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Perfectionism, Shame, and Trichotillomania Symptoms in Clinical and Nonclinical Samples.

This study explored the relationships between multidimensional perfectionism (adaptive and maladaptive), shame (characterological, behavioral, and bodily), and trichotillomania (TTM) symptom severity in a nonclinical sample of 284 college students and a clinical sample of 125 individuals with TTM. Results suggested that the clinical sample reported significantly higher levels of maladaptive perfectionism, all three subtypes of shame, and TTM compared to the nonclinical sample. While none of the three subtypes of shame mediated the relationship between either form of perfectionism and TTM for the nonclinical sample, behavioral shame was a significant mediator between maladaptive perfectionism and TTM for the clinical sample. Implications for mental health counselors are discussed.

The treatment of compulsive hairpulling is a significant issue for mental health counselors. Some research indicates that current treatments have resulted in limited success and fail to address symptom presentation in different types of hair pullers (Keuthen, Tung, Tung, Curley, & Flessner, 2016; Woods, Wetterneck, & Flessner, 2006). Despite the limited treatments, Woods (2011) suggested that trichotillomania (TTM) rates "are approaching, matching, or even exceeding those of more commonly researched disorders" (p. 747). Estimates of TTM prevalence range from 0.6% to 3.4% of the population (e.g., Duke, Keeley, Geffken, & Storch, 2010). In addition, several researchers (Duke, Keeley, Ricketts, Geffken, & Storch, 2009; Woods & Miltenberger, 1996) have found behavioral patterns (e.g., problematic hairpulling) consistent with some aspects of TTM occurring at rates up to 13.3% in college students. TTM is often comorbid with other mental health issues. Frequently cooccurring disorders include anxiety and depression (Duke et al., 2009), personality disorders (Christenson, Chernoff-Clementz, & Clementz, 1992; Keuthen et al., 2015), and TTM-related social avoidance (Mansueto, 1990). Despite the increase in diagnoses of TTM, very limited research exists in the literature, particularly within the last decade.

A growing body of research suggests a significant relationship between obsessive-compulsive disorder (OCD) and TTM (Christenson & Mackenzie, 1995; Duke et al., 2010). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) developed an independent chapter for OCD and related disorders, including TTM. This change has been attributed to recent research that identified commonalities with obsessive thoughts and repetitive behaviors (American Psychiatric Association [APA], 2013). The high comorbidity and strength of the connection between TTM and OCD symptomatology have led TTM to be conceptualized as an obsessive-compulsive (OC) spectrum disorder. For example, Stewart, Jenike, and Keuthen (2005) found that 18.8% of individuals in an inpatient sample treated for OCD reported low rates of hairpulling, 15.6% reported moderate to severe hairpulling, and 7.8% reported severe hairpulling. Similarly, Hajcak, Franklin, Simons, and Keuthen (2006) found positive relationships between hairpulling, anxiety, stress reactivity, skin picking, and OC symptoms in a nonclinical sample. Wetterneck, Lee, Flessner, Leonard, and Woods (2016) found that individuals with TTM displayed significantly higher impulsivity levels, as well as anxiety, anxiety-related, and borderline features, when compared to a control group of individuals without TTM.

Although TTM poses a significant issue for many clients seeking counseling, few studies have investigated how individual characteristics, such as personality, may be related to TTM (e.g., Chamberlain & Odlaug, 2014; Keuthen, Altenburger, & Pauls, 2014; Keuthen et al., 2015; Keuthen et al., 2016; Wetterneck et al., 2016). An increasing amount of research in the counseling field is being focused on how personality traits and individual characteristics may be connected to emotions and behaviors (Ghorpade, Lackritz, & Singh, 2007; Moate, Gnilka, West, & Bruns, 2016; O'Connor & Paunonen, 2007). How TMM may relate to the personality trait of perfectionism is of particular interest. Stanley, Borden, Mouton, and Breckenridge (1995) compared nonclinical hair pullers with individuals with TTM or OCD and found that mean neuroticism scores for all compulsive hair pullers and those with OCD were present relative to published norms of those without TTM or OCD (Stanley et al., 1995). Mansueto, Golomb, Thomas, and Stemberger (1999) suggested that individuals with TTM and comorbid OCD or depression often demonstrate a "tendency toward perfectionism" (p. 571). In addition, a number of self-help materials for TTM management have noted the connection between TTM and perfectionism (Keuthen, Stein, & Christenson, 2001; Penzel, 2003). The purpose of this study was to investigate the relationships between multidimensional perfectionism, different forms of shame, and TTM in clinical and nonclinical samples.

