Elsevier

Psychiatry Research

Volume 261, March 2018, Pages 154-160
Psychiatry Research

Types of avoidance in hair-pulling disorder (trichotillomania): An exploratory and confirmatory analysis

https://doi.org/10.1016/j.psychres.2017.12.056Get rights and content

Highlights

  • Five types of avoidance were found in those experiencing hair-pulling symptoms.

  • Avoidance of non-social goals was both cognitive and behavioural for those experiencing hair-pulling disorder.

  • Self-concealment could be thought of as a type of avoidance in this cohort.

  • Social avoidance was behavioural in nature for those with hair-pulling.

  • Thinking about the future and problems in relationships were topics avoided by those with hair-pulling.

Abstract

Hair-pulling disorder (HPD) or Trichotillomania is a complex disorder with frequent relapses. Avoidance has been highlighted as an important behavioural feature in HPD. To improve our understanding of avoidance, two studies were conducted to identify the types of avoidance that may be experienced by those who pull hair. Internet questionnaires were used to collect data. Data from study one was split into two subsets. An exploratory factor analysis was conducted to identify the different types of avoidance experienced by those reporting symptoms of hair pulling (subset one, n = 278), followed by a confirmatory factor analysis (subset two, n = 295). In study two a MANOVA was conducted (n = 300) to examine whether levels of avoidance differed between controls and those with hair pulling symptoms. Participants with hair pulling symptoms had greater levels of avoidance on each of the five types: ‘Avoidance of non-social goals’, ‘Self-concealment’, ‘Behavioural social avoidance’, ‘Avoidance of relationship problem solving’ and ‘Avoidance of thinking about the future’. These data expand on the current literature, which has predominantly focused on experiential avoidance. Future research will need to validate these findings in a clinical group.

Introduction

Hair-pulling disorder (HPD) has been defined as the recurrent pulling out of hair, with repeated attempts to stop the behaviour whilst experiencing clinically significant distress that is not explained by another condition (American Psychiatric Association, 2013). Avoidance has been highlighted as an important behavioural feature in HPD (Begotka et al., 2004, Houghton et al., 2014, Keuthen et al., 2012, Norberg et al., 2007, Shusterman et al., 2009, Woods et al., 2006a). More specifically, studies have demonstrated that individuals with HPD avoid social, recreational and occupational activities, which results in a sense of isolation and secretiveness (Casati et al., 2000, Diefenbach et al., 2005, Stemberger et al., 2000, Woods et al., 2006a).

It has been argued that a wide range of psychopathological symptoms can arise from systematic avoidance (Hayes and Wilson, 1996). This is most commonly referred to as experiential avoidance, and is the coping style is targeted therapeutically through Acceptance and Commitment Therapy (ACT). Experiential avoidance is operationalized in research settings by the Acceptance and Avoidance Questionnaire AAQ (Hayes et al., 2004). Not only has a correlational relationship been found between experiential avoidance and HPD (Shusterman et al., 2009), but higher experiential avoidance has been linked to more urges, higher intensity of urges, and less ability to control the urge to pull hair (Begotka et al., 2004). High experiential avoidance has been found to reduce response to psychological therapies (Keuthen et al., 2012, Woods et al., 2006a); and to mediate the relationship between fear of negative evaluation, feelings of shame and dysfunctional beliefs about appearance, with hair pulling severity (Norberg et al., 2007).

The role of experiential avoidance in HPD is increasingly recognised as an important feature to be addressed during psychological therapies. Yet there has been limited research on avoidance more broadly in HPD. For example, Ottenbreit and Dobson (2004) distinguished between behavioural avoidance and cognitive avoidance, and avoidance in social and non-social situations. These four avoidance types, measured by the cognitive behavioural avoidance scale (CBAS) were evident in depression and anxiety disorders (Ottenbreit and Dobson, 2004), and have been argued to contribute to maladaptive beliefs around negative emotion and avoidance of negative affect (Stapinski et al., 2014). Yet, it is not clear from the literature to what extent avoidance in HPD is cognitive or behavioural, and the degree to which people with HPD avoid social and non-social events.

Briefly in the limited literature to date, people with HPD tend to be less harm-avoidant and more novelty-seeking than people with obsessive compulsive disorder (Lochner et al., 2005), their fear of negative judgment and humiliation seem justified, as disclosure of hair pulling often results in a negative evaluation by others (Casati et al., 2000, Marcks et al., 2005). Not surprisingly, individuals with HPD can go to extreme lengths to avoid disclosure and ‘being found out’ about hair pulling, including the avoidance of intimacy (Stemberger et al., 2000). Indeed, 87% of individuals who pull hair did things to hide hair loss e.g., worn wigs, scarves and hats (Christenson et al., 1991), and over their lifetime 100% of people with HPD exhibit some degree of secretiveness (Diefenbach et al., 2005). The desire to avoid disclosure and keep HPD a secret could be construed as self-concealment, but this notion has not yet been systematically explored in HPD. Self-concealment measured by the Self-Concealment Scale (SCS) has been defined as a tendency to maintain personal boundaries around distressing negatively valanced personal information (Larson and Chastain, 1990). In other words, the avoidance of intimacy and avoidance of self-exposure. In sum, given the pervasiveness of avoidance in HPD, and limitations to current treatment, it seems prudent to further clarify types of avoidance as experienced by those with HPD.

The first aim of study one was to explore the types of avoidance experienced by those who scored ≥ 1 on the Massachusetts General Hospital Hair Pulling Scale (MGH). Types of avoidance were examined using an exploratory factor analysis of the items belonging to three avoidance measures; The Cognitive Behaviour Avoidance Scale (CBAS), The Self Concealment Scale (SCS), and The Action and Avoidance Questionnaire (AAQ). Correlational analyses were then performed to assess the relationship between the exploratory factor analysis results, hair pulling symptoms and general negative thoughts as measured by a depression and anxiety questionnaire. The second aim of study one was to confirm and refine these avoidance types with confirmatory factor analysis. Finally, study two aimed to examine whether scores on the types of avoidance identified from study one differed between those scoring ≥ 1 on the MGH and controls.

Section snippets

Procedure and participants

For study 1, participants were recruited via postings of an anonymous online questionnaire on websites that are popular with individuals with trichotillomania, including online support groups and sites with information about trichotillomania. They were also recruited from the research experience program for first year psychology students at the University, who were given course credit for participation. Once clicking the link, potential participants read an informed consent document and were

Exploratory factor analysis

Data from subset one was used for the EFA. The first solution to meet all criteria was a 6-factor solution (see supplementary material, Table A1). It converged in eight iterations. The communalities ranged between 0.28 to 0.81, i.e., the six factors explained from 28% to 81% of the variation in individual items. The six extracted factors explained 53.56% of the total variance. Thirty-seven of the original 50 items remained in the six-factor solution. Items that were not included in the solution

Discussion

The study sought to clarify the different types of avoidance experienced by those who have a tendency to pull their hair. Based on the analyses, five main areas of avoidance were found that were relevant to hair-pulling symptoms: ‘Avoidance of non-social goals’, ‘Self-concealment’, ‘Behavioural social avoidance’, ‘Avoidance of thinking about the future’ and ‘Avoidance of relationship problem solving’.

The factor ‘Avoidance of distressing emotions’ consisting of four items of the AAQ, identified

Funding

This research was supported by Australian Rotary Health.

Conflict of interest

All authors declare they have no conflict of interest.

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