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<p class="ltrs-br-ltr-br-title"><span class="bold">Hair Pulling and Borderline Personality Symptomatology Among Obstetrics/Gynecology Outpatients</span></p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor:</span> In a previous study of internal medicine outpatients, we found a statistically significant relationship between hair pulling and borderline personality symptomatology,<span class="htm-cite"><a href="#ref1">1</a></span> suggesting associations with impulsive behavior rather than compulsive behavior.<span class="htm-cite"><a href="#ref2">2</a></span> In this study, we reexamined this association, as well as potential racial differences, in a consecutive sample of obstetrics/gynecology outpatients.</p>
<p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Method.</span> Participants were consecutive female outpatients, aged 18 years or older, who were seeking nonemergent care through a university-affiliated obstetrics/gynecology outpatient clinic. Exclusion criteria were intellectual, medical, psychiatric, and/or cognitive impairment of sufficient severity to preclude the successful completion of a survey. A total of 373 patients participated in the study.</p>
<p class="ltrs-br-ltr-br-body-text">The mean age of participants was 26.44 years (<span class="italic">SD</span><span class="thinspace"> </span>=<span class="thinspace"> </span>7.47), with ages ranging from 18 to 61 years. Most participants were white (54.2%) or African American (39.1%). Approximately 88% had at least a high school diploma, and 13% had completed college. The majority were never married (71.9%), 16.9% were married, 6.8% were divorced, and the remainder were separated or widowed. About 80% reported government insurance, 5.5% were privately insured, and 14.3% had no insurance or elected to self-pay.</p>
<p class="ltrs-br-ltr-br-body-text">As patients arrived at the clinic, one researcher (J.C.) solicited each, informally assessed exclusion criteria, and invited candidates to complete a 4-page survey. The cover page of the survey contained the elements of informed consent, and survey completion was presumed to be implied consent (specified on the cover page).</p>
<p class="ltrs-br-ltr-br-body-text">In the survey, we inquired about (1) demographics; (2) hair pulling (ie, with yes/no response options, “As an adult, have you engaged in hair pulling [the repeated urge to pull out scalp hair, eyelashes, eyebrows, or other body hair, <span class="italic">resulting in bald patches</span>]?); and (3) borderline personality symptomatology using 2 self-report assessments—the borderline personality disorder scale of the Personality Diagnostic Questionnaire-4 (PDQ-4)<span class="htm-cite"><a href="#ref3">3</a></span> and the Self-Harm Inventory (SHI).<span class="htm-cite"><a href="#ref4">4</a></span> The study was approved by 2 institutional review boards.</p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Results.</span> Twenty-seven participants (7.2%) reported hair pulling. Among the participants, 59.3% with hair pulling were PDQ-4–positive (cutoff score of 5) versus 17.3% without hair pulling (χ<span class="superscript">2</span><span class="subscript">1</span><span class="thinspace"> </span>=<span class="thinspace"> </span>27.14, <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.001; N<span class="thinspace"> </span>=<span class="thinspace"> </span>373). Likewise, 48.0% of participants with hair pulling were SHI-positive (cutoff score of 5) versus 18.5% without hair pulling (χ<span class="superscript">2</span><span class="subscript">1</span><span class="thinspace"> </span>=<span class="thinspace"> </span>12.39, <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.001; N<span class="thinspace"> </span>=<span class="thinspace"> </span>373). In examining racial differences, PDQ-4–positive white participants did not exhibit a statistically significant higher frequency of hair pulling (42.9% vs 25.3%; χ<span class="superscript">2</span><span class="subscript">1</span><span class="thinspace"> </span>=<span class="thinspace"> </span>2.07, <span class="italic">P</span><span class="thinspace"> </span>=<span class="thinspace"> </span>.15; N<span class="thinspace"> </span>=<span class="thinspace"> </span>200), whereas PDQ-4–positive African American women did (80.0% vs 8.3%; χ<span class="superscript">2</span><span class="subscript">1</span><span class="thinspace"> </span>=<span class="thinspace"> </span>41.53, <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.001; N<span