Several multidimensional models of perfectionism have been offered (e.g., Frost, Marten, Lahart, & Rosenblate, 1990; Hewitt & Flett, 1991; Slaney, Rice, & Ashby, 2002). Stoeber and Otto (2006) concluded after an exhaustive review of the perfectionism literature that perfectionism is made up of an adaptive dimension (perfectionistic strivings) and a maladaptive dimension (perfectionistic concerns). Adaptive perfectionism is characterized by having high standards for oneself and others and persistence in the face of adversity. Conversely, maladaptive perfectionism is characterized by excessive preoccupation with past mistakes and self-criticism (Rice & Ashby, 2007). Despite clear conceptual links between perfectionism and TTM (e.g., Penzel, 2003), a review of the professional literature produced only one published case study exploring the relationship between perfectionism and TTM (Pelissier & O'Connor, 2004). The authors noted that perfectionism is a promising clinical target for TTM treatment, with particular focus on the maladaptive perfectionism dimension.

Individuals with TMM commonly report low self-esteem (Soriano et al., 1996), irritability, depression, feelings of unattractiveness (Stemberger, Thomas, Mansueto, & Carter, 2000), feelings of sadness, anhedonia, worthlessness, hopelessness, difficulty concentrating (Wetternack et al., 2016), and shame (Winchel et al., 1992). Shame has been conceptualized as a multidimensional construct, with dimensions consistent with assertions made by experts who have identified relationships between TTM and shame around the self, actions, and appearance. For example, Penzel (2003) asserted that shame-related cognitions are related to discrepancies between the real and ideal self and behaviors. Similarly, Stemberger et al. (2000) found a significant relationship between shame and depressed mood and feelings of unattractiveness and "marked day-to-day distress, social impairments, and depressed mood" (p. 102). In an additional study, Norberg, Wetterneck, Woods, and Conelea (2007) found a significant relationship between hairpulling severity and dysfunctional beliefs about appearance, fear of negative evaluation, and feelings of shame. Various measures that differentiate between different types of shame have been constructed. For example, the Experience of Shame Scale (ESS; Andrews, Qian, & Valentine, 2002) is a multidimensional measure that assesses characterological shame ("I am ashamed because I am a 'bad' person"), behavioral shame ("I am ashamed of the behaviors I do"), and bodily shame ("I am ashamed about my body and my appearance").

Tangney (2002) noted that any perceived failure "leads perfectionists to feelings of shame" (p. 201). Consistent with Tangney's view, a number of studies have found relationships between shame and perfectionism. For example, Fedewa, Burns, and Gomez (2005) found that maladaptive perfectionism was positively correlated with state shame, state guilt, and shame proneness, whereas adaptive perfectionism was positively correlated with pride and negatively correlated with state shame and anxiety. In a related study, Stoeber, Harris, and Moon (2007) found that adaptive perfectionists reported more state pride, less state shame and guilt, and lower proneness to shame than maladaptive perfectionists. Additional studies have investigated the potentially complex relationship between perfectionism and shame. For instance, Ashby, Rice, and Martin (2006) found that internalized shame partially mediated the relationship between maladaptive perfectionism and depression.

