Paediatric Trichotillomania- Case Reports and Review
ABSTRACT:
Trichotillomania (TTM) involves repetitive hair pulling that result in significant hair loss. As
in adults, the disorder also appears to take a significant toll on affected children and
adolescents in terms of associated impairment and co-morbidity. We report two cases prepubertal onset childhood trichotillomania. It is associated with significant functional
impairment and psychiatric co-morbidity across the developmental spectrum. Childhoodonset TTM appears to be spontaneously resolved, yet the research literature involving
paediatric samples are particularly sparse. Efficacious treatments, in particular cognitive–
behavioural interventions known as habit reversal training is first-line of management of
paediatric trichotillomania.
Key Words: trichotillomania, paediatric, childhood-onset
INTRODUCTION
Trichotillomania is classified as an impulse control disorder, in which the individual
has an overwhelming urge to pluck out hair, which leads to momentary relief from associated
anxiety.1Trichotillomania is infrequently seen in psychiatric clinics. Most salient findings
include presence of an urge (rather than any cognition) prior to hair pulling, lack of resistance
or distress for plucking the hair. It is reported to be more common in females with prevalence
rates of 0.6 %.2 Trichotillomania is described to have substantial co-morbid psychopathology,
and a parental history of tics, habits, or obsessive-compulsive symptoms.3,4
Although the negative effects of TTM are documented and often readily evident, there
remains a paucity of psychopathology and treatment research on this disorder, particularly in
paediatric populations.5It frequently runs a chronic course with frequent remissions and
relapses and the main stay of treatment is behaviour therapy, although pharmacotherapy has
also been used for the treatment.6
CASE STUDIES:
Case 1:
A 3 and half year old girl was referred by her paediatrician with a complaint of partial hair
loss on her scalp. Patient attended paediatrician for fever, nausea and vomiting, pain in
abdomen and decreased appetite. She had yellow discolouration of the skin and was
diagnosed with Hepatitis. Paediatrician noticed hair loss on her scalp and referred her to
psychiatrist as she was engaged in repeated pulling of hairs.
On further exploration, mother told that patient was pulling hairs from first year of her age.
It was first noticed by mother, while patient was bathing. Onset was gradual and family
members were unaware of it. She used to pull the hairs not only from her scalp but also from
mother, aunt and younger sister. Hair pulling was almost always followed by eating
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hairballs. Even, she was collecting hairs on the floor, bed, and pillow and used to eat it
making them into small balls. There were very scanty hairs on one half (right) of the skull.
Patient’s hair pulling continued in spite of repeated telling by the parents Patient was not
properly attended in those days as both the parents are working in the fields. She was often
left with grandparents.
Patient is first born child of non-consanguineousmarriage. The older of two siblings, she had
a normal birth and developmental history. She lived with her parents, grandparents, aunt,
and a one-and-half-year-old sister. Patient had habit of thumb-sucking and used to throw
temper tantrums whenever her wishes are not fulfilled. She had feeding problems during
infancy and later developed food fads. She is light sleeper and experiences night terrors. She
is sensitive to sound while sleeping. Often she used to wake up after mid-night, for a play
with her younger sister whom she woke up. She had no family history of mental illness. Bed
wetting is seen at least twice per night.
Her behaviour is predominantly stubborn and attention seeking. During psychological tests,
she was asked to draw picture, where she drew a picture of young girl with tears rolling
down from her eyes. When enquired about, she told that girl is not happy. Depressive
thoughts and negative cognitions were explored but she never verbalised them. Hyperactivity
was also been noticed. IQ was above average.
Her haemogram was normal except for haemoglobin which was 10.4 gm%. LFT were
deranged. USG abdomen revealed clumps of linear echogenic masses suggestive of
trichobezoar. Stool examination shows hairs. The scalp was not tender or bruised. A hair pull
test did not find her hair easy to pluck and hair shaft microscopy was normal. A potassium
hydroxide preparation from the lesional skin did not show any fungal elements.
