Hair Pulling Behavior Reported by African American ... - Springer Link

P1: GXB/GVG Journal of Psychopathology and Behavioral Assessment (JOBA)

pp541-joba-376684

June 25, 2002

13:57

Style file version June 25th, 2002

C 2002) Journal of Psychopathology and Behavioral Assessment, Vol. 24, No. 3, September 2002 (°

Hair Pulling Behavior Reported by African American and Non-African American College Students Nancy G. McCarley,1,2 Charles L. Spirrison,1 and Jennifer L. Ceminsky1

Of the few attempts to determine the prevalence rate of trichotillomania, virtually none have investigated potential ethnic differences. The present study provides data on the prevalence of hair twirling and hair pulling behavior among 176 African American and 422 non-African American students and systematically explores differences between these 2 groups. Fully 10.2% of the sample reported hair pulling that resulted in noticeable hair loss, with African American women reporting the highest rate (15.7%). Overall, 2% of participants responded consistently with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) criteria for trichotillomania; rates did not differ significantly among genders or ethnic backgrounds. African Americans, and especially African American women, were more likely than other participants to report hair pulling in response to skin irritation. Results are discussed in the context of previous research, the importance of hair care in the African American community, and directions for future research. KEY WORDS: African American; DSM; hair pulling; prevalence; trichotillomania.

that “. . . best estimates suggest that trichotillomania is roughly as common as schizophrenia (about 1%) in the general population” (p. 304). Although prevalence rates for trichotillomania in the general population are lacking, a few studies have reported rates for college student samples. In the first such study, Christenson, Pyle, and Mitchell (1991) found that 3.4% of women and 1.5% of men reported hair pulling that resulted in visible hair loss and 0.6% of both women and men met the full diagnostic criteria for trichotillomania. Rothbaum, Shaw, Morris, and Ninan (1993) investigated the prevalence of hair pulling behavior in two separate college student samples and found that 10 and 13%, respectively, of students reported that they recurrently pulled out their hair and 1–2% of surveyed students reported resulting baldness or bald patches. Of students who selfreported hair pulling, 31 and 41% were men (Rothbaum et al., 1993). Christenson et al. (1991) and Rothbaum et al. (1993) provided an important contribution to the understanding of trichotillomania by illustrating that hair pulling was both generally more common and, in particular, more common among men than was previously believed. The purpose of the present study is to provide a preliminary report of the rates of hair pulling behavior in a

Trichotillomania is classified as an impulse control disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSM-IV-TR; American Psychiatric Association, 2000). DSM-IV-TR (2000) criteria for a diagnosis of trichotillomania includes (a) recurrent hair pulling that results in noticeable hair loss; (b) building tension experienced prior to pulling hair or attempting to resist pulling; (c) pleasure or relief associated with pulling; (d) determination that hair pulling is not the result of another mental disorder or general medication condition; and (e) the behavior causes significant distress or impairment in functioning. Due to the lack of epidemiological research on trichotillomania in the general population, prevalence rates for the disorder remain speculative. Extrapolating from estimates on the prevalence of nail biting, Azrin and Nunn (1978) estimated that 10% of the general population has engaged in hair pulling at some point and that 4% currently evidences such behavior. In their review of research on trichotillomania, Diefenbach, Reitman, and Williamson (2000) conclude 1 Mississippi

State University, Starkville, Mississippi. whom correspondence should be addressed at Department of Psychology, P.O. Drawer 6161, Mississippi State University, Starkville, Mississippi 39762-6161; e-mail: [email protected].

