Styles of pulling in youths with trichotillomania: exploring differences in symptom severity, phenomenology, and comorbid psychiatric symptoms.

To date, no studies have examined possible phenomenological differences between the automatic and focused styles of pulling in youths with TTM. The aims of the current study were to examine differences in TTM severity, phenomenology, comorbid psychiatric symptoms, and functional impact across youths with varying degrees of these pulling styles. Youths between the ages of 10 and 17 years (and their parent) were recruited via an Internet-based survey. A total of 186 youths with chronic hair pulling was classified as "high-focused" or "low-focused" and either "high-automatic" or "low-automatic" based upon scores obtained on the Milwaukee Inventory for Styles of Trichotillomania-Child Version (MIST-C) using a median-split procedure. Results demonstrated significant differences between pulling styles. More specifically, "high-focused" pullers reported more severe TTM and greater symptoms of anxiety and depression than "low-focused" pullers, and "high-automatic" pullers reported greater symptoms of depression than "low-automatic" pullers. Subsequent analyses suggest that, in comparison to youths with low levels of both automatic and focused pulling, those experiencing high levels of focused pulling but low levels of automatic pulling reported phenomenological differences and were more likely to engage in additional repetitive behaviors (i.e., skin picking, lip/cheek biting). Clinical and research implications, study limitations, and future areas of research are discussed.