She was diagnosed as a case of depression with trichotillomania and trichobezoar. She was
prescribed with antidepressants along with psychotherapy. After few weeks of consultation
and treatment, her hair-plucking behaviour decreased but she now-a-days threatens parents
that she will pluck hair and eat only to seek attention. (See Photograph 1)
Photograph 1: Loss of eyebrows as a result of hair-pulling from eyebrows
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Case 2:
An eight-year-old girl was consulted in child psychiatry outpatient clinic withcomplaints of
poor attention, concentration, irritability and rebellious behaviour and poor academic
performance. When asked about, patient also complained about frequent episodes of
giddiness, headache, neck and chest pain. She often refuses to go to school and presently
studying in class II. She repeated twice in KG I.
She has history of occasional bed wetting. Parents gave history that patient was pulling
scalp hairs which follows eating those plucked hairs. This pulling and plucking behaviour
started when patients was 7 months old. Patient was taken to the paediatrician and
dermatologist who assured parents that behaviour would disappear as child grows. Patient
continued pulling, plucking and eating scalp hairs. She was then taken to traditional faith
healers and pray centres because of lack of knowledge about psychiatric illness. For the last
2-3 years, she had stopped eating hairs but continued to pull and pluck. Past 5-6 months, she
doesn’t pull scalp hairs but plucks eyelashes.
She was diagnosed as a case of anxiety-depressionwith trichotillomania and treated with
antidepressants.(See Photograph 2)
Photograph 2: Patchy hair loss (shown by arrows) due to hair plucking in paediatric
trichotilomania.
DISCUSSION
TTM is included under other disorders of “impulse control” such as pyromania,
kleptomania, and pathologic gambling in the 4th edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV). These conditions share in common a sense of tension
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before performing a given act and gratification and/or relief after completion.However, many
patients with TTM, especially children, deny this tension/gratification phenomenon and
therefore do not meet DSM-IV criteria for the disorder.7 It is possible that young children
have not developed the expressiveness skills and emotional awareness required to be able to
identify or to report such phenomena.8 Our patients were also too young and they denied
either prior tension or gratification after hair-pulling.
Hair-pulling behaviour occurs along a continuum, ranging from a relatively common
benign form without significant cosmetic and emotional distress, to a more serious disorder
that is often disfiguring and leads to great personal suffering.The mean age of TTM onset is
prepubertal (between 9 and 13 years),9though it is difficult to distinguish TTM from the
habitual hair-pulling that occurs in younger children (<5 years old). The occurrence of hairpulling in the first year of life is a rare event.Also known as “baby trichs,” infants with such
behaviours have been observed to pull their mothers hair while being held and/or
nursing.10One of our patients also had been pulling hairs from caregivers in the first year of
life. Another girl child also started pulling hairs at 7 months of her age.The true prevalence of
hair-pulling among children and adolescents is unknown but is probably 1%.10
Scalp is the most common site of pulling,where the pattern of hair loss is often
bizarre, withirregularly shaped angular or linear borders.11 Hair-pulling also tends to be
biased toward the sideof a patient’s handedness. Patients tend to pull frommore than one site
and simultaneous TTM of eyelashand eyebrow hair is especially common amongprepubertal
children, as seen in one of our patients.However, TTM has been reported from almost
everyimaginable location, including pubic, perianal, nasal,ear, and abdominal sites, in
decreasing order of frequency.12 Affected areas are never completelybald, displaying clues of
short, broken-off hairs of varying lengths.
On average, children with TTM spend over an hour per day engaged in hairpulling.Ninety-five percent of patients note that “bingeing” describes at least some episodes
of hair-pulling.13 One third bite off the root of the hair, and 5% to 18% engage in trichophagy
(ingestion of the hair).14Trichophagy can also lead to the rare, serious complication of the
trichobezoar (“hair ball”). This also can clot with vegetable matter (trichophytobezoar), in
which complete casting of the gastric lumen can occur, known as the “Rapunzel” sign.15Not
surprisingly, this can result in a number of gastrointestinal complications including anaemia,
infections, intestinal obstruction, ulceration, and/or perforation. Our patients also ingest the
plucked hairs which lead to gastrointestinal infections and development of trichobezoar in
one patient.
