How reward and punishment are viewed by individuals experiencing trichotillomania according to revised reinforcement sensitivity theory

Objective: Improving our understanding of how reward and punishment are experienced by those with trichotillomania (TTM) may assist in the advancement of psychological interventions. The purpose of this study was to describe in detail the behaviours and experiences of relevance to individuals with TTM, with particular reference to reward and punishment. Methods: Qualitative, semi-structured interviews were conducted, recorded, and transcribed for analysis. Participants included 16 women with a mean age of 31.50 years and with clinically diagnosed TTM, the majority of whom were engaged in part-time work, had completed tertiary education, and were in a committed relationship. A theoretical thematic analysis, based on the behavioural activation system, behavioural inhibition system, fight, flight, freeze system, and constraint were used to organise a complex description of how reward and punishment are experienced. Results: Participants perceived themselves as generally highly sensitive to punishment, and distrustful and suspicious of positive and rewarding life experiences. Conclusions: Individuals with TTM need encouragement to find reward outside of hair-pulling behaviour. The rich, complex, and sometimes intricate descriptions given by participants may be useful to clinicians to help them understand and relate to clients. Particularly challenging was the separation of TTM, anxiety, and depression, leading to the suggestion of behavioural activation as a potential treatment, and topic for future research.