The BDI-II demonstrates excellent internal consistency and test–retest reliability, and good convergent validity with depressed mood symptoms endorsed in a clinical interview (Sprinkle et al., 2002). 2.2.2.2. State-trait Anxiety Inventory-Trait Version (STAI-T). The STAI-T (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) was administered to assess self-reported trait anxiety. The STAI-T is comprised of 20 anxiety statements rated on a 4-point scale (1=almost never to 4=almost always) for how the participants ‘‘generally feel.’’ The STAI-T demonstrates good internal consistency, test–retest reliability, concurrent validity, and ability to discriminate patients with anxiety from those without psychiatric problems (Spielberger et al., 1983). 2.2.3. Quality-of-life measures 2.2.3.1. Quality of Life Inventory (QOLI). The QOLI (Frisch, 1999) measures life satisfaction over 17 domains (e.g., home, work, health, money, play). Ratings are made first on the importance of that domain to the person’s life satisfaction and then satisfaction ratings are made over a 6-point scale (3=very dissatisfied to 3=very satisfied). Only domains rated as important are included in scoring the QOLI. Research on psychometric properties of the QOLI indicates acceptable levels of internal consistency, test–retest reliability, and convergent validity with other quality-of-life measures (Frisch, 1999; Frisch, Cornell, Villanueva, & Retzlaff, 1992; Johnson, 2001). On the QOLI, TTM participants also provided written descriptions of how hair pulling impacts their life satisfaction. 2.2.3.2. The Social Adjustment Scale-Self Report (SAS-SR). The SAS-SR (Weissman & Bothwell, 1976) is a 54-item scale that assesses role performance over the past 2 weeks. Areas assessed include work, leisure, family, and economic functioning. The SAS-SR demonstrates strong convergent validity with ratings on social adjustment made in clinical interviews (Weissman & Bothwell, 1976). 2.2.3.3. Sheehan Disability Scale (SDS). The Sheehan Disability Scale is a measure of the impact of symptomatology on work, social, and family functioning. Individuals rate the degree to which their symptoms have impaired each area of life using a 10-point Likert scale from 0 (not at all impaired) to 10 (very severely impaired). The three item ratings are added to create a total score. The SDS demonstrates good internal consistency (Leon, Olfson, Portera, Farber, & Sheehan, 1997). Construct validity was demonstrated through significantly different scores between individuals with and without psychiatric disorders, and significant relationships between anxiety symptoms and SDS impairment scores (Leon et al., 1997; Leon, Shear, Portera, & Klerman, 1992). 2.2.4. Self-esteem 2.2.4.1. Rosenberg Self-Esteem Scale (RSES). The RSES (Rosenberg, 1965) is one of the most widely used self-report measures of self-esteem. It consists of 10 items, assessing feelings of global personal self-esteem. Respondents rate their agreement to each item on a 4-point Likert scale (1=strongly agree to 4=strongly disagree). The scale demonstrated strong internal consistency, test–retest reliability, and face validity (Gray-Little, Williams, & Hancock, 1997). The RSES is not
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administered as part of the general clinical intake procedure. Thus, data were unavailable on the RSES for the PC group. 2.2.5. Clinical Global Impression The Clinical Global Impression (CGI) was administered as an assessment of global illness. For patients with TTM, ratings were made taking into consideration TTM as well as comorbid psychopathology. All ratings were made with reference to general patient populations rather than disorder specific populations. CGI severity was assessed using a 7-point Likert scale, from 1=normal, not at all ill to 7=extremely ill. Previous research using the CGI has found interrater reliability of r ¼ :66 for severity scores (Dahlke, Lohaus, & Gutzmann, 1992). 2.3. Procedure TTM participants completed interviews and self-report measures within the context of an intake evaluation for a TTM treatment study. Interviews for the TTM group were administered by either a licensed psychologist or a postdoctoral fellow under the supervision of a licensed psychologist. Alopecia Ratings were completed by licensed psychologists with experience in the assessment of TTM. Participants in the PC group completed assessment measures as part of their regular intake evaluation for the outpatient clinic. Either a postdoctoral fellow or psychology intern completed diagnostic interviews for the PC group. A licensed psychologist supervised all clinic intake evaluations and confirmed diagnoses with a separate unstructured interview. Several of the measures (Rosenberg Self-Esteem Scale, TTM assessment measures) are not administered as part of the clinic intake assessment, and are therefore unavailable for this group. Nonclinical community volunteers completed interviews and self-report questionnaires for the purposes of the current study and were compensated $20.00 for their participation. Diagnostic interviews for the NC group were administered by a research associate under the supervision of a licensed psychologist. The NC group did not complete TTM measures with the exception of the MGHHPS; however, NC participants were excluded from analyses using the MGH-HPS due to a floor effect and lack of variability among the scores.
3. Results 3.1. Demographic characteristics Demographic information for the three participant groups is presented in Table 1. Group comparisons were conducted using one-way analysis of variance (ANOVA) and chi-square. The participant groups did not differ on age, gender distribution, ethnicity, marital status, or educational level. The groups differed significantly on employment status, due to a higher percentage of employed individuals in the NC group than in the TTM group [w2 ð1Þ ¼ 4:31; po:05] or PC group [w2 ð1Þ ¼ 12:17; po:001]. Severity of illness as assessed by the Clinician’s Global Impression (CGI; Guy, 1976) was in the moderate to markedly ill range for both the TTM (M ¼ 4:64; SD=.83) and PC (M ¼ 4:84; SD=1.11) groups [tð44Þ ¼ :73; p=ns].
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Table 1 Demographic information
Age Gender Male Female Ethnicity Noncaucasian Caucasian Relationship status Not married Married Employment status Working/student Not working/disability/retired Education Some graduate school or degree Some college or degree Some high school or degree
TTM (n ¼ 28)
NC (n ¼ 28)
PC (n ¼ 28)
Statistical test
38.64 (12.17)
36.89 (13.08)
39.00 (12.32)
F ð2; 81Þ ¼ :23 w2 ð2Þ ¼ :00
2 (7.1%) 26 (92.9%)
2 (7.1%) 26 (92.9%)
2 (7.1%) 26 (92.9%)
6 (21.4%) 22 (78.6%)
4 (14.3%) 24 (85.7%)
2 (7.1%) 26 (92.9%)
w2 ð2Þ ¼ 2:33
w2 ð2Þ ¼ :90 16 (57.1%) 12 (42.9%)
19 (67.9%) 9 (32.1%)
16 (57.1%) 12 (42.9%) w2 ð2Þ ¼ 13:03
24 (85.7%) 4 (14.3%)
28 (100.0%) 0 (0%)
18 (64.3%) 10 (35.7%)
6 (21.4%) 17 (60.7%) 5 (17.9%)
10 (35.7%) 16 (57.1%) 2 (7.1%)
9 (33.3%) 18 (66.7%) 0 (0%)
w2 ð4Þ ¼ 6:57
Note: Means are shown with standard deviations in parentheses. Frequencies are shown with percentages in parentheses. ***po:001:
Given group differences on employment status (employed versus unemployed), point-biserial correlational analyses were used to determine whether or not this variable was associated with quality-of-life measures. Employment status correlated significantly (range absolute value rpb ¼ :392:48; po:001) with all outcome measures except the RSES (rpb ¼ :17; p=ns). In addition, participants within the TTM group differed on the QOLI as a function of employment status [tð25Þ ¼ 2:97; po:01], with employed participants reporting higher levels of life satisfaction. Participants in the PC group differed on the SAS-SR [tð26Þ ¼ 2:24; po:05] and SDS [tð23Þ ¼ 3:66; po:001] as a function of employment status, with the employed participants reporting superior functioning. Therefore, in order to control for the potential confound of differing employment status, analyses were run with and without employment status used as a covariate in betweengroup analyses, except those using the RSES as the dependent variable. 3.2. Group comparisons 3.2.1. Anxiety and depression measures Descriptive statistics and univariate comparisons across groups for the anxiety and depression measures are reported in Table 2. Tukey post hoc tests indicated that the TTM and PC groups reported significantly more severe depression than the NC group. The TTM and PC groups did not differ from each other on depression. With respect to the STAI-T, all groups differed from
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Table 2 Group comparisons for psychological distress, quality of life, and self-esteem TTM
NC
PC
Statistical test
Psychological distress BDI-II 13.25 (11.30)a STAI-T 44.64 (11.85)a
2.18 (2.26)b 28.33 (6.13)b
19.43 (13.84)a 53.21 (14.72)c
F ð2; 81Þ ¼ 19:78 F ð2; 74Þ ¼ 26:73
Quality of life SDS SAS-SR QOLI
6.14 (6.17)a 2.10 (.64)a 1.61 (2.22)a
1.61 (3.69)b 1.61 (.29)b 3.21 (1.14)b
16.78 (8.53)c 2.01 (.60)a 1.20 (2.13)a
F ð2; 80Þ ¼ 40:41 F ð2; 81Þ ¼ 6:76 F ð2; 77Þ ¼ 8:69
Self-esteem RSES
30.75 (5.77)a
36.68 (3.89)b
N/A
tð54Þ ¼ 4:51
Note. Means are shown with standard deviations in parentheses. **po:01; ***po:001: Means with different superscripts indicate significant differences according to Tukey post hoc tests, po:05: BDI-II=Beck Depression Inventory-II; STAI-T=State-Trait Anxiety Inventory-Trait Scale; SDS=Sheehan Disability Scale, SAS-SR=Social Adjustment Scale-Self-Report, QOLI=Quality of Life Inventory; RSES=Rosenberg Self-Esteem Scale.