2 To

139 C 2002 Plenum Publishing Corporation 0882-2689/02/0900-0139/0 °


pp541-joba-376684

June 25, 2002

13:57

140 college student sample that includes a meaningful proportion of African Americans. So far as we are aware, the present study is the first to examine the prevalence of hair pulling behaviors among African Americans as well as the first to contrast the hair pulling behavior of African Americans with that of non-African Americans. Consistent with the literatures on many other forms of aberrant behavior, research on the prevalence of trichotillomania has not meaningfully addressed African Americans. For example, of the students surveyed by Christenson et al. (1991), 97.1% were described as White and 0.3% as Black (Native Americans comprised 0.5% and other, 2.1%). Rothbaum et al. (1993) did not detail the ethnic backgrounds of their participants. So far, only one study of which we are aware has investigated hair pulling behavior among African Americans (Neal-Barnett, Ward-Brown, Mitchell, & Krownapple, 2000). Citing the special importance of hair within the African American community and the economic and social implications of good (naturally wavy or straight) and bad (tightly curled hair that would require heat or chemical treatment to become straight) hair, Neal-Barnett et al. (2000) interviewed cosmetologists, barbers, and braiders with African American clientele on their clients’ hair pulling behavior. Twenty-nine (74%) of the 39 hair care professionals stated that they had regular customers who were missing facial (beard, eyebrows, eyelashes, or mustache) and/or scalp hair. Of the clients regularly seen by these 29 hair care professionals, about 1% were identified by the hair care professionals as having noticeable and persistent facial or scalp hair loss secondary to chronic hair pulling. All clients identified as chronic hair pullers were women. Another 1.7% of the clients exhibited hair loss that was assumed to be caused by other factors (e.g., chemical overprocessing, 0.5%; male pattern baldness, 0.3%; nerves, stress, and trauma, 0.3%; and tension from tight braids or ponytails, 0.1%). It should be noted that Neal-Barnett et al. (2000) designed their study to document the existence, but not prevalence, of trichotillomania among African Americans and to explore hair care professionals’ perceptions of and interventions for chronic hair pulling. The data indicate that pathologic hair pulling is found among African Americans. For a variety of reasons, it would be inappropriate to assume that their data would be sensitive to the rate of trichotillomania. For example, trichotillomania may involve the pulling of hair that is not located on the face or scalp. Also, male hair loss secondary to hair pulling often can be easily disguised (e.g., through shaving facial and scalp hair) or misinterpreted as male pattern baldness. In the present attempt to replicate previous survey research on the prevalence of pathological hair pulling,


McCarley, Spirrison, and Ceminsky we included a critical mass of African Americans in our college student sample. METHOD The participants were 635 undergraduate students (384 women, 251 men; M age = 19.54 years, SD = 3.08) who were enrolled in introductory psychology sections. Most of the participants were Caucasian (250 women, 192 men) or African American (121 women, 55 men), although 10 women and 3 men specified other racial backgrounds (Hispanic, n = 6; Asian American, n = 2; Hispanic/Caucasian, n = 2; African/Asian American, n = 1, African/Hispanic American, n = 1; African/ Caucasian American, n = 1). Three women and one man provided no response. Extra credit was offered for their participation. In a large classroom setting, participants completed a questionnaire that addressed demographics, a range of potentially impulsive and/or compulsive behaviors (e.g., binge drinking and eating, nail biting, body rocking) and history of psychological treatment. The questionnaire was a modified and condensed version of an inventory originally used by Wilhelm et al. (1999). Six questions concerned hair-related behavior. The first asked participants if they engaged in hair twirling. The remaining five questions addressed hair pulling: (1) Have you ever pulled out your hair (scalp, facial, pubic, other) so that there was noticeable loss, such as bare patches or thin hair? (2) Do you feel a sense of tension or nervousness building up before you pull the hair? (3) Do you feel a sense of pleasure or relief during or after you have pulled? (4) Did you pull the hair because your skin was inflamed or itchy due to a medical condition? (5) Have you heard voices that tell you to pull your hair? RESULTS Table I presents a summary of the college students’ responses to six hair-related questions. Chi-square statistics were conducted to clarify group differences. Women were more likely to report hair twirling behavior than men, 65.6% vs. 20.3%; χ 2 (1, N = 634) = 124.122, p > .001. Rates of hair twirling did not differ significantly between African American and non-African American participants, 50.3% vs. 46.8%; χ 2 (1, N = 634) = 0.603, p = .438. Women were more likely to report hair pulling with noticeable hair loss than were men, 13.3% vs. 5.6%; χ 2 (1, N = 635) = 9.803, p = .002. The rate of such hair pulling did not differ between African American and non-African American participants, 12.5% vs. 9.4%;


