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13 The self in the obsessive–compulsive-related disorders: hoarding disorder, body dysmorphic disorder, and trichotillomania
The most recent DSM saw a reclassification of obsessive–compulsive disorder (OCD) as the prototypical disorder within a separate grouping that also includes hoarding disorder, body dysmorphic disorder (BDD), trichotillomania (TTM; hair pulling disorder), and skin-picking disorder (American Psychiatric Association [APA], 2013). This followed a long-standing debate over whether there is a spectrum of disorders sharing etiological underpinnings or phenomenology with OCD (Abramowitz, McKay, & Taylor, 2011; Moulding, Nedeljkovic, & Kyrios, 2011). While much research has highlighted the role of self in the symptomatology and treatment of OCD per se (see Ahern & Kyrios, Chapter 12 in this volume; Aardema et al., 2013; Bhar & Kyrios, 2007; Doron, Moulding, Kyrios, & Nedeljkovic, 2008; Moulding, Aardema, & O’Connor, 2014), less has considered the role of self in the OCD spectrum. This chapter aims to address this gap – specifically with reference to hoarding disorder, BDD, and TTM.
Hoarding disorder
In hoarding disorder, the individual accumulates a large amount of possessions due to psychological difficulty in discarding them, regardless of the value that others apply to these possessions (APA, 2013). Individuals typically hoard the same kinds of items as are collected by individuals without hoarding, albeit more of them, but they also often collect idiosyncratic items that they find of particular interest or importance (Mogan, Kyrios, Schweitzer, Yap, & Moulding, 2012). Concepts related to self-concept often saturate therapeutic conversations with individuals who hoard – it has been suggested that this reflects a “fusion” between identity and possessions, which itself is a normative process. For example, Steketee and Frost (2010) note that people seem to value possessions more if they are connected to a celebrity (e.g., Jerry Seinfeld’s pirate shirt), as if the laws of sympathetic contagion apply to objects and identity (i.e., where objects become similar through touching each other). Such notions are not new – in 1890 William James stated that “… it is clear that between what a man calls me and what he simply calls mine the line is difficult to draw … a man’s Self is the sum-total of all that he can call his …” (p. 291). Belk (1988) discusses such notions in terms of the “extended self,” whereby objects partially form part of, and determine, one’s identity. Belk suggests that the extended self comprises not just the body and internal processes, but also the person’s ideas and experiences, and the persons, places, and things to which they feel attached; albeit that the self also is hierarchically composed such that some possessions are more central to self.
Steketee and Frost (2010) suggest that the same issues apply to hoarding, as when discussing their client “Irene,” whose possessions “… connected her to something bigger than herself. They gave her an expanded identity, a more meaningful life. It wasn’t the objects themselves that she valued, but the connections they symbolised” (p. 45). The efforts of individuals with hoarding to “rehouse” their possessions to a good (and known) home, and acquiring objects to give to others, can be seen as an extension of this idea. Belk (1988) discusses Sartre’s notion that such gift-giving is part of the process of self-expansion – “A gift continues to be associated with the giver so that the giver’s identity is extended to include the recipient” (p. 151). This dovetails with our own observations of individuals with hoarding who keep relationships alive (in a symbolic sense) through buying gifts for friends and relatives; while sometimes these are active relationships, at other times these relationships are estranged or fractured and the individual may not have seen the potential recipient for many years.