each other, with the NC group, TTM groups, and PC groups reporting increasingly higher levels of trait anxiety. Given the group differences on employment status, and point-biserial correlations between employment status and BDI-II (rpb ¼ :48; po:001) and STAI-T (rpb ¼ :39; po:001), analyses were rerun with employment status as a covariate. First, multivariate analysis of covariance (MANCOVA) was used to explore group differences on measures of anxiety and depression. Group (TTM, PC, NC) was entered as the between-subjects factor and employment status as the covariate. BDI-II and STAI-T total scores were entered as the dependent variables. The multivariate group effect was statistically significant [F ð4; 144Þ ¼ 8:74; po:001]. Next, analysis of covariance (ANCOVA) was used to explore group differences on the BDI-II and STAI-T, respectively. Again group was entered as the between-subjects factor and employment status as a covariate. The group effect was significant for both the BDI-II [Fð2; 80Þ ¼ 12:17; po:001] and STAI-T [Fð2; 73Þ ¼ 19:70; po:001]. Pairwise comparisons using Bonferroni-correction indicated that the TTM and PC groups reported higher levels of anxiety and depression than did the NC group. The TTM and PC groups did not differ on anxiety or depression.
3.2.2. Quality-of-life measures Descriptive statistics and univariate analyses for the quality-of-life measures are reported in Table 2. Results indicated that the groups differed significantly from one another on each measure. Tukey post hoc tests indicated that all three groups differed significantly from each other on the SDS, with the NC group, TTM group, and PC group each reporting increasingly higher levels of disability. In addition, the TTM and PC participants reported significantly higher disability on the SAS-SR, and significantly lower life satisfaction on the QOLI, than did the NC group. The TTM and PC participants did not differ from one another on the SAS-SR or QOLI.
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However, previous analyses have indicated that the groups differed significantly on employment status and levels of psychological distress. In addition, depression has been found to mediate relationships between hair pulling symptoms and quality-of-life measures in previous research (Keuthen et al., 2002). Given group differences reported on anxiety and depression measures, as well as significant correlations for the BDI-II and STAI-T with quality-of-life measures (range absolute value r ¼ :342:74; po:01) we considered controlling for both the BDI-II and STAI-T as covariates in subsequent analyses. However, the BDI-II and STAI-T correlated highly with each other (r ¼ :83) and missing data on the STAI-T (as a result of a clerical error) for a portion of the NC group would have decreased the sample size and reduced statistical power for all subsequent analyses. Thus, only the BDI-II was covaried in subsequent analyses. Analyses were rerun with BDI-II and employment status entered as covariates. Results indicated that MANCOVA with Group (TTM, PC, NC) entered as the between-subjects factor; BDI-II and employment status as the covariates, and SAS-SR, SDS, and QOLI entered as dependent variables, was statistically significant [F ð6; 144Þ ¼ 6:56; po:001]. Next ANCOVA was used to explore group differences on the SAS-SR, SDS, and QOLI, respectively. Again group was entered as the between-subjects factor and BDI-II and employment status as covariates. The group effect was significant for the SDS [F ð2; 78Þ ¼ 19:14; po:001] and SAS-SR [Fð2; 79Þ ¼ 6:95; po:002]. Pairwise comparisons using Bonferroni-correction indicated the PC group reported significantly more severe impairment and disability on the SDS and SAS-SR than did the TTM or NC groups. The TTM and NC groups did not differ on the SDS or SAS-SR. The ANCOVA group effect was not statistically significant for the QOLI once depression and employment status were covaried in analyses [F ð2; 75Þ ¼ :74; p=ns].2 3.2.3. Self-esteem Descriptive statistics and univariate tests for the RSES are reported in Table 2 for the TTM and NC groups. Results indicated significantly lower self-esteem reported by the TTM group. A strong trend toward statistical significance remained when rerun as an ANCOVA with group entered as the between-subjects factor and BDI-II entered as a covariate [F ð1; 53Þ ¼ 4:01; p ¼ :05]. 3.3. Prediction A series of regression analyses were used to explore the relationship between hair pulling symptoms and the following outcome measures: SDS, SAS-SR, QOLI, and RSES. These analyses were conducted with TTM participants only. Given a high level of shared variance between depression and quality of life, it was important to control for depression scores within the regression analysis to determine the unique variance contributed by TTM measures to quality of life. Thus, BDI-II scores were entered into the first block to first control for that variance attributed to depression. Two measures of hair pulling were entered into the second block: the MGH-HPS total score and Alopecia Rating to determine the amount of variance contributed by TTM measures above that attributed to depression. Results are presented in Table 3. Results indicate that MGH-HPS was a significant predictor of disability as measured by the SDS; 2
Analyses run with and without employment status as a covariate did not differ substantively from one another. Therefore, only results from those analyses controlling for employment status are reported here.
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Table 3 Hierarchical regression analyses predicting quality of life in TTM patients Predictor SDS Step 1 BDI-II Step 2 MGH-HPS Alopecia SAS-SR Step 1 BDI-II Step 2 MGH-HPS Alopecia QOLI Step 1 BDI-II Step 2 MGH-HPS Alopecia RSES Step 1 BDI-II Step 2 MGH-HPS Alopecia
t
b
.49
2.77
.56 .01
3.81*** .08
.69
4.81***
.06 .10
DR2
P
.24
o.01
.30
o.01
.48
o.001
.01
ns
.42
o.001
.14
o.05
.28
o.01
.20
o.05
.38 .68
.65
4.15***
.11 .37
.76 2.52*
.53
3.13**
.25 .36
1.64 2.33*
Note: *po:05 level , **po:01; ***po:001: BDI-II=Beck Depression Inventory-II; MGH-HPS=Massachusetts General Hospital Hair Pulling Scale, SDS=Sheehan Disability Scale, SAS-SR=Social Adjustment Scale-Self-Report, QOLI=Quality of Life Inventory; RSES=Rosenberg Self-Esteem Scale.
however, hair pulling measures did not predict disability as measured by the SAS-SR. Severity of hair loss was a significant predictor of life satisfaction as measured by the QOLI, and self-esteem as measured by the RSES.