Given the conceptual links between perfectionism and TTM (e.g., Penzel, 2003) and the paucity of research investigating these relationships, the current study was designed to assess the relationships among multidimensional perfectionism, shame, and TTM symptom severity in a clinical and nonclinical sample. Specifically, the following hypotheses were explored:

1. Perfectionistic concerns will be positively associated with the three subtypes of shame that will be positively associated with TTM in both samples.

2. Perfectionistic strivings will be negatively associated with the three subtypes of shame that will be positively associated with TTM in both samples.

3. The three dimensions of shame (characterological, behavioral, and bodily shame) will mediate the relationships between both perfectionistic concerns and strivings and TTM in both samples.

METHOD

Participants and Procedures

Internal review board approval was obtained before starting the study. All participants completed an online assessment that included a demographic form; a screening tool composed of criteria for TTM from the Diagnostic and Statistical Manual of Mental Disorders (4"' ed., text rev. [DSM-IV-TR]; APA, 2000); general information about hairpulling behaviors; psychotropic medication history; the Almost Perfect Scale--Revised (APS-R; Slaney, Rice, Mobley, Trippi, & Ashby, 2001); the Massachusetts General Hospital Hairpulling Scale (MGH; Keuthen, O'Sullivan, Ricciardi, Shera, & Savage, 1995); and the ESS (Andrews et al., 2002). DSM-IV-TR criteria were used in data collection. DSM-5 criteria largely mirror the DSM-IV-TR criteria for TTM, apart from some minor changes to specifier language and changing the name to "hair-pulling disorder" (APA, 2013).

Participants consisted of a clinical sample and a nonclinical sample of undergraduate students attending a large urban university in the southeastern United States. Clinical sample participants (n = 125) were recruited through a combination of social networking sites, online message boards and forums, support groups for OC spectrum disorders, and a national conference for individuals with TTM. Participants were included in the clinical sample if they met Criterion A for TTM according to the DSM-IV-TR (i.e., recurrent pulling out of one's hair, resulting in noticeable hair loss). Of the 125 clinical participants, 4.8% identified as male, and 95.2% identified as female. The vast majority of the participants self-identified as White (89.6%), followed by 4.0% multiracial, 3.2% Asian, 1.6% Black, 0.8% Latino, and 0.8% Native American; none declined to answer. Their ages ranged from 18 to 65, with a mean age of 28.80. A total of 76.8% reported that they had been in counseling, and 57.6% reported that they had taken psychotropic medication at some point in the past.

Participants in the college nonclinical sample (n = 284) were recruited from undergraduate online courses in an urban southeastern university and awarded extra credit for their participation. A total of 35.2% identified as male, and 64.8% identified as female. This sample was considerably more diverse than the clinical sample, with 49.6% of the sample self-identifying as Black, 28.5% as White, 12.0% as Latino, 5.3% as multiracial, and 4.6% as Asian; none declined to answer. Their ages ranged from 18 to 66, with a mean age of 24.73. Of the nonclinical sample participants, 25.5% reported that they had participated in counseling at some time, and only 8.1% reported taking psychotropic medication in the past.

Measures

Almost Perfect Scale--Revised. The APS-R (Slaney et al., 2001) is a 23-item inventory designed to measure adaptive and maladaptive dimensions of perfectionism. The Standards subscale was designed to measure a person's standards set across a variety of domains ("I have high standards for my performance at work or at school"). The Discrepancy subscale was designed to measure the negative reaction experienced when there is a discrepancy between standards and performance ("My best just never seems to be good enough for me"). As in previous studies (e.g., Gnilka, Ashby, & Noble, 2012), the Order subscale was not used in this study, as it does not assist in the differentiation of adaptive and maladaptive perfectionism (Gnilka et al., 2012; Rice & Ashby, 2007).

Slaney et al. (2002) conducted confirmatory factor analyses that supported the configuration and independence of the APS-R subscales and provided evidence for the convergent and discriminant validity of the APS-R. Slaney et al. (2001) reported Cronbach coefficients alphas of .85 for the Standards subscale and .92 for the Discrepancy subscale. Cronbach coefficients alphas for the scales in this study were .84 for the Standards subscale and .93 for the Discrepancy subscale for the clinical sample, and .79 for the Standards subscale and .91 for the Discrepancy subscale for the nonclinical.