This emotional attachment to objects, as an extension of self and social identity, is a key cognition within Steketee and Frost’s influential hoarding model (Kyrios, 2014; Steketee & Frost, 2007; Steketee, Frost, & Kyrios, 2003). Endorsement of items comprising this subscale in Steketee et al.’s Savings Cognitions Inventory, such as “Throwing away this possession is like throwing away a part of me,” and “Losing this possession is like losing a friend” relate to higher hoarding symptoms in both non-clinical and clinical samples (Kyrios, Mogan, Moulding, Frost, & Yap, in preparation; Steketee et al., 2003). Similarly, through a qualitative study, Kellett, Greenhalgh, Beail, and Ridgway (2010) identified individuals’ relationships with hoarded items as a key theme – with emotional relationships characterized by anthropomorphizing of objects and a sense of object–person fusion. For example, one participant reported acquiring an object because “I think that that thing will be really lonely left on the shelf” (p. 146), while another reported that “The person that has all this stuff, it’s theirs, it’s a part of them, even ridiculous year old newspapers” (p. 146). Non-clinical studies have related the tendency to anthropomorphize to hoarding behaviors (Neave, Jackson, Saxton, & Hönekopp, 2015; Timpano & Shaw, 2013). Anthorpomorphizing (at least with regard to non-human agents) has generally been linked to an unfulfilled desire for human connection (Epley, Waytz, & Cacioppo, 2007), which may be a factor in some individuals who hoard who have disrupted family or social relationships or a traumatic social history.
Such “self”-involvement in stuff is likely exacerbated by other beliefs in individuals who hoard. Perceived or real deficits in memory are common in hoarding, along with a need to have possessions “in view,” and character traits of extreme perfectionism (Steketee & Frost, 2003, 2007). Such factors are likely to contribute to the need in hoarding to maintain objects as “reminders” or diaries of experience (indeed, individuals often seem to “hoard” their experiences in the same way as their objects). If the objects are part of the extended self as suggested by Belk (1988), then they also help maintain one’s identity over time, which is perceived as necessary if one doubts one’s memory. At the other extreme, clinical experience suggests that to individuals who hoard, objects also seem to represent possible future selves – whom one might become, what one might do, opportunities one has. Therapeutic discussions commonly include letting possible selves go, or even “die,” when discarding the related items (e.g., to let go of crochet needles is to let go of the improved future self that has learnt to crochet).
However, such a discussion prompts the question as to why individuals feel such an excessive need to focus on their extended self as manifested through objects. Unfortunately, few studies have directly examined self-concept in hoarding as an underlying dimension. Building on work in OCD, Frost, Kyrios, McCarthy, and Matthews (2007) suggested that there may be an underlying difficulty with self-concept in hoarding, in the form of an ambivalent self-concept characterized by a preoccupation with a dichotomous and reactive self (i.e., self as both good and bad). Related work on compulsive buying (which is distinguished by the lack of value given to possessions once acquired) has drawn on the idea of material possessions substituting for an underlying negative self-view (Dittmar, 2005; Kyrios, Frost, & Steketee, 2004). Alternatively, when considering that individuals with hoarding also often use terms such as “building a cocoon,” “nesting,” and “building a wall” (see Steketee & Frost, 2010), there is the idea that to these individuals, their “stuff” represents safety or a “secure base” (see attachment theory; Bowlby, 1988; Mikulincer and Doron, Chapter 3 in this volume). Such ideas regarding objects imply a self-concept characterized by vulnerability associated with insecure attachment relationships (see Mikulincer & Doron, this volume) and perceptions of the world as a dangerous place (this is also consistent with high levels of comorbid generalized anxiety disorder in hoarding; e.g., Moulding, Nedeljkovic, Kyrios, Osbourne, & Mogan, in preparation). Steketee and Frost (2010) reported that after a stressful day, “Irene” spoke of wanting to go home in order to “gather my treasures around me.” This notion is not surprising, given the background of trauma that is highly prominent in many – but not all – individuals with hoarding (Cromer, Schmidt, & Murphy, 2007; Hartl, Duffany, Allen, Steketee, & Frost, 2005). In their qualitative study, Kellett et al. (2010) similarly report childhood factors as a key theme, for example, “Well as a kid I had a cupboard full of toys and that was where I retreated from the hostile world …” (p. 145). More generally, a study linking anxious attachment with materialism was taken to suggest that relationships with objects can sometimes serve as a substitute for relationships with people when the individual finds it hard to form such relationships (Norris, Lambert, DeWall, & Fincham, 2012). These speculations suggest that further research on the function of the wider attachment construct in hoarding may be useful (cf. Kellett et al., 2010; Kellett & Holden, 2013).