3.4. TTM interference checklist Endorsement rates of lifetime and current (i.e., past week) interference are presented in Table 4. Data indicate a high rate of endorsement of lifetime interference for items within the 6 categories. Prevalence ranged from 67.9% of patients endorsing any problems with recreational activities to 100% endorsing any problems with social interaction and negative affect/negative self-evaluations over their lifetime. Current problems due to hair pulling also were common. Prevalence ranged from 64.3% of patients endorsing any problems with physical health to 96.4% endorsing any
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Table 4 Number and percentage of TTM participants endorsing interference due to hair pulling over lifetime and past week time periods Lifetime
Past week
Grooming
Any grooming Wear wig, hat, etc. Fix hair style a certain way Special make-up Avoid hairdressers
26 12 19 11 12
(92.9%) (42.9%) (67.9%) (39.3%) (42.9%)
24 10 11 9 4
(85.7%) (35.7%) (39.3%) (32.1%) (14.3%)
Physical health
Any physical health Avoid doctors Eat hair-stomach upset Broken skin Skin infections Bleeding Scars Muscle pain Skin irritation
24 11 6 6 4 13 5 16 17
(85.7%) (39.3%) (21.4%) (21.4%) (14.3%) (46.4%) (17.9%) (57.1%) (60.7%)
18 0 4 3 0 5 3 10 10
(64.3%)
Any social interaction Avoid dating Sex life inhibited Avoid group social events Arguments with loved ones Spent less time with family/friends Spend more time alone Keeping hair pulling a secret
28 8 6 8 7 9 9 28
(100%) (28.6%) (21.4%) (28.6%) (25.0%) (32.1%) (32.1%) (100%)
27 3 4 1 0 5 6 26
(96.4%) (10.7%) (14.3%) (3.6%) (17.9%) (21.4%) (92.9%)
Recreational activities
Any recreational activities Avoid swimming Avoid other physical activities Avoid activity on windy days Spent less time on other things I enjoy Avoid sitting in front rows Avoid brightly lit rooms Avoid group events
19 13 8 7 11 6 8 8
(67.9%) (46.4%) (28.6%) (25.0%) (39.3%) (21.4%) (28.6%) (28.6%)
21 1 3 2 7 2 2 1
(75.0%) (3.6%) (10.7%) (7.1%) (25.0%) (7.1%) (7.1%) (3.6%)
Work productivity
Any work productivity Less productive at home Less productive at work Problems with concentration Late for work, appts, meetings
22 10 7 17 7
(78.6%) (35.7%) (25.0%) (60.7%) (25.0%)
20 9 6 15 3
(71.4%) (32.1%) (21.4%) (53.6%) (10.7%)
Negative affect
Any negative affect Feel alone Feel ‘‘weird’’ or ‘‘strange’’ Feel guilty Feel down on myself Feel unattractive Had low self-esteem Worry about hair pulling
28 15 21 18 26 23 22 24
(100%) (53.6%) (75.0%) (64.3%) (92.9%) (82.1%) (78.6%) (85.7%)
27 8 17 14 22 17 19 20
(96.4%) (28.6%) (60.7%) (50.0%) (78.6%) (60.7%) (67.9%) (71.4%)
Social interaction
(14.3%) (10.7%) (17.9%) (10.7%) (35.7%) (35.7%)
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problems with social interaction and negative affect/negative self-evaluations within the past week.
4. Discussion This study explored the impact of hair pulling on three variables associated with psychosocial functioning: psychological distress, functioning/quality of life, and self-esteem. Group comparisons indicated that TTM participants reported higher levels of distress than did individuals without hair pulling problems. In addition, participants with TTM were generally comparable to participants with other psychological disorders on reported distress level. These results highlight the emotional toll that can be associated with hair pulling problems. Findings also suggest that hair pulling is associated with impairments in functioning and life satisfaction; however, this relationship was multifaceted and complex. For example, the TTM group reported more severe disability, and lower life satisfaction than the NC group; however, group differences disappeared once controlling for depression. In addition, after controlling for depression, the TTM group demonstrated lower disability than did participants in the PC group. Therefore, consistent with previous research (Keuthen et al., 2002), these results suggest that hair pulling may not be associated with significant functional impairments unless accompanied by an increase in depression. Current results should be considered preliminary, and additional research with larger samples using more sophisticated statistical analyses (i.e., structural equation modeling) are needed to provide stronger support for the mediational role of depression. Nevertheless, if this model if borne out in future research, integrating techniques to target depression (e.g., cognitive therapy, behavioral activation) into TTM programs may improve efficacy for reducing impairments and increasing life satisfaction for these patients. However, current results also suggest that hair pulling may, in some cases, have an independent relationship with quality of life for patients with TTM. For example, dimensional analyses indicated that severity of hair pulling symptoms predicted more severe functional disability on one measure even after controlling for depression. In addition, hair loss severity predicted lower life satisfaction even after controlling for depression. Thus, the relationship between TTM severity and impairments in psychosocial functioning could not be explained entirely by depression severity. There are several reasons that may explain the inconsistency in findings. First, there is no generally accepted definition of quality of life nor agreement on how best to measure quality of life (Mendlowicz & Stein, 2000). The three measures administered in the current study assess different aspects of this construct, with the SDS providing an assessment of global disability (work, social, family), the SAS-SR providing an assessment of role impairment, and the QOLI a measure of life satisfaction. In addition, group analyses may have obscured the impact of hair pulling by averaging across the severity of TTM. Logistical regression within the TTM group, however, may have allowed for finer differentiations along the continuum of TTM severity. Thus, as a group, depression may be a mediating factor for patients with TTM, although within a group of TTM patients, severe hair pulling may impact quality of life independent of depression. The impact of TTM on self-esteem demonstrated a more consistent relationship, with the TTM group demonstrating a strong trend (p ¼ :05) toward lower self-esteem compared with the NC
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group, even after controlling for depression. In addition, the severity of hair loss was a significant predictor of self-esteem, again even after controlling for depression. These results are consistent with previous research indicating a relationship between hair pulling and lower self-esteem, although in previous research the severity of pulling and not the severity of hair loss was a significant predictor (Soriano et al., 1996). To better understand this relationship we reviewed participant’s written descriptions of how TTM affects their self-esteem. Several themes were identified which in some ways mirrored negative consequences of hair pulling reported in previous research (Casati et al., 2000). First, the impact of hair loss on personal appearance was highlighted. For example, patients with TTM reported ‘‘I feel ugly and unappealing,’’ and ‘‘I don’t think I’m that pretty.’’ Relatedly, many TTM patients expressed feelings of embarrassment and fear public exposure of the hair pulling habit. For example, patients expressed ‘‘embarrassment,’’ ‘‘shame,’’ and ‘‘worry about discovery by others.’’ These comments are not surprising given the well-established relationship between evaluations of physical appearance and self-esteem in previous research (Harter, 1999). In addition, frustrations associated with the inability to control pulling appeared to impact self-esteem. For example, patients stated hair pulling ‘‘makes me feel inept,’’ ‘‘makes me feel like I can’t control myself,’’ and ‘‘I see it as a weakness in myself.’’ Again, these statements are consistent with previous research suggesting perceived personal weaknesses or flaws are core elements of low self-esteem (Harter, 1999). The impact of hair pulling on self-esteem also was demonstrated in a qualitative interview, wherein all TTM patients reported symptoms of negative affect during their lifetime and nearly all participants (96.4%) reported current problems with negative affect/negative self-evaluations as a result of pulling. Low self-esteem, feeling down on myself, and feeling unattractive were some of the most common types of negative affect/negative self-evaluations endorsed. Results from the qualitative interview also indicated lifetime and current problems with grooming, physical health, social interaction, recreational activities, and work productivity. It is difficult to compare these results to previous qualitative reports given differences in item wording and methodology. However, results are generally consistent with previous research documenting frequent and diverse types of impairment on daily functioning as a result of hair pulling (e.g., Keuthen et al., 2002; Seedat & Stein, 1998; Stemberger et al., 2000). It is important to note that some research has found low clinician ratings of impairment for patients with TTM (Stanley, Prather, Wagner, Davis, & Swann, 1993).These results contradict accumulating support for significant negative consequences of hair pulling. Perhaps the degree of interference caused by hair pulling is small relative to the patient’s ability to continue functioning despite hair pulling (e.g., it is rare for hair pulling to cause unemployment). Thus, patients may not recognize and/or report certain impairments from hair pulling. As a result we have begun assessing the impact of hair pulling using the Trichotillomania Interference Checklist (TIC), which uses recognition rather than recall to assess the impact of hair pulling across a variety of specific items. Perhaps current results from the TIC, in conjunction with previous work, will provide clinicians with direction to use a similar methodology to specifically assess for common interference items for their TTM patients. Identification of impairments can be important clinically to enhance patient motivation, identify treatment targets and goals, as well as limit dismissal of hair pulling symptoms as benign. In conclusion, results indicate that TTM is associated with psychosocial impairment, although for some variables this relationship may be mediated by the presence of depression. In addition,
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there are common and diverse types of impairments reported by TTM patients. However, these results also need to be considered within the limitation that this study included a small sample of patients who were predominantly female, Caucasian, treatment-seeking, and prescreened to exclude for a number of variables (e.g., recent medication change). Therefore, results may not generalize to the general population of TTM patients. In addition, given that the TTM group was prescreened while the PC group was not, it is possible that these groups were not matched on clinical severity. This argument is mitigated somewhat by similar mean CGI scores for the TTM and PC group. However, if recruitment strategies did bias the TTM group toward milder clinical severity, current results may underestimate the levels of impairment of TTM patients. Questions such as these highlight the need for additional research on more diverse samples of TTM patients. In addition, for ethical reasons clinician-rated assessment of hair loss severity was based only on those areas of alopecia that could be rated in a nonintrusive way. Self-report was used to substitute data for one patient who pulled solely from pubic regions. Perhaps self-report ratings made by all participants, in addition to clinician-rated measures, could be used to in future research to provide a more comprehensive assessment of hair loss severity. Despite some limitations, these results highlight the importance of promoting and improving resources for the clinical care of TTM patients, and provide some directions for clinicians to enhance assessment of interference caused by TTM.