pp541-joba-376684

June 25, 2002

13:57


Hair Pulling Behavior

141 Table I. Hair Twirling and Pulling Behavior Among 635 College Students Incidence of hair twirling

Group

Hair pulling with noticeable hair loss

Tension builds before hair pulling

Pleasure/relief with hair pulling

Hair pulling due to itch/inflammation

Voices direct hair pulling

N

n

%

n

%

n

%

n

%

n

%

n

%

Gender Women Men

384 251

252 51

65.6 20.3

51 14

13.3 5.6

27 9

7.0 3.6

36 14

9.4 5.6

14 13

3.6 5.2

3 0

0.8 0.0

Total

635

303

47.7

65

10.2

36

5.7

50

7.9

27

4.3

3

0.5

176 459

88 215

50.3 46.8

22 43

12.5 9.4

14 22

8.0 4.8

21 29

11.9 6.3

14 13

8.0 2.8

3 0

1.7 0.0

121

77

63.6

19

15.7

11

9.1

17

14.0

8

6.6

3

2.5

263

175

66.5

32

12.2

16

6.1

19

7.2

6

2.3

0

0.0

55

11

20.0

3

5.5

3

5.5

4

7.3

6

10.9

0

0.0

196

40

20.4

11

5.6

6

3.1

10

5.1

7

3.6

0

0.0

Ethnicity African American Non-African American Gender by ethnicity African American women Non-African American women African American men Non-African American men

χ 2 (1, N = 635) = 1.358, p = .244; however, African American women reported a significantly higher rate of hair pulling with noticeable hair loss when compared to all other respondents, 15.7% vs. 9.8%; χ 2 (1, N = 635) = 4.861, p = .027. Neither gender, women, 7.0%, men, 3.6%; χ 2 (1, N = 635) = 3.370, p = .066, nor race, African American, 8.0%, non-African American, 4.8%; χ 2 (1, N = 635) = 2.378, p = .123, were significantly associated with mounting tension or nervousness prior to hair pulling. Overall, female and male participants did not report significantly different rates of reported pleasure or relief during or after hair pulling, 9.4% vs. 5.6%; χ 2 (1, N = 635) = 3.017, p = .082. However, African Americans, especially African American women, reported higher rates of pleasure or relief associated with hair pulling as compared to remaining participants, African American, 11.9%, non-African American, 6.3%; χ 2 (1, N = 635) = 5.527, p = .019; African American women, 14.0%, all other participants, 5.1%; χ 2 (1, N = 635) = 7.859, p = .005. African Americans reported a higher rate of hair pulling secondary to inflamed or itchy skin than the nonAfrican American participants, 8.6% vs. 2.9%; χ 2 (1, N = 634) = 8.162, p = .004. There was no statistically significant difference in the rates of hair pulling due to itch or inflammation reported by the female and male participants in this study, women, 3.6%, men, 5.2%; χ 2 (1, N = 634) = 0.864, p = .353.

