Trichotillomania: impact on psychosocial functioning and quality of life

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Abstract

This study explored the impact of hair pulling on psychosocial functioning for patients diagnosed with trichotillomania (TTM; n=28). TTM patients were compared to age and gender-matched groups of psychiatric patients without TTM (n=28) and nonpsychiatric control volunteers (NC, n=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.

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 (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.

Section snippets

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

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 [χ2(1)=4.31, p<.05] or PC group [χ2(1)=12.17, p<.001]. Severity

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

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    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.

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