References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the beck depression inventory (2nd ed.). San Antonio, TX: Psychological Corporation, Harcourt, Brace. Bouwer, C., & Stein, D. J. (1998). Trichobezoars in trichotillomania: case report and literature review. Psychosomatic Medicine, 60, 658–660. Brown, T. A., DiNardo, P. A., & Barlow, D. H. (1994). Anxiety disorders interview schedule for DSM-IV. San Antonio, TX: The Psychological Corporation. Casati, J., Toner, B. B., & Yu, B. (2000). Psychosocial issues for women with trichotillomania. Comprehensive Psychiatry, 41, 344–351. Christenson, G. A., MacKenzie, T. B., & Mitchell, J. E. (1991). Characteristics of 60 adult chronic hair pullers. American Journal of Psychiatry, 148, 365–370. Christenson, G. A., Pyle, R. L., & Mitchell, J. E. (1991). Estimated lifetime prevalence of trichotillomania in college students. Journal of Clinical Psychiatry, 52, 415–417. Crocetto, J. S., Diefenbach, G. J., Tolin, D. F., & Maltby, N. (2003). Self-report and clinician-rated hairpulling scales: a psychometric evaluation. Presented to The Annual Meeting of the Association for Advancement of Behavior Therapy, Boston, MA. Dahlke, F., Lohaus, A., & Gutzmann, H. (1992). Reliability and clinical concepts underlying global judgments in dementia: implications for clinical research. Psychopharmacology Bulletin, 28, 425–432. Diefenbach, G. J., Reitman, D., & Williamson, D. A. (2000). Trichotillomania: a challenge to research and practice. Clinical Psychology Review, 20, 289–309. Diefenbach, G. J., Tolin, D. F., Maltby, N., Hannan, S., & Crocetto, J. S. (2003). Group treatment for trichotillomania: CBT versus supportive therapy. In M. E. Franklin, N. J. Keuthen (chairs), New developments in Trichotillomania research. Symposium presented to the Annual Meeting of the Association for Advancement of Behavior Therapy, Boston, MA.
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Stemberger, R. M. T., Thomas, A. M., Mansueto, C. S., & Carter, J. G. (2000). Personal toll of trichotillomania: behavioral and interpersonal sequelae. Journal of Anxiety Disorders, 14, 97–104. Tolin, D. F., Franklin, M. E., & Diefenbach, G. J., Gross, A. (2002). Cognitive-behavioral therapy for pediatric trichotillomania: an open trial. Presented to the Association for Advancement of Behavior Therapy, Reno, NV. Weissman, M. M., & Bothwell, S. (1976). Assessment of social adjustment by patient self-report. Archives of General Psychiatry, 33, 1111–1115.
Behaviour Research and Therapy 43 (2005) 869–884 www.elsevier.com/locate/brat
Trichotillomania: impact on psychosocial functioning and quality of life$ Gretchen J. Diefenbach, David F. Tolin, Scott Hannan, Johanna Crocetto, Patrick Worhunsky Anxiety Disorders Center, Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA Received 27 December 2003; received in revised form 22 April 2004; accepted 21 June 2004
Abstract This study explored the impact of hair pulling on psychosocial functioning for patients diagnosed with trichotillomania (TTM; n ¼ 28). TTM patients were compared to age and gender-matched groups of psychiatric patients without TTM (n ¼ 28) and nonpsychiatric control volunteers (NC, n ¼ 28) on measures of psychological distress, functioning/quality of life, and self-esteem. Results indicated that TTM patients reported more severe psychosocial impairments than did NC volunteers; however, these differences were mediated by differences in level of depression. Regression analyses indicated significant relationships between some measures of psychosocial functioning and severity of hair pulling, independent of level of depression. Finally, an interview of the impact of hair pulling on 6 domains of daily functioning (negative affect/negative self-evaluations, grooming, recreational activities, social interaction, work/housework productivity, and physical health) indicated common and wide-ranging impairments for both lifetime and current (i.e., past week) ratings. These results highlight the importance of promoting and improving resources for the clinical care of TTM patients, and provide some directions for clinicians to enhance assessment of interference caused by TTM. r 2004 Elsevier Ltd. All rights reserved. Keywords: Trichotillomania; Hair pulling; Quality of life
$
This research was funded by grants from Hartford Hospital (Grants 126073 and 126082) to the first author. These data were presented at the national meeting of the Association for Advancement of Behavior Therapy, November 2003, Boston, MA. Corresponding author. +Tel.: +1-860-545-7685; fax: +1-860-545-7156. E-mail address: [email protected] (G.J. Diefenbach). 0005-7967/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2004.06.010
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1. Introduction Trichotillomania (TTM) is an impulse control disorder characterized by repetitive hair pulling resulting in noticeable hair loss. The exact prevalence of TTM is unknown; however, estimates from university surveys suggest that 1.5% of males and 3.4% of females endorse clinically significant hair pulling, with .6% endorsing all diagnostic criteria of TTM (Christenson, Pyle, & Mitchell, 1991). The prevalence of nonclinical hair pulling behaviors range even higher, up to 15.3%, in university surveys (Stanley, Borden, Bell, & Wagner, 1994). Although hair pulling was once considered benign, TTM has recently gained recognition as a distressing and impairing psychiatric condition (Diefenbach, Reitman, & Williamson, 2000). However, research is only beginning to outline the psychosocial impairments associated with TTM. The goal of the current study was to examine the impact of TTM on psychosocial functioning and quality of life. Most previous research has categorized impairments associated with TTM based on patient interviews, chart reviews, or descriptive questionnaires (e.g., Casati, Toner, & Yu, 2000; du Toit, van Kradenburg, Niehaus, & Stein, 2001; Seedat & Stein, 1998; Stemberger, Thomas, Mansueto, & Carter, 2000). From these data, several different domains of impaired quality of life have been reported. First, research suggests consequences on psychological distress and lowered self-esteem (du Toit et al., 2001; Seedat & Stein, 1998; Soriano et al., 1996; Stemberger et al., 2000). Similarly, patients with TTM commonly report negative self-referencing emotions such as guilt and shame, as well as frustrations with being unable to control hair pulling (Casati et al., 2000; du Toit et al., 2001; Stemberger et al., 2000). Hair pulling can also negatively impact social functioning. For example, individuals with TTM will often attempt to conceal hair loss through extra time and expense grooming (e.g., special hair styles or make-up) or avoidance of recreational activities (e.g., du Toit et al., 2001; Stemberger et al., 2000). The quality of interpersonal relationships can also be affected by increased arguments or decreased sexual intimacy (Stemberger et al., 2000). In addition, patients report that hair pulling can be socially isolating, by keeping hair pulling a secret from even close friends and family. Preliminary data also suggest impact on occupational functioning, such as missed work days or lowered occupational goals (Keuthen et al., 2002; Seedat & Stein, 1998). Finally, hair pulling can impact physical health. For example, physical damage from pulling (e.g., scarring) (e.g., O’Sullivan, Keuthen, Jenike, & Gumley, 1996), avoidance of medical care, or in some rare instances medical complications from trichophagia (eating hair) (Bouwer & Stein, 1998; du Toit et al., 2001) can occur. These studies suggest that TTM may be associated with functional impairment and decreased quality of life. However, most previous investigations are limited by the absence of data from standardized and psychometrically validated quality-of-life measures. Such data would provide a clearer indication of the degree of impairment (not just presence or absence of various problems) and would allow for comparisons of TTM patients to other groups of individuals. To date, only one preliminary investigation has used standardized quality-of-life measures to demonstrate that patients with TTM report impaired quality of life in comparison with published norms, and these impairments were attributed to coexistent depression (Keuthen et al., 2002). However, this study was limited by the absence of a matched comparison group of participants without TTM. The goal of the current study was to extend previous research by comparing TTM patients with gender- and age-matched comparison groups on several measures of quality of life. Two comparison groups were included: a psychiatric control (PC) group and a nonpsychiatic control
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(NC) group. The PC group was comprised of patients with anxiety and mood disorders, but without TTM. The NC group was comprised of community volunteers with no psychiatric diagnoses or history of psychiatric treatment. Three categories of measures were administered: psychological distress (i.e., anxiety, depression), psychosocial functioning/life satisfaction, and self-esteem. It was predicted that patients with TTM and patients in the PC group would report more psychological distress, more severe functional disability, lower life satisfaction, and lower self-esteem than would the volunteers in the NC group. In addition, the relationship between hair pulling symptoms and outcome measures was explored using regression analyses. It was predicted that hair pulling symptoms would be associated with higher psychological distress, lower functional disability, lower life satisfaction, and lower self-esteem. Finally, a qualitative interview was administered to patients with TTM to identify specific ways in which hair pulling impacts daily life within 6 domains: negative affect/negative self-evaluations, grooming, recreational activities, social interaction, work/housework productivity, and physical health.