Finally, and somewhat orthogonally, notions of self-regulation are also prominent in hoarding. Individuals with hoarding commonly experience comorbid attention deficit hyperactivity disorder, implying difficulties with goal-setting that are reflected in their problems in organization and carrying through with discarding tasks (cf. Lynch, McGillivray, Moulding, & Byrne, 2015). Examining this notion, Timpano and Schmidt (2013) found that (a) questionnaire-based self-control deficits were associated with hoarding symptoms in a non-clinical sample; (b) such deficits were similarly pronounced in hoarding vs. samples with OCD, GAD or SAD; and (c) that experimental tasks in non-clinical participants designed to deplete self-regulation resources resulted in fewer objects discarded. Conversely, individuals with hoarding often acquire impulsively, although such deficits seem particularly pronounced when the individual is experiencing emotions, particularly negative emotions. Hoarding tendencies are strongly linked to anxiety sensitivity and poor distress tolerance (Coles, Frost, Heimberg, & Steketee, 2003; Timpano, Buckner, Richey, Murphy, & Schmidt, 2009; Timpano, Shaw, Cougle, & Fitch, 2014). Hoarding (Phung, Moulding, Taylor, & Nedeljkovic, 2015; Timpano et al., 2013) and compulsive buying tendencies (Alemis & Yap, 2013) have been linked to negative urgency – impulsivity as a way of avoiding or reducing negative emotions.
Turning to treatment implications, the dominant treatment for hoarding is derived from the cognitive-behavioral model of Steketee and Frost (2007; Tolin, Frost, & Steketee, 2007), with the limited available evidence suggesting it is effective (Tolin, Frost, Steketee, & Muroff, 2015). Components of this approach could be conceptualized as influencing self-concept, in particular, the restructuring of beliefs such that items are implicitly or explicitly viewed as things external to the self; this potential is hardly surprising, given the acknowledgment given by Steketee and Frost to self-concept (e.g., Steketee & Frost, 2010). For example, it is suggested to clients that making art is the defining characteristic of an artist, rather than owning art resources.
However, consideration of self-themes may open therapy up to a broader consideration of “how to define self,” to the use of exercises such as activity scheduling, and to values-exercises emphasized within acceptance and commitment therapy (e.g., Zettle, Chapter 6, this volume). Equally, being aware of the “self” implied by items makes the therapist more mindful of the potential difficulties in discarding. After CBT strategies have been introduced, there may be a need for more specific work on self-concept. Given the normalcy of self-concept expanding to comprise one’s “stuff,” it could be said that an issue with hoarding clients is not that they extend the self to include possessions, but the extent to which they do so, the lack of recognition of hierarchies of importance of objects, and the extent to which objects are privileged over other parts of the extended self. Finally, we and others have noted the particular value of group-based work, which seem particularly useful in alleviating the common sense of shame in hoarding (itself reflected in the way individuals with hoarding often “hide” their hoards or refuse visitors) – that the very act of hoarding itself makes one defective – which could work in a vicious cycle if the hoarding is acting partially to alleviate an initial underlying negative self-concept (Moulding et al., submitted; Schmalisch, Bratiotis, & Muroff, 2010).
Body dysmorphic disorder
BDD is characterized by a preoccupation with one or more perceived defects in physical appearance that are not observable or appear slight to others (APA, 2013). The importance of physical appearance is considered an idealized value in BDD – individuals with BDD typically equate their self-worth or sense of self almost exclusively in terms of their physical appearance (Didie, Kuniega-Pietrzak, & Phillips, 2010; Hrabosky et al., 2009; Phillips, Moulding, Kyrios, Nedeljkovic, & Mancuso, 2011; Veale, 2002a). This overvalued ideation, however, reinforces the processing of the self as an aesthetic object (Neziroglu, Khemlani-Patel, & Veale, 2008; Veale, 2004).
