Elsevier

Psychiatry Research

Volume 239, 30 May 2016, Pages 12-19
Psychiatry Research

Comorbidity and quality of life in adults with hair pulling disorder

https://doi.org/10.1016/j.psychres.2016.02.063Get rights and content

Highlights

  • Hair pulling disorder is though to be associated with significant comorbidity.

  • Data from a treatment-seeking sample of adults with hair pulling were examined.

  • Results indicated that both current and lifetime comorbidity were high (38.8% and 78.8%).

  • Current depressive symptoms were significantly correlated with quality of life.

  • People with hair pulling might benefit from parallel treatment for depression.

Abstract

Hair pulling disorder (HPD; trichotillomania) is thought to be associated with significant psychiatric comorbidity and functional impairment. However, few methodologically rigorous studies of HPD have been conducted, rendering such conclusions tenuous. The following study examined comorbidity and psychosocial functioning in a well-characterized sample of adults with HPD (N=85) who met DSM-IV criteria, had at least moderate hair pulling severity, and participated in a clinical trial. Results revealed that 38.8% of individuals with HPD had another current psychiatric diagnosis and 78.8% had another lifetime (present and/or past) psychiatric diagnosis. Specifically, HPD showed substantial overlap with depressive, anxiety, addictive, and other body-focused repetitive behavior disorders. The relationships between certain comorbidity patterns, hair pulling severity, current mood and anxiety symptoms, and quality of life were also examined. Results showed that current depressive symptoms were the only predictor of quality of life deficits. Implications of these findings for the conceptualization and treatment of HPD are discussed.

Introduction

Hair Pulling Disorder (HPD) is an obsessive-compulsive spectrum condition in which individuals pull hairs from their own body, resulting in significant hair loss (American Psychiatric Association, 2013). Subclinical hair pulling is relatively common (i.e., 11%) while clinical hair pulling, or diagnosable HPD, is less frequent (Woods et al., 1996). The lifetime prevalence rate of HPD as defined in DSM-IV-TR is estimated at about 0.6% (APA, 2000), but may be as high as 3.4% for women and 1.5% for men (Christenson et al., 1991a, Christienson et al., 1991b). Studies on the gender distribution of HPD suggest it is more common in females (9:1; Christenson, 1995, Duke et al., 2009, Reeve, 1999).

Research has identified two distinct styles of pulling: “automatic” and “focused” (Christenson et al., 1991a). Automatic pulling is a passive process in which pulling occurs with little conscious awareness. In contrast, focused pulling is an active and purposeful process, which some suggest, functions to regulate negative affect and/or aversive cognitions (Woods et al., 2006b). In either case, hair pulling can create a vicious cycle in which both types of pulling are present in the same individual: out of awareness (automatic) pulling leads to emotional consequences (e.g., sadness, anger, and guilt), which can lead to further (focused) pulling (Diefenbach et al., 2002).

HPD has been consistently associated with negative psychosocial consequences. Hair pulling is viewed negatively by peers (Woods et al., 1999), can lead to avoidance of social and recreational activities (Woods et al., 2006a), and can result in anxiety during intimate situations (Christenson and Mansueto, 1999, Diefenbach et al., 2005a, Duke et al., 2010). In addition, individuals with HPD experience academic, occupational, and psychological difficulties (Woods et al., 2006a). Research shows that the majority of people with HPD report feeling physical unattractiveness, depression, shame, and feelings of low self-worth (Stemberger et al., 2000).

Beyond measuring specific facets of psychosocial functioning in HPD, researchers have also investigated the relationship between HPD and global indices of quality of life, with results being mixed. Keuthen et al. (2004) found no significant differences on quality of life measures between persons with HPD (N=58) and healthy controls (from published norms). In contrast, two other studies found that persons with HPD (n=28 and 70) had poorer quality of life scores than non-psychiatric controls (n=28 and 25) (Diefenbach et al., 2005b, Odlaug et al., 2010). Three studies (Diefenbach et al., 2005b, Keuthen et al., 2004, Tung et al., 2014) with various sample sizes (n=28, 58 and 187) found that depression severity significantly predicted quality of life, even while controlling for hair pulling severity, and a fourth study (Odlaug et al., 2010) (n=70) showed that persons with HPD who reported poor quality of life also reported higher scores on depression indices. Furthermore, in a related study examining life disability in HPD (N=153), focused hair pulling severity and pulling-related distress and interference predicted life disability while controlling for depression, but depression also correlated with life disability (Tung et al., 2015). These results indicate that quality of life and HPD might be at least partially mediated through an association with depression.