2. Method 2.1. Participants Three groups of participants were included in this study: TTM participants, PC, and nonpsychiatric control participants (NC). TTM participants included 28 adults recruited for participation in a TTM treatment outcome study (Diefenbach, Tolin, Maltby, Hannan, & Crocetto, 2003). All participants were assigned a primary diagnosis of TTM based on administration of the Trichotillomania Diagnostic Interview (TDI, Rothbaum & Ninan, 1994). As is customary in TTM research, diagnosis was based on DSM-IV criteria (American Psychiatric Association, 1994) with or without the endorsement of increasing and decreasing tension associated with pulling (criteria B and C).1 Comorbid diagnoses were assessed through administration of the Structured Clinical Interview for DSM-IV (SCID, First, Spitzer, Gibbon, & Williams, 1995). Comorbid disorders in the TTM group included major depression or dysthymic disorder (n ¼ 6; 21.4%), specific phobia (n ¼ 5; 17.9%), pain disorder (n ¼ 3; 10.7%), social phobia (n ¼ 3; 10.7%), and posttraumatic stress disorder, hypochondriasis, panic disorder, and anxiety disorder NOS (n ¼ 1; 3.6% each). Two comparison groups comprised of participants matched for age (75 years) and gender to the TTM participants were included in this study. First, a PC group was comprised of 28 patients who sought treatment at an anxiety outpatient clinic associated with a large private hospital. All procedures were completed by the PC group within the context of their regular clinic intake appointment. Participants in the PC group were diagnosed using the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV, Brown, DiNardo, & Barlow, 1994). Principal Axis I diagnoses for participants in the PC group included obsessive–compulsive disorder (n ¼ 8; 28.6%), generalized anxiety disorder (n ¼ 7; 25.0%), panic disorder with or without agoraphobia (n ¼ 5; 1
Endorsement of these criteria was not required as they have been found to exclude participants with clinically significant hair pulling (Christenson, MacKenzie, & Mitchell, 1991). In the current sample 53.6% (n ¼ 15) endorsed full diagnostic criteria.
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17.9%), major depressive disorder (n ¼ 3; 10.7%), specific phobia (n ¼ 2; 7.1%), posttraumatic stress disorder (n ¼ 1; 3.6%), social phobia (n ¼ 1; 3.6%), and anxiety disorder NOS (n ¼ 1; 3.6%). Second, a NC group was comprised of 28 volunteers who were recruited through a hospital-wide e-mail distribution. Community volunteers were free from psychiatric disorders as evidenced by TDI and SCID interviews, and denied history of psychiatric treatment. 2.2. Measures 2.2.1. TTM measures Massachusetts General Hospital Hair Pulling Scale (MGH-HPS). The Massachusetts General Hospital Hair Pulling Scale (Keuthen et al., 1995) is a 7-item self-report measure of hair pulling symptoms. Items assess frequency, intensity, controllability, resistance, and distress from pulling. The MGH-HPS has demonstrated strong internal consistency, test–retest reliability, convergent validity with clinician-rated hair pulling scales, and divergent validity with measures of anxiety and depression (Keuthen et al., 1995; O’Sullivan et al., 1995). Similar psychometric properties of the MGH-HPS were found in analyses with data from the TTM sample of the current study (Crocetto, Diefenbach, Tolin, & Maltby, 2003). However, in this latter study, the MGH-HPS did not correlate with ratings of hair loss severity (r ¼ :10; p=ns). Therefore, a measure of hair loss severity also was included in the current study to complement the MGH-HPS. 2.2.1.1. Alopecia Rating. A measure of hair loss severity was rated using a 7-point Likert scale with the following anchors: 1=no evidence of hair pulling to 7=large bald spots that are difficult to conceal. The Alopecia Rating was administered by trained psychologists examining all readily visible areas of hair loss (e.g., scalp, eyebrows, arms). In one case, the alopecia rating was adminstered as a self-report, given that this participant pulled solely from the pubic region. This scale has demonstrated good interrater agreement in previous treatment outcome research when rating photographs of alopecia (Tolin, Franklin, Diefenbach, & Gross, 2002), as well as the current sample of TTM patients (rs ¼ :93) (Crocetto et al., 2003). 2.2.1.2. Trichotillomania Interference Checklist. The Trichotillomania Interference Checklist is an interview developed for the present study to obtain descriptive information regarding the presence or absence of 36 different areas of TTM interference. Interference items were grouped into 6 different categories: negative affect/negative self-evaluations (e.g., low self-esteem), grooming (e.g., fix hair style a certain way), recreational activities (e.g., avoid swimming), social interaction (e.g., arguments with loved ones), work/housework productivity (e.g., late for work and other appointments), and physical health (e.g., skin infections). For each item participants endorse whether or not hair pulling had ‘‘ever’’ caused them these problems and whether or not they had these problems ‘‘within the past week.’’ Reliability of item categorization was excellent (Kappa=.97) as obtained by asking a second clinician with extensive experience in TTM to rate each item into the 6 categories. 2.2.2. Anxiety and depression measures 2.2.2.1. Beck Depression Inventory-II (BDI-II). The BDI-II (Beck, Steer, & Brown, 1996) is a widely used self-report measure of depression containing 21 items of common depressive
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symptoms rated on a 4-point severity scale. The BDI-II demonstrates excellent internal consistency and test–retest reliability, and good convergent validity with depressed mood symptoms endorsed in a clinical interview (Sprinkle et al., 2002). 2.2.2.2. State-trait Anxiety Inventory-Trait Version (STAI-T). The STAI-T (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) was administered to assess self-reported trait anxiety. The STAI-T is comprised of 20 anxiety statements rated on a 4-point scale (1=almost never to 4=almost always) for how the participants ‘‘generally feel.’’ The STAI-T demonstrates good internal consistency, test–retest reliability, concurrent validity, and ability to discriminate patients with anxiety from those without psychiatric problems (Spielberger et al., 1983). 2.2.3. Quality-of-life measures 2.2.3.1. Quality of Life Inventory (QOLI). The QOLI (Frisch, 1999) measures life satisfaction over 17 domains (e.g., home, work, health, money, play). Ratings are made first on the importance of that domain to the person’s life satisfaction and then satisfaction ratings are made over a 6-point scale (3=very dissatisfied to 3=very satisfied). Only domains rated as important are included in scoring the QOLI. Research on psychometric properties of the QOLI indicates acceptable levels of internal consistency, test–retest reliability, and convergent validity with other quality-of-life measures (Frisch, 1999; Frisch, Cornell, Villanueva, & Retzlaff, 1992; Johnson, 2001). On the QOLI, TTM participants also provided written descriptions of how hair pulling impacts their life satisfaction. 2.2.3.2. The Social Adjustment Scale-Self Report (SAS-SR). The SAS-SR (Weissman & Bothwell, 1976) is a 54-item scale that assesses role performance over the past 2 weeks. Areas assessed include work, leisure, family, and economic functioning. The SAS-SR demonstrates strong convergent validity with ratings on social adjustment made in clinical interviews (Weissman & Bothwell, 1976). 