The self as an aesthetic object is key to Veale’s cognitive-behavioral model of BDD (Neziroglu et al., 2008; Veale, 2001, 2004; Veale & Neziroglu, 2010). An impression of the self is constructed by an individual with BDD using somatic sensations, thoughts, and feelings about their physical appearance. This impression is usually experienced as visual, negative, recurrent, and viewed from the perspective of an observer (Osman, Cooper, Hackmann, & Veale, 2004). In the absence of a discrete visual image, the individual may instead experience a “felt impression” of the constructed self as a combination of physical sensations, verbal thoughts, and feelings of shame or anxiety (Neziroglu et al., 2008; Veale, 2004). However, this mental image or “felt impression” is distorted and inaccurate (Cooper & Osman, 2007; Veale, 2004).
Due to excessive self-focused attention in non-social situations, the “felt impression” is compared to an internalized appearance ideal (Neziroglu et al., 2008), but there is a marked discrepancy between the two (Veale, Kinderman, Riley, & Lambrou, 2003; Veale & Riley, 2001). As a result, individuals with BDD may experience increased self-consciousness, negative self-judgments about their appearance, and negative emotions including distress, anxiety, internal shame, and depression (Cooper & Osman, 2007; Neziroglu et al., 2008; Osman et al., 2004; Veale, 2002b, 2004; Veale et al., 2003). Distraction, checking behaviors, camouflaging, avoidance, and reassurance-seeking behaviors may then be performed in an attempt to alleviate these emotions (Cooper & Osman, 2007; Neziroglu et al., 2008).
An individual with BDD may also use the “felt impression” to check how they appear or compare to others during social situations (Neziroglu et al., 2008). This self-focused attention has two main consequences. First, feelings of external shame are triggered when the individual rates their appearance as more unattractive than others (Veale, 2002b). Second, attention to the environment is reduced so that an individual is unable to disconfirm fears of negative evaluation (Neziroglu et al., 2008; Veale & Neziroglu, 2010), which may in turn elicit feelings of external shame (Veale, 2002b).
In addition to self-focused attention, self as an aesthetic object contributes to the lack of a self-serving bias in relation to self-judgments of attractiveness (Neziroglu et al., 2008; Veale & Neziroglu, 2010). Individuals with BDD, for example, rate their own facial attractiveness as significantly lower than do independent evaluators (Buhlmann, Etcoff, & Wilhelm, 2008). Veale and Neziroglu (2010) suggest that selective attention to disliked appearance features produces more accurate self-evaluations of such features in persons with BDD. However, the lack of the self-serving bias to compensate or override this increased accuracy results in pronounced negative appraisals of their appearance. It has been suggested that these negative appraisals result in lower self-esteem observed among individuals with BDD (Labuschagne, Castle, Dunai, Kyrios, & Rossell, 2010). In addition to lower self-esteem, Labuschagne et al. found that BDD patients have higher levels of self-ambivalence relative to matched controls (see also Phillips et al., 2011). According to the authors, the high self-ambivalence results in continuous re-evaluation of their self-concept, which would serve to further increase ambivalence. Consistent with psychological theories about the etiology of OCD (see Ahern and Kyrios, Chapter 12 in this volume), sensitivities relating to the self in BDD (e.g., appearance, social rejection) could lead to rituals or neutralizing aimed at “alleviating” underlying negative self-perceptions by avoiding situations or “fixing” perceived appearance-related deficits (Buhlmannn, Teachman, Naumann, Fehlinger, & Rieg, 2009).
