Previous research on trichotillomania (TTM) has demonstrated an emotion regulation function of hair pulling behavior. One condition that can impede the regulation of emotions is alexithymia. The present study aimed to explore the relationship between the degree of alexithymia and the severity of hair pulling behavior in individuals with TTM. Multiple strategies were used to recruit a sample of 105 participants via the internet. All participants were diagnosed with TTM by an experienced clinician via a subsequent phone-interview. Multiple linear regression analysis was performed to test the potential predictive value of the different facets of alexithymia (20-item Toronto Alexithymia Scale) on the severity of TTM (Massachusetts General Hospital Hair-Pulling Scale). Both the difficulty in identifying feelings (DIF) facet of alexithymia (p=0.045) and depression (p=0.049) were significant predictors of the severity of TTM. In conclusion, alexithymia seems to play a role in hair pulling behavior in individuals with TTM. However, the significant association was small in terms of the overall variance explained, thus warranting further research. If replicated in prospective studies, then these results indicate that therapeutic approaches aimed at supporting patients in recognizing and differentiating feelings might be useful for the treatment of TTM.
Trichotillomania (TTM) is characterized by the repetitive pulling out of one׳s own hair from the scalp, eyebrows, eyelashes, or other areas of the body. Epidemiological studies have demonstrated a lifetime prevalence rate of about 1% (Duke et al., 2010). TTM often has negative psychosocial consequences such as low self-esteem, strong feelings of shame, and avoidance of social activities. In the DSM-IV-TR, TTM was classified as an impulse control disorder (not classified elsewhere). In the DSM-5, TTM is listed in a new chapter entitled Obsessive Compulsive and Related Disorders and the term “hair pulling disorder” has been added parenthetically to the disorder׳s name. This change in the classification reflects some important similarities between TTM and obsessive-compulsive disorder (OCD).
In OCD, the most prominent function of obsessive-compulsive symptoms is emotion regulation, such as dealing with anxiety, anger, or disgust (Kulz et al., 2010). Similarly, previous research on TTM has demonstrated an emotion regulation function of hair pulling behavior (Diefenbach et al., 2008 and Shusterman et al., 2009). The hair pulling behavior is frequently preceded by an increase of tension followed by relief when pulling out the hair. In addition, situations associated with unpleasant emotions are common triggers for hair pulling. Thus, it has been suggested that TTM can be conceptualized as a maladaptive method of regulating emotions (Shusterman et al., 2009).
Most previous studies have explored emotions that directly accompany hair pulling behavior. To our knowledge, only one study has addressed difficulties in emotion regulation beyond the arc of emotions that accompany hair pulling behavior: An internet survey of 1154 people with hair pulling behavior showed a significant relationship between difficulties in regulating emotions and problematic hair pulling (Shusterman et al., 2009). However, this study had a rather narrow focus on emotions that are typically related to TTM, such as boredom. As far as we know, the question of whether emotion regulation in general is impaired in patients suffering from TTM has never been studied.
One condition that may generally impede the regulation of emotions is alexithymia, which has a prevalence rate of 10% in the German general population (Franz et al., 2008). Alexithymia, which was introduced in the early 1970s (Nemiah, 1977 and Sifneos, 1973), is a personality construct characterized by difficulty in identifying and describing one׳s own feelings, an externally oriented style of thinking, and a restricted imagination (Taylor and Bagby, 2012).
Alexithymia is considered to be an important factor in the maintenance and possible etiology of various psychiatric and psychosomatic conditions such as anxiety and obsessive-compulsive disorders (Rufer et al., 2010 and Rufer et al., 2004), binge eating (Wheeler et al., 2005), functional gastrointestinal disorders (Porcelli et al., 1999), depression (Honkalampi et al., 2007), addictions (de Haan et al., 2012) and schizophrenia (Cedro et al., 2001). Due to their deficits, high-alexithymic individuals have difficulties in tolerating and regulating emotional arousal (Chen et al., 2011 and Majohr et al., 2011). Theoretically, alexithymic deficits may impede coping with aversive affective states in some people with TTM, and hair pulling may serve a function of the regulating of emotional arousal. However, to our knowledge, no previous study has examined alexithymia in TTM.
The present study aimed therefore to explore the relationship between alexithymic features and hair pulling behavior in individuals with TTM. The hypothesis was that the degree of alexithymic deficits would positively correlate with the severity of hair-pulling, independent of potentially confounding factors such as depression.