Massachusetts General Hospital Hairpulling Scale. The MGH (Keuthen et al., 1995) is a self-report instrument that assesses TTM through the measurement of the frequency, intensity, and perceived control of a participant's hair-pulling urges; the frequency, resistance, and perceived control over hair-pulling behaviors; and the participant's distress associated with hairpulling. Participants rate each of the 7 items on a 5-point Likert scale. O'Sullivan et al. (1995) found that the MGH had acceptable validity in measuring current symptom severity as well as symptom change. The MGH has demonstrated strong test--retest reliability (r = .97) and strong internal consistency (Cronbach coefficient alpha = .89; Keuthen et al., 1995; O'Sullivan et al., 1995). Cronbach coefficients alphas for the scale in this study were .85 for the clinical sample and .85 for the nonclinical sample.

Experience of Shame Scale. The ESS (Andrews et al., 2002) is a 25-item questionnaire that assesses shame on experiential, cognitive, and behavioral levels. The ESS yields a total score as well as three subscale scores: characterological, behavioral, and bodily shame. Participants respond on a 4-point Likert scale according to how they have felt in the past year. The ESS has been shown to have sufficient construct validity and concurrent and discriminant validity (Andrews et al., 2002). The total scale exhibits high internal consistency (Cronbach coefficient alpha = .92) and test-retest reliability. The Cronbach coefficients alphas for the characterological, behavioral, and bodily subscales were .90, .87, and .86, and the 11-week test--retest reliabilities were .78, .74, and .82, respectively (Andrews et al., 2002). For the clinical sample in this study, the Cronbach coefficients alphas for the characterological, behavioral, and bodily subscales were .90, .92, and .76, respectively. For the nonclinical sample in this study, the internal consistencies for the characterological, behavioral, and bodily subscales were .93, .92, and .83.

Data Analysis

The data analysis for the study consisted of four steps. First, bivariate correlations between the variables were calculated. Second, ANOVAs were conducted to evaluate mean differences between clinical and student groups on all measures. Cohen's (1992) guidance on effect sizes was followed with Cohen's d, designated as small (0.20), medium (0.50), and large (0.80). Third, to test the hypothesis that multidimensional shame (characterological, behavioral, and bodily shame) mediated the relationship between both dimensions of perfectionism and TTM, Preacher and Hayes's (2008) multiple mediation bootstrapping approach was used. (For a detailed explanation about bootstrapping in an earlier issue of the Journal of Mental Health Counseling, see Gnilka, Ashby, Matheny, Chung, & Chang, 2015.) The indirect effect (ab) was the product of the effect of the independent variable (adaptive or maladaptive perfectionism) on the mediators (characterological, behavioral, and bodily shame; i.e., the a path) and the effect of the mediators on the dependent variable (TTM as measured by the MGH, i.e., the b path). Using the bootstrapping technique, 5,000 random samples of the original sample were taken from the data, replacing each value as it was sampled; the indirect effect (ab path) was computed in each sample along with a 95% confidence interval. If the upper and lower bounds of these bias-corrected and accelerated (BCa) confidence intervals did not contain zero, the indirect effect was significant.

RESULTS

For the clinical and nonclinical samples, within-sample correlations between APS-R subscales, ESS subscales, and the TTM symptom severity appear in Table 1. For the clinical group, the APS-R Standards subscale showed significant positive correlations with the APS-R Discrepancy subscale and with the ESS Behavioral Shame subscale. The APS-R Discrepancy subscale showed significant positive correlations with the APS-R Standards subscale and all three of the ESS subscales (characterological, behavioral, and bodily shame). For the student group, the APS-R Standards subscale showed significant positive correlations with the APS-R Discrepancy subscale and significant inverse correlations with TTM and with two of the ESS subscales (characterological, shame, and bodily shame). The APS-R Discrepancy subscale showed significant positive correlations with the APS-R Standards subscale and all three of the ESS subscales.