Given the difficulties in psychosocial functioning experienced by persons with HPD, perhaps it is not surprising that HPD patients are generally believed to suffer from comorbid psychiatric disorders at a higher rate than the general population. In reviewing the HPD literature, 20 studies reported comorbidity rates in adults with HPD, but these rates varied widely from study to study. For example, rates for comorbid depressive disorders ranged from 14% to 60% (Christenson and Mansueto, 1999, Keijsers et al., 2006, van Minnen et al., 2003, Odlaug et al., 2010), anxiety disorders from 2.3% to 57% (van Minnen et al., 2003, Christenson et al., 1991a), and OCD from 5% to 27% (Christenson et al., 1991a, Schlosser et al., 1994). It is unclear what factors contributed to these inconsistencies, but many of the studies reporting comorbidity rates in HPD possess methodological limitations. First, some studies used unstructured assessment instruments (e.g., Christenson et al., 1991a, Christienson et al., 1991b) or (online) self-report measures (e.g., Woods et al., 2006a). Second, some studies reported current comorbid disorders, while others reported on lifetime comorbidity. Third, not all studies were published in peer-reviewed journals (Hand et al., 1996). Finally, some study samples did not consist entirely of persons with HPD and failed to report statistics specifically for HPD (e.g., Grant and Christenson, 2007).

After 4 studies with significant limitations were set aside, there remained 16 studies of sufficient methodological scrutiny that report comorbidity rates in HPD. These studies were all published in peer-reviewed journals, used structured or semi-structured diagnostic assessments, used samples that clearly consisted of individuals with HPD, and provided clearly delineated results for specific diagnoses (e.g., “major depression” rather than “mood disorder”). A summary of the characteristics of these studies and their data are presented in Table 1, Table 2, Table 3. Visual analysis of these tables showed that comorbidity rates and study characteristics (i.e., sample sizes) still vary considerably across studies. This variability could have been caused by the fact that several diagnostic classification systems were used in these studies. Also, most studies did not report data on many comorbid disorders. Finally, these studies used a variety of recruitment practices, meaning that selection bias likely impacted comorbidity rates.

Due to the limitations of the literature on comorbidity rates in HPD, there is a need to characterize comorbidity patterns in persons with HPD using larger and well-characterized samples with psychometrically sound and rigorous assessment instruments. These results can then be compared to those of previous research in order to create better-established norms of HPD comorbidity. The current study reports on comorbidity data from a recently completed, federally funded clinical treatment trial of adults with HPD (R01MH080966; Woods, PI) that includes one of the top three largest samples of HPD collected to date. In addition to describing patterns of comorbidity, the relationship between psychiatric comorbidity and psychosocial functioning in persons with HPD are explored.

Section snippets

Participants

Eighty-five adults with HPD participated in a randomized controlled trial comparing the relative efficacy of Acceptance-Enhanced Behavior Therapy to supportive psychotherapy. Participants were recruited via local newspaper ads, public transportation flyers, newsletters, website advertisements via the Trichotillomania Learning Center, and clinic referrals to a university-based HPD specialty clinic. The recruitment advertisements stated:

Are you an adult between the ages of 18 and 65 who pulls

Hair pulling and psychosocial functioning

The baseline sample reported moderately severe hair pulling according to both the MGH-HPS (M=16.93, SD=4.53) and NIMH-TSS (M=14.34, SD=3.64).

The average Quality of Life t-score was near the upper bound of the low range (M=41.2, SD=14.7). Mean BDI and BAI scores were in the minimal to mild range at 12.92 (SD=10.19) and 13.35 (SD=13.25), respectively, and both had large standard deviations.

Comorbidity

According to the SCID-P (Table 4), the majority of patients (78.8%) met criteria for at least one lifetime

Discussion

The aims of the current study were to describe psychosocial functioning and comorbid psychopathology within a well-characterized sample of adults with HPD with moderate hair pulling severity and to investigate the relationships between these variables and quality of life.

In this study, persons with HPD reported quality of life in the upper part of the low range, which was very similar to that reported by three previous studies utilizing the same measure (Raw score means on the QOLI=41.20 vs.

Contributors

Mr. Houghton and Dr. Compton had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of data analysis.

Study concept and design: Woods, Franklin, Neal-Barnett, Saunders, Twohig, Compton, Maas, Houghton.

Acquisition of data: Woods.

Analysis and interpretation of data: Houghton, Compton, Franklin, Woods.

Drafting of the manuscript: Houghton, Maas, Compton, Woods.

Critical revision of the manuscript for important intellectual content:

Conflict of interest

Drs. Twohig and Woods receive royalties from Oxford University Press for their published treatment guide for Trichotillomania. Dr. Woods has also received funding from the Trichotillomania Learning Center. Drs. Franklin, Neal-Barnett, and Saunders and Mr. Houghton and Ms. Maas report no financial conflicts of interest.

We would like to report that this study was supported by the NIMH of the National Institutes of Health under Award number grant R01MH080966 (Woods: PI). The funding organization

Acknowledgment

Drs. Woods and Twohig receive authors' royalties from Oxford University Press. Dr. Woods receives author's royalties from Springer Press.

Research reported in this paper was supported by the NIMH of the National Institutes of Health under Award number R01MH080966 (Woods; PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The authors would like to thank the Trichotillomania Learning Center for

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