While the dominant treatment for BDD is based on cognitive-behavioral interventions (e.g., Veale, 2010; Wilhelm, Phillips, Fama, Greenberg, & Steketee, 2011), these approaches may be ineffective in addressing the problematic overidentification of appearance with the self in BDD (Jarry & Ip, 2005). Neziroglu et al. (2008) suggested that acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) may have potential utility as an intervention for BDD, particularly in relation to experiencing the self from a first-person perspective as well as the idealized value placed on appearance. The central tenet of ACT is that psychological distress and functional impairment are caused by experiential avoidance (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), which occurs when an individual is unwilling to remain in contact with unwanted private events (i.e., thoughts, emotions, memories, and bodily sensations). An ACT approach for BDD would therefore focus on the dysfunctional processes of overinvestment in physical appearance and avoidance by directly targeting psychological inflexibility related to body image; or the capacity to experience the perceptions, sensations, feelings, thoughts, and beliefs about the body fully and intentionally (Sandoz, Wilson, Merwin, & Kellum, 2013).
ACT for BDD commences with the identification of unwanted private events and experiential avoidance strategies, with examination of the effectiveness of these strategies (Hayes et al., 1999). Values clarification is conducted in conjunction with this phase (Hayes et al., 1999). Individuals with BDD may have difficulty in defining and articulating their values (Mancuso, Knoesen, Chamberlain, Cloninger, & Castle, 2009) and may give the impression that they value appearance above all else (Didie et al., 2010; Hrabosky et al., 2009; Neziroglu et al., 2008; Silver, Reavey, & Fineberg, 2010). Merwin and Wilson (2009), however, suggest that core values may be hidden in layers of language for persons who overvalue their appearance. Therefore, values may be identified by asking the individual with BDD why their appearance is important (e.g., “What does looking attractive promise?”), with their answer reflecting valued life directions.
Cognitive defusion, the next phase of an ACT intervention, helps individuals to observe their appearance-related thoughts dispassionately and without attempts to control or change them (Hayes et al., 1999). Mindfulness techniques help the person shift focus from thought-content (e.g., “I am unattractive”) to thought-process (e.g., “I notice I am having the thought that ‘I am unattractive’”; Blackledge, 2007). The final phase of an ACT intervention involves committed action, where the individual commits to pursuing values-consistent behavior instead of engaging in behaviors that interfere with movement towards their values (Fletcher & Hayes, 2005; Hayes et al., 1999). Therefore, a person with BDD may commit to reducing their safety-seeking and avoidance behaviors and increasing their values-consistent behavior (Merwin & Wilson, 2009).
Trichotillomania (hair pulling disorder)
TTM is characterized by the repetitive removal of hair causing hair loss, typically from the scalp, eyebrows, and eyelashes (APA, 2013). Hair can symbolically express one’s social status and conformity to the norms of a social group; gender identity (i.e., femininity/masculinity) and sexuality; racial and cultural identity; and can even be perceived as a reflection of personality traits (Basow & Braman, 1998; Cash, 2001; Hunt & McHale, 2005; Synnott, 1987). As such, it is understandable that hair loss for both men and women has been found to adversely impact upon one’s self-concept, including body image and self-worth (Alfonso, Richter-Appelt, Tosti, Viera, & García, 2005; Cash, 1999; Hilton, Hunt, Emslie, Salinas, & Ziebland, 2008; Münstedt, Manthey, Sachsse, & Vahrson, 1997). When physical appearance is a source of self-esteem, hair loss resulting from androgenic alopecia (i.e., male-/female-pattern baldness) has been found to have a greater negative impact upon one’s psychological well-being (Cash, 2001).
Surprisingly, there is a dearth of research that has investigated the impact of TTM on self-concept, despite most afflicted females having 30%–70% of hair missing from their hairpulling site(s) at any stage of the lifespan (Flessner, Woods, Franklin, Keuthen, & Piacentini, 2009). Individuals with TTM are secretive about their disorder, go to great lengths to hide their hair loss (e.g., with make-up, wigs, clothes), avoid activities that may reveal their hair loss, and are selective about whom they disclose their hairpulling to (Casati, Toner, & Yu, 2000; Stemberger, Thomas, Mansueto, & Carter, 2000). This is understandable given that negative social evaluation is greater when hair loss is attributed to TTM as opposed to when it is attributed to genetic reasons (Ricketts, Brandt, & Woods, 2012). Arguably, this may be due to others’ perceptions that individuals with TTM lack self-control (Ricketts et al., 2012). Women with TTM report having very limited control over their hairpulling (Casati et al., 2000), which may contribute to perceptions of self as weak, flawed or inept (Diefenbach, Tolin, Hannan, Crocetto, & Worhunsky, 2005).