Sample means, standard deviations, effect sizes, and results of the ANOVA tests are listed in Table 2. The results of the ANOVA analyses showed significant differences between the clinical and nonclinical samples on all scales, with the exception of the APS-R Standards subscale. Specifically, clinical sample participants had significantly higher scores for APS-R Discrepancy (Cohen's d = 0.90); for characterological (1.61), behavioral (1.15), and bodily shame (1.39); and for TTM symptom severity (3.41) than the nonclinical sample participants. All effect sizes were classified as large.

Tests of mediation were then conducted to examine whether any of the three subtypes of shame mediated the relationship between the two dimensions of perfectionism and hairpulling severity. Results of the bootstrapping analyses for the clinical sample showed that none of the ESS subscales mediated the relationship between adaptive perfectionism and TTM, as shown by zero being in all of the confidence intervals (see Table 3). However, the results of the study did indicate that behavioral shame mediated the relationship between maladaptive perfectionism and TTM, as shown by zero not being in the constructed confidence intervals (see Table 3 and Figure 1). In regard to the nonclinical sample, none of the ESS subscales mediated the relationships between either form of perfectionism and TTM, as shown by zero being in all of the constructed confidence intervals.

DISCUSSION

The results of the study indicated that participants in the clinical sample reported higher levels of maladaptive perfectionism, all three types of shame, and TTM than the nonclinical sample. While there were numerous significant relationships between perfectionism, shame, and TTM in both samples, the results of mediational analysis indicated that only behavioral shame mediated the relationship between maladaptive perfectionism and TTM in the clinical sample.

The results of correlational tests showed that higher maladaptive perfectionism was related to higher levels of all three types of shame. This is consistent with the view that maladaptive perfectionists perceive that they are consistently falling short of their goals and, as a result, experience distress. In contrast, individuals higher in adaptive perfectionism have high standards and are more flexible and forgiving in their personal evaluations, experiencing less distress and shame. These results are consistent with previous research showing that adaptive perfectionism is positively associated with lower levels of depressive symptoms and increased levels of hope and life satisfaction (Ashby et al., 2006; Rice & Ashby, 2007; Suh, Gnilka, & Rice, 2017), whereas maladaptive perfectionism is related to frequent use of unhealthy and avoidant coping strategies, increased levels of depressive symptoms, and lower levels of life satisfaction (Dunkley, Sanislow, Grilo, & McGlashan, 2009; Gnilka et al., 2012; Suh et al., 2017).

In this study, behavioral shame mediated the relationship between maladaptive perfectionism and TTM for the clinical sample. These results suggest that individuals with TTM who are high in maladaptive perfectionism likely feel shameful about their hairpulling behaviors. Further, it may be that this shame results in more severe and frequent hairpulling behavior, decreased levels of perceived control over hairpulling, and increased levels of perceived distress and impairment. It is notable that, while individuals from the clinical sample also exhibited significant positive relationships between maladaptive perfectionism and all three subtypes of shame, behavioral shame was the only one of these that accounted for the relationship between maladaptive perfectionism and hairpulling symptom severity. The finding that individuals with TTM have higher levels of different types of shame supports the idea that shame is an important factor for clients dealing with TTM. This finding is consistent with previous research findings that individuals engaging in repeated self-injurious behavior, which included hairpulling, experienced shame (Kakhnovets, Young, Purnell, Huebner, & Bishop, 2010).

The results of this study suggest that, for individuals with TTM who also experience maladaptive perfectionism, behavioral shame is a mechanism that may partially explain the severity of TTM behaviors. These findings suggest that individuals with TTM may not experience more severe hairpulling behaviors or impairment because of shame around their physical appearance or because they feel that they are characterologically flawed in some way, but that they may experience more severe hairpulling because of shame around the behaviors. This finding is in contrast to other body-focused repetitive behaviors, such as nonsuicidal self-injury (NSSI). Often individuals with NSSI initially do damage to their bodies because they view themselves as inherently bad or flawed (e.g., Yip, 2006). The results of the current study suggest that feelings of characterological shame do not necessarily explain symptom severity in clients with TTM. Instead, shame over the hairpulling behavior itself appears to explain the relationship between maladaptive perfectionism and symptom severity for individuals in this clinical population.

