by Michael D. Anestis, M.S.
There is simply no way to cover every DSM diagnosis in great detail regularly on PBB, but we like to make a legitimate effort to touch upon as many as possible. One disorder yet to be subject to any attention on thus far on the site is trichotillomania (TTM). TTM is characterized by the repetitive pulling of one's own hair and is estimated to impact approximately 1-2.5% of the population (Christianson, Pyle, & Mitchell, 1991). Depending upon the strictness with which the criteria for TTM are defined, that estimate can balloon to as high as 15% (Rothbaum, Shaw, Morris, & Ninan, 1993). Hair pulling is not limited to the hair on one's head and some individuals pull hair from multiple locations. The resulting impact on physical appearance in severe cases can be highly upsetting for the individual struggling with TTM and, as such, the disorder can have a highly problematic impact on an individual's social life.
In a study just released in Behaviour Research and Therapy, Anna Shusterman, Lauren Feld, Lee Baer, and Nancy Keuthen (2009) utilized data from a massive online survey to examine the role that emotions play in prompting and sustaining this disorder. The description of TTM in the DSM-IV-TR as well as a number of prior studies have linked TTM behaviors with a sense of relief on the part of the individual exhibiting the behavior. In other words, many individuals have reported that pulling out their own hair has resulted in immediate decreases in negative emotions. Despite this potentially valuable function, the behavior also includes a variety of less comfortable correlates, namely subsequent feelings of shame and guilt and a strong desire to cease the behavior. So, the behavior becomes rewarding through its ability to quickly reduce certain negative emotions, but also results in several emotional and social consequences.
If you have read any of our articles on binge eating, you might notice a parallel here - individuals who engage in dysregulated behaviors when upset because the behavior offers immediate relief from aversive emotions, but who then subsequently regret the behavior and wish they could escape the pattern. Keep this parallel in mind as you read the rest of this article, as it is an important consideration that also generalizes to several other dysregulated behaviors (e.g., non-suicidal self-injury, drinking alcohol to cope with negative affect).
Shusterman and colleagues (2009) used the terms "pullers" and "non-pullers" throughout the paper to refer to individuals who do and do not pull their own hair and were interested in testing three hypotheses. First, they believed that pullers would endorse greater difficulty in regulating emotions than would non-pullers. Second, they believed that the degree to which pullers reported difficulty regulating emotions would correspond to the degree to which they pull their own hair, with greater difficulty regulating emotions resulting in greater levels of hair pulling. Third, they believed that the degree to which a puller reports difficulty regulating a specific emotion would correspond with the degree to which that particular emotion serves as a prompt for hair pulling. In other words, if a puller indicated that she generally struggles to regulate anger, the authors anticipated that anger would be a common cue that led to her pulling her hair.
The data for this study was accumulated online through a massive survey project and participants were recruited through advertisements and word of mouth. In total, the sample included 1,162 "pullers" and 175 "non-pullers." All of the data reflected participants' responses to self-report questionnaires. Additionally, no formal diagnostic procedures were utilized, as the authors believed it would be more useful to examine trichotillomania as a continuum rather than simply looking at folks who do or do not meet criteria for the disorder based upon the DSM-IV-TR. Despite these limitations, we believe the study offered an interesting glimpse at the role of emotions in this particular behavior.
Consistent with their hypotheses, the authors found that pullers reported greater difficulty "snapping out" of emotions than did non-pullers. "Snapping out" was not clearly defined, which raises legitimate questions regarding the validity of their assessment, but nonetheless, this represents preliminary evidence that individuals exhibiting symptoms of trichotillomania have a particularly difficult time effectively altering emotional states in a healthy manner. Additionally, the authors found that the degree to which pullers reported difficulty regulating emotions correlated with the severity of their hair pulling behavior. So, pullers who had a particularly difficult time regulating emotions typically exhibited more severe hair pulling behavior. Additionally, this relationship held even when comparing the individuals with the mildest level of hair pulling to non-pullers, with mild pullers reporting significantly greater difficulty regulating emotions.
Perhaps the most interesting finding, however, was related to the authors' third hypothesis. In this sample, they found that individuals were often prompted to pull their hair in response to the specific emotions they reported having the most difficulty regulating. In other words, if an individual who pulls his hair struggles to regulate feelings of boredom, than boredom is likely to be a particularly salient cue that prompts him to pull his hair.
Importantly, as I hinted at above, the online self-report measures represent a weakness in examining these particular questions. Asking somebody how they typically feel right before and right after a behavior that occurred in the past is an unreliable form of measurement. We simply are not particularly accurate when we try to recall this type of information over extended periods of time. A better approach would involve taking real time measurements of mood, etc...over a period of time and then using more sophisticated statistical analyses such as hierarchical linear modeling to examine the data. As such, this study should be seen as preliminary and its results should be interpreted with caution; however, there is nothing wrong with preliminary data as long as folks do not overstep the bounds of what such data care capable of telling us and the authors did nothing of the sort here.
As I read this article, I could not help but reflect upon the similarities between hair-pulling and a variety of other problematic behaviors. In past PBB articles, we have covered these behaviors on their own, but we have also called attention to variables like negative urgency and distress tolerance that have been shown to predict a variety of problematic behavioral outcomes. Thus far, to our knowledge, there is no empirical data linking distress tolerance or negative urgency to hair pulling, but it seems likely that individuals who pull their hair in an effort to regulate emotions likely exhibit elevations in these same risk factors. If so, this has important treatment implications, as clinicians could stress emotion regulation skills and test the utility of emotion-based therapeutic approaches such as dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT). In fact, as Shusterman and colleagues pointed out in their article (2009), there is preliminary evidence indicating that ACT might be an effective treatment capable of reducing hair pulling behaviors (Begotka, Woods, & Wetterneck, 2004; Woods & Twohig, 2008).
A question left unanswered by this and similar studies on other problematic behaviors is why emotion regulation difficulties would lead to this particular behavior. As a researcher focused on treatment, I often de-emphasize this particular question. I do this for several reasons. First, treatments such as DBT appear effective for reducing disparate behaviors (e.g., NSSI, binge eating) that are prompted by difficulties regulating emotions. As such, the reason an individual chose a particular behavior does not appear to impact the effectiveness of treatment, at least in certain circumstances. Second, I believe that the "insight fallacy" is one of the primary weaknesses of most non-scientific approaches to psychotherapy. The belief that understanding the origins of a behavior (beyond risk factors such as negative urgency or other prompting events) is a necessary and sufficient means for altering that behavior has simply not stood up to testing and, as such, while there is nothing harmful about such insights, I often do not emphasize them in my attempts to consider treatments. Nonetheless, it remains interesting to consider why one individual may resort to NSSI, another might binge eat, and another might pull hair in efforts to regulate emotions. For some, I suspect the initial episodes result from peer or family modeling and the inherently reinforcing emotion regulation properties of the behavior then sustain it for those who are vulnerable. For others, I think might simply be chance. One day, they are upset and they happen to stumble upon a behavior that works, drastically increasing the chances that the behavior will be repeated in the future. I'm curious what you think about this question. Is there a specific reason why some individuals choose one behavior while others choose another?
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.