Styles of pulling in trichotillomania: Exploring differences in symptom severity, phenomenology, and functional impact

Christopher A. Flessner, Christine A. Conelea, Douglas W. Woods, Martin E. Franklin, Nancy J. Keuthen, Susan E. Cashin

Research output: Contribution to journalArticlepeer-review

105 Scopus citations


Previous research has examined possible phenomenological differences between "focused" (i.e., with a compulsive quality) and "automatic" (i.e., with decreased awareness) pulling associated with trichotillomania (TTM), but these constructs have not been assessed using psychometrically sound measures. In the current study, differences in TTM severity, phenomenology, comorbid psychiatric symptoms, and functional impact were examined across individuals with varying combinations of "focused" and "automatic" pulling styles. Participants aged 18 and older were recruited via an internet-based survey. Those meeting inclusion criteria and completing the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A; n=1545) were classified as either high- or low-focused and either high- or low-automatic based on scores obtained from the focused and automatic scales of the MIST-A using a median split procedure. Results showed some significant differences between pulling styles. For example, "high-automatic" pullers reported more severe TTM and greater stress than "low-automatic" pullers, and "high-focused" pullers reported more severe TTM, greater stress and depression, and greater functional impact than "low-focused" pullers. Subsequent analyses suggest that, in comparison to individuals experiencing low levels of both automatic and focused pulling, those experiencing high levels of each pulling style reported greater severity, psychological impact, and functional impact. Clinical and research implications, study limitations, and future areas of research are discussed.

Original languageEnglish (US)
Pages (from-to)345-357
Number of pages13
JournalBehaviour Research and Therapy
Issue number3
StatePublished - Mar 2008

Bibliographical note

Funding Information:
This project was funded by the Trichotillomania Learning Center (TLC).


  • Automatic
  • Focused
  • Pulling
  • Trichotillomania


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