In the nonclinical sample, approximately 4% of participants reported engaging in levels of TTM behaviors consistent with a clinical diagnosis, while approximately 12% reported engaging in nonclinical levels of hairpulling behaviors. These findings are consistent with several studies evaluating the epidemiology of TTM and compulsive hairpulling in university samples (e.g., Christenson, Pyle, & Mitchell, 1991). These studies suggest that 1.5% of male and 3.4% of female students engage in hairpulling to a clinically significant degree, with 0.6% exhibiting all diagnostic criteria of TTM. Similarly, some surveys of university students have indicated that nonclinical hairpulling behaviors are found in up to 15.3% of these participants (Stanley, Borden, Bell, & Wagner, 1994).

Limitations and Future Research

While this is one of the first studies to investigate how multidimensional shame mediates the relationships between multidimensional perfectionism and TTM symptom severity, this study has a number of limitations. First, due to the cross-sectional design, it is not possible to make directional hypotheses. Future researchers should consider using longitudinal designs to better understand how these various constructs interact. Second, this study relied upon self-report measures only. In light of this, there could be some elements of social comparison or positive self-management that may have influenced the findings. Individuals with TTM may also have had greater comfort and experience with talking about their hairpulling behaviors, as well as greater overall awareness of the impact of hairpulling, than participants in the nonclinical sample. Feelings of stigma, a lack of comfort with the topic, or limited awareness about the frequency of the behaviors might have led to underreporting of hairpulling behaviors in the nonclinical sample. Future research should further explore how elevated levels of shame subtypes impact individuals with TTM, and how they attend to well-being outcomes and mental health issues, such as anxiety and depression.

Lastly, there were differences in the demographics of the clinical sample and the college nonclinical sample. The majority of the clinical participants were female and White, tended to be older than college student participants, and were from a more geographically diverse area. Conversely, the college student data were collected at one university, and participants were significantly more ethnically diverse, with many more male participants and less variability in participant ages. The differences in the demographics of the samples may have also contributed to a lack of significant findings for the nonclinical sample. The rates of both TTM and nonclinical hairpulling behavior in the nonclinical sample highlight the need for continued research on how these issues impact the general population across the life span.

Implications for Counselors

Despite the study's limitations, the results suggest several implications for counselors working with clients with TTM and compulsive hairpulling. For instance, it is essential that counselors remember that all forms of perfectionism are not created equal. In this study, only maladaptive perfectionism was found to be associated with characterological, behavioral, and bodily shame for clinical participants, with only behavioral shame mediating the relationship between maladaptive perfectionism and TTM symptom severity. Adaptive perfectionism was not significantly related to TTM severity. These results suggest that it is important to assess a client's type of perfectionism before assuming that it is pathological or is contributing to the maintenance of TTM behaviors.

Pinto et al. (2017) suggested that decreasing perfectionism may play a critical role and precede change in OCD symptoms. Their research suggests that utilizing interventions that directly target perfectionism in OCD treatment may be effective. Brief cognitive-behavioral therapy (CBT) interventions (8-12 sessions) specifically targeting perfectionism have been found to be effective in reducing perfectionism (Lloyd, Schmidt, Khondoker, & Tchanturia, 2015). Pleva and Wade (2006) explored CBT-based therapy on perfectionism, obsessive-compulsiveness, and depressive symptoms using self-help intervention and its efficacy. Post-treatment assessments indicated that OCD, perfectionism, and depression symptoms decreased, suggesting that CBT-based self-help is an effective intervention.