Three participants, each an African American woman, reported that voices told them to pull their hair. This resulted in the African American women in this study having a significantly higher rate of citing voices than the study’s other participants, 0.8% vs. 0.0%; χ 2 (1, N = 635) = 12.804, p < .001. Another series of chi-square analyses considered hair pulling behavior (with noticeable hair loss) that was not attributable to itchy or inflamed skin. Women were more likely to report noticeable hair loss without inflamed or itchy skin than were men, 11.5% vs. 4.0%; χ 2 (1, N = 634) = 10.958, p = .001. African Americans did not differ from non-African Americans with respect to reported rate of hair pulling not associated with itch or inflammation, African American, 9.1%, non-African American, 8.3%; χ 2 (1, N = 634) = 0.103, p = .748. Reports of hair loss due to pulling hair from itchy or inflamed skin did not differ between women and men, 1.8% vs. 1.6%; χ 2 (1, N = 634) = 0.049, p = .825. However, African Americans, and especially African American women, reported higher rates of noticeable hair loss secondary to hair pulling from inflamed or itchy skin than did other participants, African American, 3.4%, nonAfrican American, 1.1%; χ 2 (1, N = 634) = 4.005, p = .045; African American women, 4.1%, all other participants, 1.2%; χ 2 (1, N = 634) = 5.040, p = .025. Applying all of the available criteria from the survey simultaneously (i.e., noticeable hair loss, with tension building before hair pulling and pleasure/relief during or


pp541-joba-376684

June 25, 2002

13:57


142 after the pulling, without a medical condition and without hearing voices), 2.0% of the participants responded consistent with DSM-IV-TR (2000) criteria for trichotillomania.3 Rates did not differ significantly between genders, women, 2.9%, men, 0.8%; χ 2 (1, N = 635) = 3.236, p = .072, or between African American (2.8%) and nonAfrican American (1.8%) participants, χ 2 (1, N = 635) = 0.765, p = .382. Finally, 86 of the 635 participants indicated that they were currently receiving or had received psychotherapy. Of the 13 participants whose responses were consistent with DSM-IV-TR (2000) criteria for trichotillomania, 30.8% (n = 4)4 reported experience with psychotherapy as compared to 13.2% (82 of the 620) of the remaining participants. This difference in rates of reported experience with psychotherapy was not statistically significant, χ 2 (1, N = 633) = 3.338, p = .086. Reported experience with psychotherapy also was not statistically related to ethnicity; 10.3% (18 of 175) of African Americans and 14.8% (68 of 458) of non-African Americans reported experience with psychotherapy, χ 2 (1, N = 633) = 2.244, p = .154. Indeed, of the variables addressed in the current study, only gender and rising tension before hair pulling shared significant variance with reported experience with psychotherapy, women, 16.4%, men, 9.2%; χ 2 (1, N = 635) = 6.771, p = .009; rising tension reported, 25%, rising tension denied, 12.9%; χ 2 (1, N = 635) = 4.236, p = .040. DISCUSSION In the present study, we gathered data from a nonclinical sample to investigate potential differences between the hair pulling behaviors of African Americans and non-African Americans. We observed a variety of significant differences in the hair pulling behavior reported by women and men, and African Americans and non-African Americans. Some aspects of the responses of African American women were particularly noteworthy. The current results are also interesting when compared with previous survey research on trichotillomania in college student samples (Christenson et al., 1991; Rothbaum et al., 1993). 3 Of

the 13 participants who provided responses consistent with DSMIV-TR (2000) criteria for trichotillomania, 4 were African American women, 1 was an African American man, 7 were non-African American women, and 1 was a non-African American man. 4 Of the 4 participants who provided responses consistent with DSM-IVTR (2000) criteria and who also reported experience with psychotherapy, 1 was an African American woman, 2 were non-African American women, and 1 was a non-African American man.