The aforementioned experiences associated with hair loss and TTM symptoms – personal weakness, vulnerability, self-consciousness – have all been implicated in definitions of shame (Blum, 2008; H. B. Lewis, 1971; M. Lewis, 1995; Weingarden & Renshaw, 2014). Blum suggested that shame is comprised of intense pain, discomfort or anger directed at the self for being “no good, inadequate, and unworthy,” accompanied by a desire to hide and reduce “any further painful exposure of the self and end the discomfort” (p. 94). Much of the secretive and avoidant behaviors of individuals with TTM can be understood in the context of shame (Noble, 2012). Weingarden and Renshaw (2014) recently reviewed the evidence for symptom-based shame (i.e., shame related to hairpulling behaviors; see Noble, 2012) and body shame (i.e., shame resulting from changes to one’s physical appearance) in TTM. Although research regarding shame in TTM is scant, they concluded that both types of shame are likely to perpetuate TTM symptoms.
Symptom-based shame and body shame are intuitively appealing concepts in relation to TTM, but fail to acknowledge the negative self-evaluations that are core to the experience of shame (Blum, 2008; H. B. Lewis, 1971; M. Lewis, 1995). Shame arises when one interprets one’s actions as a failure of the whole self as opposed to interpreting the actions/behaviors themselves as failings (H. B. Lewis, 1971; M. Lewis, 1995). Hence, cognitive appraisals of self are essential to the emotional experience of shame, yet the relevance of cognition to the etiology and phenomenology of TTM appears to have been underestimated due to the automaticity of hairpulling behavior (e.g., Mansueto, Townsley-Stemberger, McCombs-Thomas, & Goldfinger-Golomb, 1997). In their biopsychosocial model, Franklin and Tolin (2007) proposed that negative self-evaluations associated with low self-esteem or perceived low control over hairpulling are initially consequences of TTM symptoms, but become triggers of hairpulling episodes over time. As per the roles of symptom-related and body shame (Weingarden & Renshaw, 2014), negative self-evaluations were seen as secondary to or stemming from TTM. However, the content of these negative self-evaluations was not speculated upon, nor has this model been tested.
Our own research has identified a range of cognitions that contribute to the onset and maintenance of hairpulling episodes in TTM, including negative self-beliefs (Rehm, Nedeljkovic, Moulding, & Thomas, 2013). Qualitative interviews with eight women with TTM identified that all participants endorsed negative self-beliefs comprising two core themes: (1) a sense of worthlessness, and (2) a sense of being “abnormal.” As a 23-year-old woman who pulled her eyelashes and eyebrows stated, “It makes me feel crazy […] no one could ever love someone with a hairpulling syndrome.” Participants’ descriptions of themselves as worthless, “bad,” or incapable implicated shameful self-evaluations that often precipitated hairpulling episodes. All participants believed that hairpulling helped them cope with these self-judgments and associated negative emotions (e.g., anger, guilt, anxiety). For instance, several participants experienced a “trance-like” dissociative state while pulling that helped them distract from, minimize, or avoid their unpleasant internal experiences. For some, this included a near-total absence of awareness of such experiences, while for others this involved facilitating positive emotions and cognitions in place of the negative ones (Rehm et al., 2013). Similarly, among African-American women with TTM, participants with negative perceptions of their racial identity were more likely to experience happiness, calmness, or relief during and after hairpulling episodes compared to those with positive perceptions of their racial identity (Neal-Barnett & Stadulis, 2006). This suggests that self-construals may influence the type of emotion-regulation function that hairpulling serves.