class="thinspace"> </span>=<span class="thinspace"> </span>143). The same pattern emerged with SHI-positive participants: nonsignificance in white women (41.7% vs 25.4%; χ<span class="superscript">2</span><span class="subscript">1</span><span class="thinspace"> </span>=<span class="thinspace"> </span>1.53, <span class="italic">P</span><span class="thinspace"> </span>=<span class="thinspace"> </span>.22; N<span class="thinspace"> </span>=<span class="thinspace"> </span>200), but statistical significance in African American women (60.0% vs 9.9%; χ<span class="superscript">2</span><span class="subscript">1</span><span class="thinspace"> </span>=<span class="thinspace"> </span>20.17, <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.001; N<span class="thinspace"> </span>=<span class="thinspace"> </span>142).</p>
<p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
<p class="ltrs-br-ltr-br-body-text">Findings expand on our previous study in internal medicine outpatients<span class="htm-cite"><a href="#ref1">1</a></span> and affirm a relationship between hair pulling and borderline personality symptomatology, but only in African American women. The potential limitations of this study include the self-report nature of the data, potential overinclusiveness of the borderline personality symptomatology measures, and sample characteristics (ie, low-income women). However, the sample was consecutive, naturalistic, and large. Findings suggest that hair pulling may be associated with borderline personality symptomatology and that there may be racial differences.</p>
<p class="ltrs-br-ltr-br-references-head"><span class="smallcaps">References</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a>1. Sansone RA, Lam C, Wiederman MW. Hair-pulling and borderline personality symptomatology among internal medicine outpatients. <span class="italic">Int Med J</span>. In press.</p>
<p class="references-references-text-1-9"><a name="ref2"></a>2. Stein DJ, Flessner CA, Franklin M, et al. Is trichotillomania a stereotypic movement disorder? an analysis of body-focused repetitive behaviors in people with hair-pulling. <span class="italic">Ann Clin Psychiatry</span>. 2008;20(4):194–198. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=19034750&dopt=Abstract">PubMed</a></span></p>
<p class="references-references-text-1-9"><a name="ref3"></a>3. Hyler SE. <span class="italic">Personality Diagnostic Questionniare-4</span>. New York, NY: New York State Psychiatric Institute; 1994.</p>
<p class="references-references-text-1-9"><a name="ref4"></a>4. Sansone RA, Wiederman MW, Sansone LA. The Self-Harm Inventory (SHI): development of a scale for identifying self-destructive behaviors and borderline personality disorder. <span class="italic">J Clin Psychol</span>. 1998;54(7):973–983. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9811134&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1002/(SICI)1097-4679(199811)54:7%3C973::AID-JCLP11%3E3.0.CO;2-H">doi:10.1002/(SICI)1097-4679(199811)54:7&lt;973::AID-JCLP11&gt;3.0.CO;2-H</a></span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Randy A. Sansone, MD</span></p>
<p class="ltrs-br-ltr-br-author"><a href="mailto:Randy.sansone@khnetwork.org" target="_blank">Randy.sansone@khnetwork.org</a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Joy Chang, BS</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Bryan Jewell, MD</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Martin Sellbom, PhD</span></p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Author affiliations:</span> Departments of Psychiatry and Internal Medicine (Dr Sansone) and Obstetrics/Gynecology (Dr Jewell), and medical school (Ms Chang), Wright State University School of Medicine, Dayton; Department of Psychiatry Education, Kettering Medical Center (Dr Sansone), Kettering, Ohio; and the Department of Psychology, University of Alabama, Tuscaloosa (Dr Sellbom).</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Potential conflicts of interest:</span> None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Funding/support:</span> None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Published online:</span> January 12, 2012.</p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">Prim Care Companion CNS Disord 2012;14(1):</span><span class="doi italic">doi:10.4088/PCC.11l01211.</span></p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">© Copyright 2012 Physicians Postgraduate Press, Inc.</span></p>
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