McCarley, Spirrison, and Ceminsky General Findings In our data, 10.2% of the participants (13.3% of women and 5.6% of men) responded affirmatively to the question “Have you ever pulled out your hair (scalp, facial, pubic, other) so that there was noticeable loss, such as bare patches or thin hair?” Although the ratio of male to female hair pullers (i.e., 1:2.38) in our study is generally consistent with those of previous studies, the overall rate of endorsement (i.e., 10.2%) is strikingly higher than the 1–3.4% range indicated by Christenson et al. (1991) and Rothbaum et al. (1993). It is unclear why our reported rate of hair pulling with noticeable hair loss is so much greater. Our question is essentially identical to that used by Christenson et al. (1991, p. 415): “Have you ever pulled out your eyelash, eyebrow, scalp, pubic or other body hair to the point that it resulted in noticeable hair loss?” Christenson surveyed midwestern college students; Rothbaum collected data at two large southern universities. Perhaps differences in the rates reported here are attributable to demographic differences among the samples or to the approximately 10 years that separate the collection of data. Is a rate of 10.2% too high to be credible? This question is difficult to answer directly although similar rates of self-inflicted injury have been reported within the college student population. In their survey concerning selfmutilation, Favazza, DeRosear, and Conterio (1989) found that 12% of undergraduates indicated they had burned, carved, or cut themselves deliberately on at least one occasion. In our data, 2% of participants simultaneously admitted (1) noticeable hair loss secondary to hair pulling, (2) a sense of tension or nervousness building prior to hair pulling, (3) pleasure or relief during or after pulling hair, while they denied (4) pulling their hair due to inflamed or itchy skin, and (5) hearing voices that tell one to pull one’s hair. Thus 2% of our participants provided responses that were consistent with DSM-IV-TR (2000) criteria for trichotillomania. Our 2% figure is similar to the 0.6% reported by Christenson et al. (1991), and may have been closer still had we queried our participants as to whether their hair pulling behavior caused them significant distress or impairment in functioning. Interestingly, and consistent with Christenson, we found no gender differences with respect to concordance with trichotillomania criteria. We also found that African Americans and non-African Americans in our sample did not differ in providing responses consistent with diagnostic criteria for trichotillomania.


pp541-joba-376684

June 25, 2002

13:57


Hair Pulling Behavior Ethnic Differences Given the special cultural importance of hair within the African American community as well as the dearth of research addressing trichotillomania among African Americans, we were especially interested in investigating the hair pulling behavior of African American college students. In essence, we found that the African American respondents to our survey were no more likely to meet DSM-IV-TR (2000) criteria for trichotillomania than nonAfrican Americans, but that itchy and inflamed skin apparently plays a greater role in the hair pulling behavior of African Americans. Relative to non-African Americans, the African American participants exhibited a higher rate of hair pulling in response to itchy or inflamed skin. More African Americans, and especially the female African American respondents, reported pleasure or relief as a result of hair pulling as well as higher rates of noticeable hair loss due to pulling hair from itchy or inflamed skin. By contrast, the rate of hair pulling not attributed to itch or inflammation did not differ between African Americans and non-African Americans. Other forms of hair-related behaviors that do not involve itching or inflammation (i.e., hair twirling and building tension or nervousness before hair pulling) also did not differ between African Americans and non-African Americans in our sample. It should be noted that African American women spend an average of $532 per year or 41% more on personal-care services (e.g., hair care products, manicures, massages) than non-African American women; African American men spend $212 per year or 24% more than non-African American men (Fisher, 1996). Half of the 40% of African American women who color their hair do so themselves, without the assistance of a hair care professional (“African Pride,” 2000). One might assume that the commonly used chemical, heat, and braiding treatments place African Americans, and especially African American women, at greater risk of scalp irritation. Indeed, of all of our participants, African American women reported the highest rate of noticeable hair loss associated with hair pulling. We speculate that our African American participants were more likely to engage in itch-related hair pulling because they experienced more scalp irritation than non-African American participants. Put another way, we posit that the African American participants pulled more because they itched more. Our findings suggest that a substantial amount of hair pulling among African Americans is due to scalp irritation rather than to trichotillomania or some other impulse control disorder. In any event, the current findings