In the clinical sample, only behavioral shame mediated the relationship between maladaptive perfectionism and TTM symptom severity as assessed by the MGH. This finding suggests that counselors working with clients with TTM might benefit from attending to clients' feelings of shamefulness surrounding their inability to "just stop pulling" (Penzel, 2003). This finding is important, as many clinicians and clients spend significant time in treatment attempting to work through shame related to TTM's impact on physical appearance. Physical appearance and characterological shame may be present in clients with TTM. However, the finding that only behavioral shame mediates the relationship between maladaptive perfectionism and hairpulling severity suggests that behavioral shame must be a focus of treatment if the end goal is symptom reduction and reduced impairment.

Because behavioral shame is a mechanism that appears to lead to higher levels of symptom severity, counselors should target it as a means to help bring about changes in the frequency and intensity of clients' TTM behaviors. One approach is having explicit conversations about clients' shame experiences related to their behavior, using the therapeutic relationship to minimize tendencies and the frequency and severity of the behaviors. This can reduce secretiveness and shame that often prevent effective help-seeking behaviors (O'Sullivan, Keuthen, Christenson, Mansueto, & Stein, 1997). In addition, counselors can help clients reduce shame around their TTM behaviors by explaining that these behaviors have a function. Some of these functions include pulling for emotional regulation purposes, neurochemical rewards experienced while pulling, and a means to focus attention or avoid boredom (e.g., Duke et al., 2010). This can help to reduce clients' feelings of shame, increase levels of openness, and promote the learning of new coping skills and alternative, healthier behaviors.

Consistent with the results of the current study, previous research findings suggest that individuals with TTM commonly report negative self-referencing emotions, such as shame in response to their hairpulling and frustration with their inability to control hairpulling behaviors (du Toit, van Kradenburg, Niehaus, & Stein, 2001; Stemberger et al., 2000). This study suggests that while other types of shame may not directly contribute to TTM symptom severity and impairment, characterological and bodily shame do appear to be elevated in individuals with TTM as compared to traditional college students.

Of additional note in the current study is the significant number of student participants who experienced compulsive hairpulling or met criteria for TTM, but who had never been diagnosed or were unaware of TTM as a diagnosable condition. Although standard intake interviews rarely assess for body-focused repetitive behaviors (BFRBs) such as TTM, these findings support the idea that many individuals experience these behaviors, even if their hairpulling does not meet criteria for TTM. Although clients may not mention these behaviors because they see them as a problematic habit, a number of studies suggest that people can experience significant impairment and distress from TTM and compulsive hairpulling (e.g., Keuthen et al., 2001). Consequently, counselors may want to regularly ask their clients about compulsive hairpulling and other NSSIs or BFRBs.

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Christina M. Noble, The Anxiety and Stress Management Institute; Philip B. Gnilka, Department of Counseling and Special Education, Virginia Commonwealth University; Jeffrey S. Ashby and Sarah E. McLaulin, Department of Counseling and Psychological Services, Georgia State University.

Correspondence concerning this article should be addressed to Philip B. Gnilka, Department of Counseling and Special Education, Virginia Commonwealth University, 1015 W. Main Street, Richmond, VA 23284. E-mail: pbgnilka@vcu.edu
Table I Within-Sample Correlations Among Perfectionism, Shame,
and Trichotillomania Symptom Severity

Measure                    1          2          3           4

1. Standards               --       -.045      -.283 (**)  -.184 (**)
2. Discrepancy            .419 (*)     --       .417 (**)   .375 (**)
3. Character Shame        .044       .457 (*)     --        .747 (**)
4. Behavioral Shame       .307 (*)   .532 (*)   .604 (*)      --
5. Bodily Shame           .030       .376 (*)   .537 (*)    .421 (*)
6. TTM Symptom Severity  -.099       .067       .172        .248 (*)

Measure                    5           6

1.Standards              -.232 (**)  -.223 (**)
2. Discrepancy            .360 (**)  -.006
3. Character Shame        .664 (**)   .086
4. Behavioral Shame       .660 (*)    .037
5. Bodily Shame             --        .052
6. TTM Symptom Severity   .248 (*)      --

