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Letter to the Editor

Hair Pulling and Borderline Personality Symptomatology Among Obstetrics/Gynecology Outpatients

Randy A. Sansone, MD; Joy Chang, BS; Bryan Jewell, MD; and Martin Sellbom, PhD

Published: January 12, 2012

Hair Pulling and Borderline Personality Symptomatology Among Obstetrics/Gynecology Outpatients

To the Editor: In a previous study of internal medicine outpatients, we found a statistically significant relationship between hair pulling and borderline personality symptomatology,1 suggesting associations with impulsive behavior rather than compulsive behavior.2 In this study, we reexamined this association, as well as potential racial differences, in a consecutive sample of obstetrics/gynecology outpatients.

Method. 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.

The mean age of participants was 26.44 years (SD = 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.

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).

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, resulting in bald patches]?); and (3) borderline personality symptomatology using 2 self-report assessments—the borderline personality disorder scale of the Personality Diagnostic Questionnaire-4 (PDQ-4)3 and the Self-Harm Inventory (SHI).4 The study was approved by 2 institutional review boards.

Results. 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 (χ21 = 27.14, P < .001; N = 373). Likewise, 48.0% of participants with hair pulling were SHI-positive (cutoff score of 5) versus 18.5% without hair pulling (χ21 = 12.39, P < .001; N = 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%; χ21 = 2.07, P = .15; N = 200), whereas PDQ-4-positive African American women did (80.0% vs 8.3%; χ21 = 41.53, P < .001; N = 143). The same pattern emerged with SHI-positive participants: nonsignificance in white women (41.7% vs 25.4%; χ21 = 1.53, P = .22; N = 200), but statistical significance in African American women (60.0% vs 9.9%; χ21 = 20.17, P < .001; N = 142).

Findings expand on our previous study in internal medicine outpatients1 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.


1. Sansone RA, Lam C, Wiederman MW. Hair-pulling and borderline personality symptomatology among internal medicine outpatients. Int Med J. In press.

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. Ann Clin Psychiatry. 2008;20(4):194-198. PubMed

3. Hyler SE. Personality Diagnostic Questionniare-4. New York, NY: New York State Psychiatric Institute; 1994.

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. J Clin Psychol. 1998;54(7):973-983. PubMed doi:10.1002/(SICI)1097-4679(199811)54:7<973::AID-JCLP11>3.0.CO;2-H

Randy A. Sansone, MD

Joy Chang, BS

Bryan Jewell, MD

Martin Sellbom, PhD

Author affiliations: 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).

Potential conflicts of interest: None reported.

Funding/support: None reported.

Published online: January 12, 2012.

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