143 suggest that the appropriate assessment of hair pulling behavior within diverse populations should consider the motivational factors that mediate this behavior. Limitations and Suggestions for Future Research The present study is a preliminary attempt to explore hair pulling behavior among African Americans. Two limitations of the study concern the use of survey methodology and the representativeness of the sample. First, although our use of anonymous self-report responses to a questionnaire is consistent with previous research (e.g., Christenson et al., 1991; Rothbaum et al., 1993), this method is imperfect. For example, clinical interviews and physical inspection of hair pulling areas may have provided more authoritative data. Second, our sample was gathered from a state land grant university that enrolls approximately 16,000 students and which is located in a rural area of a southeastern state. The current sample is not representative of the general population, the national college student population, nor of African Americans in the general or college student populations. Thus it is uncertain the extent to which the endorsement rates in our data generalize beyond our sample. Nevertheless, our results add interesting data to the small but growing literature on trichotillomania. It would be instructive for future studies to include, for example, questions covering such details as specific hair care products used, descriptions of hair styles, and how often hair is treated or colored. Certainly future studies will ask participants whether hair pulling behavior causes significant distress or impairment in functioning. Future studies should investigate ethnic differences in the frequency of scalp irritation and itchiness as well as differential reactions to these sensations (e.g., Do African Americans experience more scalp itch and irritation than non-African Americans? Are African Americans more likely to pull rather than scratch in response to scalp irritation? Is pulling hair from, rather than scratching, an irritated scalp more adaptive given that scratched skin is particularly sensitive to subsequent chemical treatments?). It might also be helpful to compare ethnic differences in rates of hair pulling from the scalp to rates of hair pulling from other areas (e.g., eyebrows, arms, legs, pubic hair). In our data, three African American women reported hearing voices telling them to pull their hair. We assume that this finding was an anomaly; however, future research may elaborate on the role of command hallucinations in hair pulling behavior. Although not the focus of the present study, we collected limited data on history of psychological treatment


pp541-joba-376684

June 25, 2002

144 and found that of the six hair-related behaviors surveyed, only reports of rising tension prior to hair pulling were significantly associated with experience with psychotherapy. Christensen et al. (1991) noted that compared to nonhair pullers, hair pullers more often reported treatment for depression, emotional problems, and drug problems. Future research might consider whether it is the preceding anxiety rather than hair pulling per se that is most predictive of comorbidity. ACKNOWLEDGMENTS The authors are grateful to Catherine Croft, Cynthia Harris, Keli Holloway, Brittny Mathies, Robin Mitchell, Annemarie Pimental, and Joel Tucker for their assistance with data entry. REFERENCES African Pride HiLites wins national retail award. (2000, December 6). New York Voice, 42(33), p. 23.

13:57


McCarley, Spirrison, and Ceminsky American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. Azrin, N. H., & Nunn, R. G. (1978). Habit reversal in a day. Simon & Schuster: New York. Christenson, G. A., Pyle, R. L., & Mitchell, J. E. (1991). Estimated lifetime prevalence of trichotillomania in college students. Journal of Clinical Psychiatry, 52, 415–417. Diefenbach, G. J., Reitman, D., & Williamson, D. A. (2000). Trichotillomania: A challenge to research and practice. Clinical Psychology Review, 20, 289–309. Favazza, A., DeRosear, L., & Conterio, K. (1989). Self-mutilation and eating disorders. Suicide and Life-Threatening Behavior, 19, 352– 361. Fisher, C. (1996). Black, hip and primed (to shop). American Demographics, 18(9), 52–58. Neal-Barnett, A. M., Ward-Brown, B. J., Mitchell, M., & Krownapple, M. (2000). Hair-pulling in African Americans— Only your hairdresser knows for sure: An exploratory study. Cultural Diversity and Ethnic Minority Psychology, 6, 352– 362. Rothbaum, B. O., Shaw, L., Morris, R., & Ninan, P. T. (1993). Prevalence of trichotillomania in a college freshman population. Journal of Clinical Psychiatry, 54, 72. Wilhelm, S., Keuthen, N. J., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., et al. (1999). Self-injurious skin picking: Clinical characteristics and comorbidity. Journal of Clinical Psychiatry, 60, 454–459.