The interrelated roles of shame and self-concept pose questions about the directionality of their relationship to TTM development. The cognitive-affective experience of shame has long been suggested to play a predisposing role in the development of psychopathology (H. B. Lewis, 1971; Tangney, Wagner, & Gramzow, 1992). Tangney et al. suggested that individuals who are prone to experiencing shame may be more likely to experience repeated threats to their self-concept, and as such, are vulnerable to developing psychological maladjustment. In turn, the resulting psychological symptoms may elicit symptom-related shame, triggering further shame and maladjustment (Tangney et al., 1992).
Indeed, shame proneness is associated with dissociative behavior (Irwin, 1998; Talbot, Talbot, & Tu, 2004), a phenomenon that is increasingly being recognized in TTM (Gupta, 2013; Lochner et al., 2004; Lochner, Simeon, Niehaus, & Stein, 2002). Experiential avoidance has also been implicated in TTM (Begotka, Woods, & Wetterneck, 2004; Houghton et al., 2014; Norberg, Wetterneck, Woods, & Conelea, 2007). Norberg et al. reported that experiential avoidance mediated the relationships between TTM severity and shame, fear of negative evaluation, and dysfunctional beliefs about appearance. What this may suggest is not that these cognitions are irrelevant to TTM, but that they may be so threatening to the self-concept that the individual is compelled to engage in hairpulling as a means to distract from or avoid the negative emotions that arise from such cognitions. This process has been termed “shame bypassing” (H. B. Lewis, 1971; M. Lewis, 1995), which may be the function of dissociation in shame-prone individuals (Talbot et al., 2004). As one of our participants explained, “You’re also thinking about how bad you are … I guess that’s a feeling you want away, so you want to pull and take that feeling away” (Rehm et al., 2013). Empirical evaluation of the bypassed shame model is, however, very limited (Platt, 2014), and the single study that evaluated the role of shame dimensions in TTM reported that characterological shame was not associated with TTM severity (Noble, 2012). However, using a newly validated measure of TTM-relevant beliefs with a large internet-based sample of individuals with TTM symptoms, our research group have found that the negative-self beliefs identified in our qualitative study (Rehm et al., 2013) did indeed account for a small but significant portion of the variance in TTM severity, even after controlling for depression (Rehm, Nedeljkovic, Moulding, & Thomas, 2014).
Research on the interrelationships between shame, self-concept, avoidance-based emotion regulation strategies, and TTM remains preliminary. Models of TTM do not acknowledge that hair makes an important contribution to identity, and underestimate the influence of cognitions, including-self evaluations, in the onset and maintenance of hairpulling episodes. Furthermore, shame is typically viewed as a psychological consequence of TTM (e.g., Stemberger et al., 2000), with shame-related self-construals rarely considered as potential vulnerability factors. These oversights flow on to psychological treatments for TTM (e.g., adjunctive ACT or dialectical behavior therapy [DBT]), which currently omit the role of shame and self-concept in TTM (e.g., Crosby, Dehlin, Mitchell, & Twohig, 2012; Keuthen & Sprich, 2012). As Noble (2012) advocated, addressing shame and negative self-evaluation could be highly beneficial for TTM treatments. One, formulating hairpulling as a coping behavior that serves an important emotion regulation function (i.e., “something I do to cope”) may help clients detach TTM from their sense of self, and reduce the presence or impact of negative self-evaluations (e.g., “I’m worthless, I’m abnormal, I’m weak”) that may be perpetuating their symptoms. Two, by reducing the impact of shame, clients may be more inclined to disclose other “shameful” but risky and relatively common behaviors associated with their hairpulling, such as trichophagia (hair-eating; Grant & Odlaug, 2008). Both ACT and DBT could help clients to identify the influence that shame and negative self beliefs have upon their symptoms, and importantly, to establish a sense of self that is not constrained to the impact of TTM.
Related posts:
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Future directions in examining the self in psychological disorders
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