2.2.3.3. Sheehan Disability Scale (SDS). The Sheehan Disability Scale is a measure of the impact of symptomatology on work, social, and family functioning. Individuals rate the degree to which their symptoms have impaired each area of life using a 10-point Likert scale from 0 (not at all impaired) to 10 (very severely impaired). The three item ratings are added to create a total score. The SDS demonstrates good internal consistency (Leon, Olfson, Portera, Farber, & Sheehan, 1997). Construct validity was demonstrated through significantly different scores between individuals with and without psychiatric disorders, and significant relationships between anxiety symptoms and SDS impairment scores (Leon et al., 1997; Leon, Shear, Portera, & Klerman, 1992). 2.2.4. Self-esteem 2.2.4.1. Rosenberg Self-Esteem Scale (RSES). The RSES (Rosenberg, 1965) is one of the most widely used self-report measures of self-esteem. It consists of 10 items, assessing feelings of global personal self-esteem. Respondents rate their agreement to each item on a 4-point Likert scale (1=strongly agree to 4=strongly disagree). The scale demonstrated strong internal consistency, test–retest reliability, and face validity (Gray-Little, Williams, & Hancock, 1997). The RSES is not
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administered as part of the general clinical intake procedure. Thus, data were unavailable on the RSES for the PC group. 2.2.5. Clinical Global Impression The Clinical Global Impression (CGI) was administered as an assessment of global illness. For patients with TTM, ratings were made taking into consideration TTM as well as comorbid psychopathology. All ratings were made with reference to general patient populations rather than disorder specific populations. CGI severity was assessed using a 7-point Likert scale, from 1=normal, not at all ill to 7=extremely ill. Previous research using the CGI has found interrater reliability of r ¼ :66 for severity scores (Dahlke, Lohaus, & Gutzmann, 1992). 2.3. Procedure TTM participants completed interviews and self-report measures within the context of an intake evaluation for a TTM treatment study. Interviews for the TTM group were administered by either a licensed psychologist or a postdoctoral fellow under the supervision of a licensed psychologist. Alopecia Ratings were completed by licensed psychologists with experience in the assessment of TTM. Participants in the PC group completed assessment measures as part of their regular intake evaluation for the outpatient clinic. Either a postdoctoral fellow or psychology intern completed diagnostic interviews for the PC group. A licensed psychologist supervised all clinic intake evaluations and confirmed diagnoses with a separate unstructured interview. Several of the measures (Rosenberg Self-Esteem Scale, TTM assessment measures) are not administered as part of the clinic intake assessment, and are therefore unavailable for this group. Nonclinical community volunteers completed interviews and self-report questionnaires for the purposes of the current study and were compensated $20.00 for their participation. Diagnostic interviews for the NC group were administered by a research associate under the supervision of a licensed psychologist. The NC group did not complete TTM measures with the exception of the MGHHPS; however, NC participants were excluded from analyses using the MGH-HPS due to a floor effect and lack of variability among the scores.
3. Results 3.1. Demographic characteristics Demographic information for the three participant groups is presented in Table 1. Group comparisons were conducted using one-way analysis of variance (ANOVA) and chi-square. The participant groups did not differ on age, gender distribution, ethnicity, marital status, or educational level. The groups differed significantly on employment status, due to a higher percentage of employed individuals in the NC group than in the TTM group [w2 ð1Þ ¼ 4:31; po:05] or PC group [w2 ð1Þ ¼ 12:17; po:001]. Severity of illness as assessed by the Clinician’s Global Impression (CGI; Guy, 1976) was in the moderate to markedly ill range for both the TTM (M ¼ 4:64; SD=.83) and PC (M ¼ 4:84; SD=1.11) groups [tð44Þ ¼ :73; p=ns].
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Table 1 Demographic information
Age Gender Male Female Ethnicity Noncaucasian Caucasian Relationship status Not married Married Employment status Working/student Not working/disability/retired Education Some graduate school or degree Some college or degree Some high school or degree
TTM (n ¼ 28)
NC (n ¼ 28)
PC (n ¼ 28)
Statistical test
38.64 (12.17)
36.89 (13.08)
39.00 (12.32)
F ð2; 81Þ ¼ :23 w2 ð2Þ ¼ :00
2 (7.1%) 26 (92.9%)
2 (7.1%) 26 (92.9%)
2 (7.1%) 26 (92.9%)
6 (21.4%) 22 (78.6%)
4 (14.3%) 24 (85.7%)
2 (7.1%) 26 (92.9%)
w2 ð2Þ ¼ 2:33
w2 ð2Þ ¼ :90 16 (57.1%) 12 (42.9%)
19 (67.9%) 9 (32.1%)
16 (57.1%) 12 (42.9%) w2 ð2Þ ¼ 13:03
24 (85.7%) 4 (14.3%)
28 (100.0%) 0 (0%)
18 (64.3%) 10 (35.7%)
6 (21.4%) 17 (60.7%) 5 (17.9%)
10 (35.7%) 16 (57.1%) 2 (7.1%)
9 (33.3%) 18 (66.7%) 0 (0%)
w2 ð4Þ ¼ 6:57
Note: Means are shown with standard deviations in parentheses. Frequencies are shown with percentages in parentheses. ***po:001:
Given group differences on employment status (employed versus unemployed), point-biserial correlational analyses were used to determine whether or not this variable was associated with quality-of-life measures. Employment status correlated significantly (range absolute value rpb ¼ :392:48; po:001) with all outcome measures except the RSES (rpb ¼ :17; p=ns). In addition, participants within the TTM group differed on the QOLI as a function of employment status [tð25Þ ¼ 2:97; po:01], with employed participants reporting higher levels of life satisfaction. Participants in the PC group differed on the SAS-SR [tð26Þ ¼ 2:24; po:05] and SDS [tð23Þ ¼ 3:66; po:001] as a function of employment status, with the employed participants reporting superior functioning. Therefore, in order to control for the potential confound of differing employment status, analyses were run with and without employment status used as a covariate in betweengroup analyses, except those using the RSES as the dependent variable. 3.2. Group comparisons 3.2.1. Anxiety and depression measures Descriptive statistics and univariate comparisons across groups for the anxiety and depression measures are reported in Table 2. Tukey post hoc tests indicated that the TTM and PC groups reported significantly more severe depression than the NC group. The TTM and PC groups did not differ from each other on depression. With respect to the STAI-T, all groups differed from
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Table 2 Group comparisons for psychological distress, quality of life, and self-esteem TTM
NC
PC
Statistical test
Psychological distress BDI-II 13.25 (11.30)a STAI-T 44.64 (11.85)a
2.18 (2.26)b 28.33 (6.13)b
19.43 (13.84)a 53.21 (14.72)c
F ð2; 81Þ ¼ 19:78 F ð2; 74Þ ¼ 26:73
Quality of life SDS SAS-SR QOLI
6.14 (6.17)a 2.10 (.64)a 1.61 (2.22)a
1.61 (3.69)b 1.61 (.29)b 3.21 (1.14)b
16.78 (8.53)c 2.01 (.60)a 1.20 (2.13)a
F ð2; 80Þ ¼ 40:41 F ð2; 81Þ ¼ 6:76 F ð2; 77Þ ¼ 8:69
Self-esteem RSES
30.75 (5.77)a
36.68 (3.89)b
N/A
tð54Þ ¼ 4:51
Note. Means are shown with standard deviations in parentheses. **po:01; ***po:001: Means with different superscripts indicate significant differences according to Tukey post hoc tests, po:05: BDI-II=Beck Depression Inventory-II; STAI-T=State-Trait Anxiety Inventory-Trait Scale; SDS=Sheehan Disability Scale, SAS-SR=Social Adjustment Scale-Self-Report, QOLI=Quality of Life Inventory; RSES=Rosenberg Self-Esteem Scale.