Note. Clinical sample (n = 125) correlations are below the diagonal,
and nonclinical sample (n = 284) correlations are above the diagonal.
Standards = Almost Perfect Scale-Revised (APS-R) Standards Subscale;
Discrepancy = APS-R Discrepancy Subscale; Character Shame = Experiences
of Shame Scale (ESS) Characterological Shame Subscale; Behavioral Shame
= ESS Behavioral Shame Subscale; Bodily Shame = ESS Bodily Shame
Subscale; TTM = trichotillomania; TTM Symptom Severity = Massachusetts
General Hairpulling Scale. (*) p < .01. (**) p < .001.

Table 2 Mean and Standard Deviations for Perfectionism,
Shame, and Trichotillomania Symptom Severity

                      Clinical sample  Nonclinical sample
                         (n=125)       (n = 284)

Measure                 M     SD        M      SD       F
Standards             40.23   7.71      41.55   7.00     2.90
Discrepancy           57.86  17.31      42.37  17.19    70.16
Character Shame       35.18   8.64      21.60   8.24   229.07
Behavioral Shame      27.68   7.09      19.68   6.87   115.48
Bodily Shame          12.80   3.02       8.23   3.53   158.54
TTM Symptom Severity  15.98   5.63       0.85   2.78  1322.25




Measure                 P      d
Standards             >.05   0.18
Discrepancy           <.000  0.90
Character Shame       <.000  1.61
Behavioral Shame      <.000  1.15
Bodily Shame          <.000  1.39
TTM Symptom Severity  <.000  3.41

Note. Standards = Almost Perfect Scale--Revised (APS-R) Standards
Subscale; Discrepancy = APS-R Discrepancy Subscale; Character' Shame =
Experiences of Shame Scale (ESS) Characterological Shame Subscale;
Behavioral Shame = ESS Behavioral Shame Subscale; Bodily Shame = ESS
Bodily Shame Subscale; TTM = trichotillomania; TTM Symptom Severity =
Massachusetts General Hairpulling Scale.

Table 3 Mediation Analysis Results for Maladaptive Perfectionism
Clinical Sample (n = 114)

Dependent variable        Path/effect
TTM Severity (MGHS)

[DELTA][R.sup.2] = .0987  C
F(5, 108) = 2.366 (*)     a1 (MALADAPT [right arrow] CHARSHAME)
                          a2 (MALADAPT [right arrow] BEHSHAME)
                          a3 (MALADAPT [right arrow] BODYSHAME)
                          b1 (CHARSHAME [right arrow] MGHS)
                          b2 (BEHSHAME [right arrow] MGHS)
                          b3 (BODYHAME [right arrow] MGHS)
                          c' (MALADAPT [right arrow] MGHS)
                          a1 x b1
                          a2 x b2
                          a3 x b3
                          Total

Dependent variable        B       SE     [beta]     95% CI
TTM Severity (MGHS)

[DELTA][R.sup.2] = .0987   .0648  .0393   .193
F(5, 108) = 2.366 (*)      .2775  .0538   .512 (**)
                           .2117  .0421   .460 (**)
                           .0855  .0190   .477 (**)
                          -.0018  .0860  -.003
                           .2549  .1015   .319 (*)
                          -.0488  .2183  -.025
                           .0155  .0447   .044
                          -.0005  .0235  -.002      -.0478, .0458
                           .0540  .0250   .147 (*)   .0126, .1134
                          -.0042  .0182   .012      -.0379, .0341
                           .0493  .0217   .149 (*)   .0I06, .0959
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Author:Noble, Christina M.; Gnilka, Philip B.; Ashby, Jeffrey S.; McLaulin, Sarah E.
Publication:Journal of Mental Health Counseling
Article Type:Clinical report
Geographic Code:1USA
Date:Oct 1, 2017
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