EMOTIONAL CYCLES MAINTAINING TRICHOTILLOMANIA (HAIR-PULLING DISORDER) ACROSS SUBTYPES SEBASTIAN SIWIEC B.Sc., University of Calgary, 2010 A Thesis Submitted to the School of Graduate Studies of the University of Lethbridge in Partial Fulfillment of the Requirements for the Degree MASTER OF EDUCATION COUNSELLING PSYCHOLOGY FACULTY OF EDUCATION LETHBRIDGE, ALBERTA April, 2013 NOTE: As of May 1, 2014 Signature Pages are no longer required as part of the thesis submission. A Thesis Committee Member Page should instead be used in this location. EMOTIONAL CYCLES MAINTAINING TRICHOTILLOMANIA (HAIR-PULLING DISORDER) ACROSS SUBTYPES SEBASTIAN SIWIEC Approved: Thesis Supervisor: Dawn Lorraine McBride, Ph.D. Date Thesis Committee Member: Thelma Gunn, Ph.D. Date Thesis Committee Member: Bradley Hagen, Ph.D. Date Thesis External Examiner: Christopher Flessner, Ph.D. Date Assistant Dean of Graduate Studies and Research in Education: Date Kerry Bernes, Ph.D. Dedication To those with trichotillomania who still suffer in silence. iii Abstract The emotions associated with initiating, maintaining, and reinforcing hairpulling disorder (trichotillomania) were studied. Studies conducted have only looked at small community or inpatient samples, and little is known about the interplay of hairpulling subtypes and emotions. For this study, 427 participants completed an online questionnaire around their hairpulling subtype, severity, emotions experienced by hairpulling, and comorbid anxiety and depression. Using the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A; Flessner, Woods, Franklin, Cashin, & Keuthen, 2008), this is the first study to address the regulation of emotions across subtypes. Participants were divided as either high- or low-focused and either high- or low automatic. Significant differences between hairpulling subtypes and hairpulling severity were reported. Subtypes differed in the severity they experienced emotions; individuals with high-focused pulling reported more intense negative emotions, and a greater number of emotions regulated by pulling. Positive emotions⎯happiness, relief, and calm⎯were also found to play a significant role in reinforcing hairpulling. For high-focused subtypes, negative emotions before- and after-pulling were associated with greater severity, indicating that altering negative emotions via pulling plays an important role for high-focused subtypes. High-focused subtypes also reported higher stress, depression and anxiety than either automatic subtypes or the general population, and were found to have anxiety and depression significantly associated with hairpulling severity and experiencing negative emotions that initiated hairpulling. Clinical and treatment implications, study limitations, and areas of future research are discussed. iv Acknowledgments To Bozena Siwiec, I could not have achieved this without your love and support. Thanks mom. To Dawn McBride, for helping turn my dream of completing a thesis into a reality. You pushed, you challenged, and you helped me achieve something that without your guidance would not have been possible. To Christopher Flessner, Thelma Gunn, and Brad Hagen, it was a privilege to work alongside each of you and to grow my thesis with your perspectives and experience. To the Trichotillomania Learning Center, I am humbled by all of the amazing work you do. To Gail Bailey, you were always by my side. To my friends, classmates, and colleagues, who listened to me talk on and on about trichotillomania. You all served different roles, all important. To those with trichotillomania, thank you. v Table of Contents Dedication .......................................................................................................................... iii Abstract .............................................................................................................................. iv Acknowledgments ................................................................................................................v Table of Contents ............................................................................................................... vi List of Tables .................................................................................................................. xvii Chapter 1: Introduction ........................................................................................................1 Overview ..................................................................................................................1 Statement of the Problem .........................................................................................1 Overview of the Topic .............................................................................................2 Styles and profiles of hairpulling .................................................................3 Understanding trichotillomania through a behavioural model ....................4 Purpose of the thesis ....................................................................................5 Rationale for studying trichotillomania online ............................................6 Overview of research questions ...................................................................6 Contribution of this Thesis ......................................................................................7 Key Terms ................................................................................................................8 Trichotillomania (TTM) ...............................................................................8 Criteria B/C ..................................................................................................8 Automatic pulling ........................................................................................8 Focused pulling ............................................................................................9 Pulling profile ..............................................................................................9 Affective cycles ...........................................................................................9 vi Statement of Interest ................................................................................................9 Overview of the Thesis ..........................................................................................10 Summary ................................................................................................................11 Chapter 2: Literature Review .............................................................................................13 Overview ................................................................................................................13 Trichotillomania .....................................................................................................13 History........................................................................................................13 Prevalence ..................................................................................................14 General hairpulling characteristics ............................................................15 Hairpulling sites .............................................................................16 Hair characteristics .........................................................................17 Hairpulling behaviours and oral habits ..........................................17 Duration and number of pulling episodes ......................................18 Onset ..........................................................................................................18 Conceptualizing the Impact of Trichotillomania ...................................................20 Social consequences ...................................................................................20 Occupational and academic consequences ................................................21 Physical consequences ...............................................................................21 Psychological interference .........................................................................22 Comorbidity ...............................................................................................22 Classifying Trichotillomania .................................................................................23 Trichotillomania as an obsessive-compulsive behaviour ..........................24 Revising the DSM criteria for TTM ..........................................................25 vii Automatic and Focused Hairpulling ......................................................................27 Refining the definitions of automatic and focused hairpulling ..................27 Trichotillomania subtypes represent distinct phenomenon ........................30 Subtypes occur on a continuum within individuals ...................................31 Severity across a continuum of hairpulling styles .....................................31 Assessing severity: The Massachusetts General Hospital Hairpulling Scale .......................................................................................32 Low-focused, high-automatic hairpulling (LFHA) ....................................32 High-focused, low-automatic hairpulling (HFLA) ....................................33 High-focused, high-automatic hairpulling (HFHA) ..................................33 Low-focused, low-automatic hairpulling (LFLA) .....................................34 The Comprehensive