ORIGINAL ARTICLE Cross-Sectional Study of Women with Trichotillomania: A Preliminary Examination of Pulling Styles, Severity, Phenomenology, and Functional Impact Christopher A. Flessner Æ Douglas W. Woods Æ Martin E. Franklin Æ Nancy J. Keuthen Æ John Piacentini Published online: 9 September 2008 Ó Springer Science+Business Media, LLC 2008 Abstract The current study utilized a cross-sectional design to examine pulling severity, phenomenology, functional impact, and ‘‘focused’’ and ‘‘automatic’’ pulling styles in women with TTM across a wide age spectrum. ‘‘Automatic’’ pulling refers to pulling occurring primarily out of one’s awareness, while ‘‘focused’’ pulling refers to pulling with a compulsive quality that may include pulling in response to a negative emotional state (e.g., anxiety, stress, anger, etc.), an intense thought or urge, or in an attempt to establish symmetry. In the present study, data were collected from 1,471 female participants (age 10–69) meeting modified diagnostic criteria for TTM via two separate online surveys (one for children/adolescents, one for adults). Pulling severity remained stable across the dif- ferent developmental cohorts. However, fluctuations in functional impact (e.g., social and interpersonal impairment) were noted. ‘‘Automatic’’ pulling showed relatively little fluc- tuation from adolescence to adulthood, while ‘‘focused’’ pulling demonstrated considerable fluctuation coinciding with psychological distress and typical ages of important biological changes (e.g., pubertal onset) in children/adolescents and adults (e.g., perimenopause). Conclusions, treatment implications, limitations, and future areas of research are discussed. Keywords Pulling styles Á Severity Á Phenomenology Á Functional impact C. A. Flessner (&) Á D. W. Woods Department of Psychology, Bradley/Hasbro Research Clinic, University of Wisconsin-Milwaukee, Coro West Building, 2nd floor, 1 Hoppin St., Providence, RI 02915, USA e-mail: christopher_flessner@brown.edu M. E. Franklin Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA N. J. Keuthen Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA J. Piacentini Semel Institute for Neuroscience and Human Behavior, University of California-Los Angeles, Los Angeles, CA, USA 123 Child Psychiatry Hum Dev (2009) 40:153–167 DOI 10.1007/s10578-008-0118-5