each other, with the NC group, TTM groups, and PC groups reporting increasingly higher levels of trait anxiety. Given the group differences on employment status, and point-biserial correlations between employment status and BDI-II (rpb ¼ :48; po:001) and STAI-T (rpb ¼ :39; po:001), analyses were rerun with employment status as a covariate. First, multivariate analysis of covariance (MANCOVA) was used to explore group differences on measures of anxiety and depression. Group (TTM, PC, NC) was entered as the between-subjects factor and employment status as the covariate. BDI-II and STAI-T total scores were entered as the dependent variables. The multivariate group effect was statistically significant [F ð4; 144Þ ¼ 8:74; po:001]. Next, analysis of covariance (ANCOVA) was used to explore group differences on the BDI-II and STAI-T, respectively. Again group was entered as the between-subjects factor and employment status as a covariate. The group effect was significant for both the BDI-II [Fð2; 80Þ ¼ 12:17; po:001] and STAI-T [Fð2; 73Þ ¼ 19:70; po:001]. Pairwise comparisons using Bonferroni-correction indicated that the TTM and PC groups reported higher levels of anxiety and depression than did the NC group. The TTM and PC groups did not differ on anxiety or depression.
3.2.2. Quality-of-life measures Descriptive statistics and univariate analyses for the quality-of-life measures are reported in Table 2. Results indicated that the groups differed significantly from one another on each measure. Tukey post hoc tests indicated that all three groups differed significantly from each other on the SDS, with the NC group, TTM group, and PC group each reporting increasingly higher levels of disability. In addition, the TTM and PC participants reported significantly higher disability on the SAS-SR, and significantly lower life satisfaction on the QOLI, than did the NC group. The TTM and PC participants did not differ from one another on the SAS-SR or QOLI.
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However, previous analyses have indicated that the groups differed significantly on employment status and levels of psychological distress. In addition, depression has been found to mediate relationships between hair pulling symptoms and quality-of-life measures in previous research (Keuthen et al., 2002). Given group differences reported on anxiety and depression measures, as well as significant correlations for the BDI-II and STAI-T with quality-of-life measures (range absolute value r ¼ :342:74; po:01) we considered controlling for both the BDI-II and STAI-T as covariates in subsequent analyses. However, the BDI-II and STAI-T correlated highly with each other (r ¼ :83) and missing data on the STAI-T (as a result of a clerical error) for a portion of the NC group would have decreased the sample size and reduced statistical power for all subsequent analyses. Thus, only the BDI-II was covaried in subsequent analyses. Analyses were rerun with BDI-II and employment status entered as covariates. Results indicated that MANCOVA with Group (TTM, PC, NC) entered as the between-subjects factor; BDI-II and employment status as the covariates, and SAS-SR, SDS, and QOLI entered as dependent variables, was statistically significant [F ð6; 144Þ ¼ 6:56; po:001]. Next ANCOVA was used to explore group differences on the SAS-SR, SDS, and QOLI, respectively. Again group was entered as the between-subjects factor and BDI-II and employment status as covariates. The group effect was significant for the SDS [F ð2; 78Þ ¼ 19:14; po:001] and SAS-SR [Fð2; 79Þ ¼ 6:95; po:002]. Pairwise comparisons using Bonferroni-correction indicated the PC group reported significantly more severe impairment and disability on the SDS and SAS-SR than did the TTM or NC groups. The TTM and NC groups did not differ on the SDS or SAS-SR. The ANCOVA group effect was not statistically significant for the QOLI once depression and employment status were covaried in analyses [F ð2; 75Þ ¼ :74; p=ns].2 3.2.3. Self-esteem Descriptive statistics and univariate tests for the RSES are reported in Table 2 for the TTM and NC groups. Results indicated significantly lower self-esteem reported by the TTM group. A strong trend toward statistical significance remained when rerun as an ANCOVA with group entered as the between-subjects factor and BDI-II entered as a covariate [F ð1; 53Þ ¼ 4:01; p ¼ :05]. 3.3. Prediction A series of regression analyses were used to explore the relationship between hair pulling symptoms and the following outcome measures: SDS, SAS-SR, QOLI, and RSES. These analyses were conducted with TTM participants only. Given a high level of shared variance between depression and quality of life, it was important to control for depression scores within the regression analysis to determine the unique variance contributed by TTM measures to quality of life. Thus, BDI-II scores were entered into the first block to first control for that variance attributed to depression. Two measures of hair pulling were entered into the second block: the MGH-HPS total score and Alopecia Rating to determine the amount of variance contributed by TTM measures above that attributed to depression. Results are presented in Table 3. Results indicate that MGH-HPS was a significant predictor of disability as measured by the SDS; 2
Analyses run with and without employment status as a covariate did not differ substantively from one another. Therefore, only results from those analyses controlling for employment status are reported here.
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Table 3 Hierarchical regression analyses predicting quality of life in TTM patients Predictor SDS Step 1 BDI-II Step 2 MGH-HPS Alopecia SAS-SR Step 1 BDI-II Step 2 MGH-HPS Alopecia QOLI Step 1 BDI-II Step 2 MGH-HPS Alopecia RSES Step 1 BDI-II Step 2 MGH-HPS Alopecia
t
b
.49
2.77
.56 .01
3.81*** .08
.69
4.81***
.06 .10
DR2
P
.24
o.01
.30
o.01
.48
o.001
.01
ns
.42
o.001
.14
o.05
.28
o.01
.20
o.05
.38 .68
.65
4.15***
.11 .37
.76 2.52*
.53
3.13**
.25 .36
1.64 2.33*
Note: *po:05 level , **po:01; ***po:001: BDI-II=Beck Depression Inventory-II; MGH-HPS=Massachusetts General Hospital Hair Pulling Scale, SDS=Sheehan Disability Scale, SAS-SR=Social Adjustment Scale-Self-Report, QOLI=Quality of Life Inventory; RSES=Rosenberg Self-Esteem Scale.
however, hair pulling measures did not predict disability as measured by the SAS-SR. Severity of hair loss was a significant predictor of life satisfaction as measured by the QOLI, and self-esteem as measured by the RSES.
3.4. TTM interference checklist Endorsement rates of lifetime and current (i.e., past week) interference are presented in Table 4. Data indicate a high rate of endorsement of lifetime interference for items within the 6 categories. Prevalence ranged from 67.9% of patients endorsing any problems with recreational activities to 100% endorsing any problems with social interaction and negative affect/negative self-evaluations over their lifetime. Current problems due to hair pulling also were common. Prevalence ranged from 64.3% of patients endorsing any problems with physical health to 96.4% endorsing any
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Table 4 Number and percentage of TTM participants endorsing interference due to hair pulling over lifetime and past week time periods Lifetime
Past week
Grooming
Any grooming Wear wig, hat, etc. Fix hair style a certain way Special make-up Avoid hairdressers
26 12 19 11 12
(92.9%) (42.9%) (67.9%) (39.3%) (42.9%)
24 10 11 9 4
(85.7%) (35.7%) (39.3%) (32.1%) (14.3%)
Physical health
Any physical health Avoid doctors Eat hair-stomach upset Broken skin Skin infections Bleeding Scars Muscle pain Skin irritation
24 11 6 6 4 13 5 16 17
(85.7%) (39.3%) (21.4%) (21.4%) (14.3%) (46.4%) (17.9%) (57.1%) (60.7%)
18 0 4 3 0 5 3 10 10
(64.3%)
Any social interaction Avoid dating Sex life inhibited Avoid group social events Arguments with loved ones Spent less time with family/friends Spend more time alone Keeping hair pulling a secret
28 8 6 8 7 9 9 28
(100%) (28.6%) (21.4%) (28.6%) (25.0%) (32.1%) (32.1%) (100%)
27 3 4 1 0 5 6 26
(96.4%) (10.7%) (14.3%) (3.6%) (17.9%) (21.4%) (92.9%)
Recreational activities
Any recreational activities Avoid swimming Avoid other physical activities Avoid activity on windy days Spent less time on other things I enjoy Avoid sitting in front rows Avoid brightly lit rooms Avoid group events
19 13 8 7 11 6 8 8
(67.9%) (46.4%) (28.6%) (25.0%) (39.3%) (21.4%) (28.6%) (28.6%)
21 1 3 2 7 2 2 1
(75.0%) (3.6%) (10.7%) (7.1%) (25.0%) (7.1%) (7.1%) (3.6%)
Work productivity
Any work productivity Less productive at home Less productive at work Problems with concentration Late for work, appts, meetings
22 10 7 17 7
(78.6%) (35.7%) (25.0%) (60.7%) (25.0%)
20 9 6 15 3
(71.4%) (32.1%) (21.4%) (53.6%) (10.7%)
Negative affect
Any negative affect Feel alone Feel ‘‘weird’’ or ‘‘strange’’ Feel guilty Feel down on myself Feel unattractive Had low self-esteem Worry about hair pulling
28 15 21 18 26 23 22 24
(100%) (53.6%) (75.0%) (64.3%) (92.9%) (82.1%) (78.6%) (85.7%)
27 8 17 14 22 17 19 20
(96.4%) (28.6%) (60.7%) (50.0%) (78.6%) (60.7%) (67.9%) (71.4%)
Social interaction
(14.3%) (10.7%) (17.9%) (10.7%) (35.7%) (35.7%)
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problems with social interaction and negative affect/negative self-evaluations within the past week.
