Emotion regulation in trichotillomania (hair-pulling disorder): the role of stress and trauma

Demetriou, Salome (2019-04)

Thesis (MA)--Stellenbosch University, 2019.

Thesis

Introduction: Trichotillomania (hair-pulling disorder, or TTM) is characterized by pathological hair-pulling, repeated unsuccessful attempts to stop the behaviour, and significant distress. Various affective states (e.g. tension, stress or pleasure) occur before, during or after hair-pulling, and difficulties in regulating these have been noted in TTM. When applied to TTM, the emotion regulation (ER) model is based on the argument that pulling serves to regulate emotions. However, this appears to be an arduous relationship. For example, stress may increase hair-pulling as a way to assuage feelings of extreme anxiety and depression, whereas hair-pulling and its sequelae may also increase stress levels. There is also evidence to suggest significantly greater severity of childhood trauma in individuals with TTM compared to controls. However, the relationship between stress, childhood trauma and ER in TTM is not yet known. This study aimed to address this gap in our knowledge, by firstly comparing the rates of these variables in TTM with matched healthy controls. A second aim was to investigate whether there was a relationship between hair-pulling severity and difficulties in ER. A third aim was to investigate whether there was a relationship between stress, childhood trauma, and ER difficulties in TTM, while controlling for the presence of mood and anxiety disorders. Methods: The majority of the data included in the study formed part of a larger ongoing study. Fifty-six adults with TTM and 31 sex- and age-matched controls were included. Participants in this study completed a battery of questionnaires, which included the Perceived Stress Scale (PSS), the Childhood Trauma Questionnaire (CTQ) and the Difficulties in Emotion Regulation Scale (DERS). The data were analysed using the Statistical Package for the Social Sciences (SPSS v. 22). Findings: Stress (p = .03), childhood trauma (p = .03), and difficulties in ER (p < .01) were all significantly increased in TTM patients compared to the healthy controls. Second, there was no statistically significant relationship between hair-pulling severity and difficulties in ER. Last, a combination of stress and childhood trauma explained 28.7% of the variance in ER difficulties in TTM [F (2.51) = 7.00, p < .01). However, stress was the only variable that significantly correlated with difficulties in ER in TTM (ß= .47, p < 0.001). Conclusion: As one of the first studies to explore ER in TTM in-depth, the study findings suggested significantly increased stress, childhood trauma, and difficulties in ER in individuals with TTM. While individuals with TTM had greater difficulty in regulating their emotions compared to healthy controls, the data showed no significant relationship between TTM severity and ER difficulties. In keeping with the ER model, one would expect that increased pulling could be used as an attempt to regulate emotions – however this data did not support this hypothesis. Rather, increased stress in TTM individuals significantly explained difficulties in ER. It may be argued that stress and difficulties in ER seem to be more closely related than hair-pulling and difficulties in ER. This suggests that the ER model may not be the best model to explain the phenomenon of pathological hair-pulling. Further research into the underlying mechanisms and dynamics of stress, trauma and ER in TTM may assist in finding a more appropriate explanatory model. In the clinic, emphasis should be placed on the assessment of difficulties in ER in patients with TTM and on addressing modifiable features (such as stress) associated with such difficulties, in addition to reducing hair-pulling.

Inleiding: Trigotillomanie (haaruittreksteuring, of TTM) word gekenmerk deur patologiese uittrek van hare, herhaaldelike onsuksesvolle pogings om die gedrag te stop, en beduidende distres. Verskeie emosies (bv. spanning, stres of plesier) kom vooraf, gedurende of na afloop van haaruittrekkery voor, en probleme met die regulering van hierdie emosies is tipies in TTM. Die model van emosieregulering (ER) bied in die geval van toepassing op TTM die argument dat haaruittrekkery daarop gemik is om emosies te reguleer. Dit blyk egter ’n komplekse verhouding te wees: stres kan byvoorbeeld haaruittrekkery wat daarop gemik is om erge angs en depressie te verminder, vererger, terwyl haaruittrekkery en die gevolge daarvan stresvlakke kan verhoog. Daar is ook bewyse dat daar beduidend meer kindertydtrauma by individue met TTM voorkom vergeleke met kontrolegroepe. Die presiese verband tussen huidige stresvlakke, kindertydtrauma en ER in patologiese haaruittrekkery is egter nog onbekend. Hierdie studie het ten doel gehad om hierdie kennisgaping aan te spreek kindertydtrauma, die stres wat die individu ervaar en ER-probleme tussen pasiënte met TTM en gesonde kontrolepersone (GK) te vergelyk. ’n Tweede doelwit was om uit te vind of daar ’n verhouding tussen die graad van haaruittrekkery en ER-probleme is. ’n Finale doelwit was om die verband tussen die stres wat die persoon ervaar, kindertydtrauma en ER-probleme te meet terwyl daar statisties vir die teenwoordigheid van komorbiede gemoeds- en angssteurings oor die leeftyd beheer word. Metode: Die meerderheid van die data wat in die analise ingesluit is, het deel uitgemaak van ʼn groter langertermyn- studie. 56 volwassenes met TTM en 31 kontrolepersone van dieselfde geslag en ouderdomsgroep is by die studie ingesluit. Die deelnemers aan hierdie studie het ’n battery vraelyste voltooi, insluitend die Perceived Stress Scale (PSS), die Childhood Trauma Questionnaire (CTQ) en die Difficulties in Emotion Regulation Scale (DERS). Die data is met behulp van die Statistical Package for the Social Sciences (SPSS weergawe 22) ontleed. Bevindinge: Kindertydtrauma (p = .03), die ervaring van stres (p = .03) en ERprobleme (p < .01) was beduidend meer in TTM-pasiënte vergeleke met die GK’s. Daar was geen beduidende verhouding tussen die graad van haaruittrekkery en die vlak van ER-probleme nie. Laastens het ’n kombinasie van kindertydtrauma en die ervaring van stres 28.7% van die variansie in ER-probleme in TTM [F (2.51) = 7.00, p < .01) verklaar. Die huidige stresvlakke was die enigste veranderlike wat beduidend met ER-probleme in TTM gekorreleer het (ß = .47, p < 0.001). Gevolgtrekkings: Hierdie is een van die eerste studies wat ER in TTM in diepte ondersoek. Die bevindinge toon verhoogde kindertydtrauma, huidige stres en ER-probleme by individue met TTM in vergelyking met GK’s. Daar was nie ’n beduidende verband tussen die erns van haaruittrekkery en ER-probleme nie. Volgens die ER-model sou daar die verwagting wees dat verhoogde uittrekkery sou gebruik kon word as ‘n poging om emosies te reguleer – hierdie data het egter nie hierdie hipotese bevestig nie. Gegewe hierdie bevinding en die meegaande bevinding wat daarop dui dat huidige stresvlakke die enigste veranderlike is wat beduidend met ER-probleme in TTM gekorreleer het, kan daar aangevoer word dat daar ʼn sterker verband tussen huidige stres en ER-probleme is as tussen haaruittrekkery en ERprobleme. Dit suggereer dat die ER-model dalk nie die mees gepaste model is om die verskynsel van patologiese haaruittrekkey te verklaar nie. Verdere navorsing oor die onderliggende meganismes en dinamika van ER in TTM en oor die verband tussen haaruittrekkery, kindertydtrauma en huidige stres kan ons help om ʼn meer gepaste model te vind. In praktyk behoort daar gefokus te word op die assessering van ER-probleme by pasiënte met TTM, die hantering van veranderbare korrelate van ER-probleme (soos huidige stresvlakke), en die vermindering van haaruittrekkery.

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