4. Discussion This study explored the impact of hair pulling on three variables associated with psychosocial functioning: psychological distress, functioning/quality of life, and self-esteem. Group comparisons indicated that TTM participants reported higher levels of distress than did individuals without hair pulling problems. In addition, participants with TTM were generally comparable to participants with other psychological disorders on reported distress level. These results highlight the emotional toll that can be associated with hair pulling problems. Findings also suggest that hair pulling is associated with impairments in functioning and life satisfaction; however, this relationship was multifaceted and complex. For example, the TTM group reported more severe disability, and lower life satisfaction than the NC group; however, group differences disappeared once controlling for depression. In addition, after controlling for depression, the TTM group demonstrated lower disability than did participants in the PC group. Therefore, consistent with previous research (Keuthen et al., 2002), these results suggest that hair pulling may not be associated with significant functional impairments unless accompanied by an increase in depression. Current results should be considered preliminary, and additional research with larger samples using more sophisticated statistical analyses (i.e., structural equation modeling) are needed to provide stronger support for the mediational role of depression. Nevertheless, if this model if borne out in future research, integrating techniques to target depression (e.g., cognitive therapy, behavioral activation) into TTM programs may improve efficacy for reducing impairments and increasing life satisfaction for these patients. However, current results also suggest that hair pulling may, in some cases, have an independent relationship with quality of life for patients with TTM. For example, dimensional analyses indicated that severity of hair pulling symptoms predicted more severe functional disability on one measure even after controlling for depression. In addition, hair loss severity predicted lower life satisfaction even after controlling for depression. Thus, the relationship between TTM severity and impairments in psychosocial functioning could not be explained entirely by depression severity. There are several reasons that may explain the inconsistency in findings. First, there is no generally accepted definition of quality of life nor agreement on how best to measure quality of life (Mendlowicz & Stein, 2000). The three measures administered in the current study assess different aspects of this construct, with the SDS providing an assessment of global disability (work, social, family), the SAS-SR providing an assessment of role impairment, and the QOLI a measure of life satisfaction. In addition, group analyses may have obscured the impact of hair pulling by averaging across the severity of TTM. Logistical regression within the TTM group, however, may have allowed for finer differentiations along the continuum of TTM severity. Thus, as a group, depression may be a mediating factor for patients with TTM, although within a group of TTM patients, severe hair pulling may impact quality of life independent of depression. The impact of TTM on self-esteem demonstrated a more consistent relationship, with the TTM group demonstrating a strong trend (p ¼ :05) toward lower self-esteem compared with the NC
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group, even after controlling for depression. In addition, the severity of hair loss was a significant predictor of self-esteem, again even after controlling for depression. These results are consistent with previous research indicating a relationship between hair pulling and lower self-esteem, although in previous research the severity of pulling and not the severity of hair loss was a significant predictor (Soriano et al., 1996). To better understand this relationship we reviewed participant’s written descriptions of how TTM affects their self-esteem. Several themes were identified which in some ways mirrored negative consequences of hair pulling reported in previous research (Casati et al., 2000). First, the impact of hair loss on personal appearance was highlighted. For example, patients with TTM reported ‘‘I feel ugly and unappealing,’’ and ‘‘I don’t think I’m that pretty.’’ Relatedly, many TTM patients expressed feelings of embarrassment and fear public exposure of the hair pulling habit. For example, patients expressed ‘‘embarrassment,’’ ‘‘shame,’’ and ‘‘worry about discovery by others.’’ These comments are not surprising given the well-established relationship between evaluations of physical appearance and self-esteem in previous research (Harter, 1999). In addition, frustrations associated with the inability to control pulling appeared to impact self-esteem. For example, patients stated hair pulling ‘‘makes me feel inept,’’ ‘‘makes me feel like I can’t control myself,’’ and ‘‘I see it as a weakness in myself.’’ Again, these statements are consistent with previous research suggesting perceived personal weaknesses or flaws are core elements of low self-esteem (Harter, 1999). The impact of hair pulling on self-esteem also was demonstrated in a qualitative interview, wherein all TTM patients reported symptoms of negative affect during their lifetime and nearly all participants (96.4%) reported current problems with negative affect/negative self-evaluations as a result of pulling. Low self-esteem, feeling down on myself, and feeling unattractive were some of the most common types of negative affect/negative self-evaluations endorsed. Results from the qualitative interview also indicated lifetime and current problems with grooming, physical health, social interaction, recreational activities, and work productivity. It is difficult to compare these results to previous qualitative reports given differences in item wording and methodology. However, results are generally consistent with previous research documenting frequent and diverse types of impairment on daily functioning as a result of hair pulling (e.g., Keuthen et al., 2002; Seedat & Stein, 1998; Stemberger et al., 2000). It is important to note that some research has found low clinician ratings of impairment for patients with TTM (Stanley, Prather, Wagner, Davis, & Swann, 1993).These results contradict accumulating support for significant negative consequences of hair pulling. Perhaps the degree of interference caused by hair pulling is small relative to the patient’s ability to continue functioning despite hair pulling (e.g., it is rare for hair pulling to cause unemployment). Thus, patients may not recognize and/or report certain impairments from hair pulling. As a result we have begun assessing the impact of hair pulling using the Trichotillomania Interference Checklist (TIC), which uses recognition rather than recall to assess the impact of hair pulling across a variety of specific items. Perhaps current results from the TIC, in conjunction with previous work, will provide clinicians with direction to use a similar methodology to specifically assess for common interference items for their TTM patients. Identification of impairments can be important clinically to enhance patient motivation, identify treatment targets and goals, as well as limit dismissal of hair pulling symptoms as benign. In conclusion, results indicate that TTM is associated with psychosocial impairment, although for some variables this relationship may be mediated by the presence of depression. In addition,
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there are common and diverse types of impairments reported by TTM patients. However, these results also need to be considered within the limitation that this study included a small sample of patients who were predominantly female, Caucasian, treatment-seeking, and prescreened to exclude for a number of variables (e.g., recent medication change). Therefore, results may not generalize to the general population of TTM patients. In addition, given that the TTM group was prescreened while the PC group was not, it is possible that these groups were not matched on clinical severity. This argument is mitigated somewhat by similar mean CGI scores for the TTM and PC group. However, if recruitment strategies did bias the TTM group toward milder clinical severity, current results may underestimate the levels of impairment of TTM patients. Questions such as these highlight the need for additional research on more diverse samples of TTM patients. In addition, for ethical reasons clinician-rated assessment of hair loss severity was based only on those areas of alopecia that could be rated in a nonintrusive way. Self-report was used to substitute data for one patient who pulled solely from pubic regions. Perhaps self-report ratings made by all participants, in addition to clinician-rated measures, could be used to in future research to provide a more comprehensive assessment of hair loss severity. Despite some limitations, these results highlight the importance of promoting and improving resources for the clinical care of TTM patients, and provide some directions for clinicians to enhance assessment of interference caused by TTM.
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