The etiology of TTM is complex; in some children, it may be triggered by a
psychosocial stressor within the family, such as separation from an attachment figure, birth of
a younger sibling, sibling rivalry, moving to a new house, or problems with school
performance. Neurobiological factors havealso been implicated in TTM. Affective,attentiondeficit, anxiety, and obsessive-compulsivedisorders have been noted in some children, but
thetrue incidence is uncertain because it is difficult inmany cases to determine whether the
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presence ofsuch co-morbid conditions is a cause or consequenceof pulling.16In our patients,
psychological distress could not be explored but co-morbid depression and hyperactivity
disorders were present.
The literature suggests that childhood-onset TTMis typically of short duration, with
resolution oftenoccurring on its own or with simple interventions.17One studyfound
spontaneous resolution or resolution afterminimal intervention to be characteristic of those
patients with hair-pulling of 6 months’ duration,whereas hair-pulling in patients who had
pulled for6 months was characterized by a more chronic andtreatment-resistant course.18 In
our patients, the durationof hair-pulling was 3years to 5 years.
Although children sometimes admitto touching the affected areas, they
frequentlydeny pulling the hair. Direct confrontation and accusationare rarely helpful.
Nonpharmacologic treatments, in the form of behavioural and/or supportive family and
professional counselling, should be considered first-line therapy for children with TTM and
were successful in the majority of our patients. Behavioural interventions in the form of habit
reversal includes three core elements: first, awareness training, wherein techniques are
implemented to improve the patient’s awareness of pulling and, better yet, the patient’s
awareness of the urge that precedes pulling (e.g., self-monitoring); second, stimulus control,
which includes a variety of methods that serve as ‘speed bumps’ to reduce the likelihood that
pulling behaviour begins; and third, competing response training, where patients are taught at
the earliest sign of pulling, or of the urge to pull, to engage in a behaviour that is physically
incompatible with pulling for a brief period of time until the urge subsides.19
Pharmacotherapy shouldonly be used as adjunctive therapy, because no controlledpaediatric
trials have been performed. The selective serotoninreuptake inhibitors are the most
commonlyused pharmacotherapy for TTM; the rationale beingthe similarities between TTM
and obsessive-compulsivedisorder.20
References:
1. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. 4th edition text revision. Washington (DC): American Psychiatric
Association; 2000.
2. Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence of
trichotillomania in college students. J Clin Psych 1991; 52: 415-417.
3. King RA, Scahill L, Vitulano LA, Schwab-Stone M, Tercyak KP Jr, Riddle MA.
Childhood trichotillomania: clinical phenomenology, co-morbidity, and family
genetics. J Am Acad Child AdolescPsychiatr 1995; 34: 1451-1459.
4. Christenson GA, Mansueto CS. Trichotillomania: descriptive characteristics and
phenomenology. In: Stein DJ, Christenson GA, Hollander E, editors.
Trichotillomania. Washington (DC): American Psychiatric Press, Inc.; 1999. p. 1-42.
5. Harrison JP, Franklin ME. Pediatric Trichotillomania. Curr Psychiatry Rep (2012)
14:188–196
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6. O’Sullivan RL, Mansueto CS, Lerner EA, Miguel EC. Characterization of
trichotillomania. PsychiatrClin North Am 2000; 23: 587-604.
7. Oranje AP, Peereboom-Wynia JDR, De Raeymaecker DMJ. Trichotillomania in
childhood. J Am AcadDermatol. 1986;15:614–619.
8. Franklin ME, Zagrabbe K, Benavides KL. Trichotillomania and its treatment: a
review and recommendations. Expert Rev Neurother. 2011; 11(8): 1165–1174.
9. Christenson GA. Trichotillomania—from prevalence to co-morbidity. Psychiatr
Times. 1995;12(9):44–48.
10. King RA, Scahill L, Vitulano LA, Schwab-Stone M, Tercyak KP Jr, Riddle MA.
Childhood trichotillomania: clinical phenomenology, comorbidity, and family
genetics. J Am Acad Child Adolesc Psychiatry. 1995;34:1451–1459.
11. Swedo SE, Leonard HL. Trichotillomania: an obsessive compulsive spectrum
disorder? PsychiatrClin North Am. 1992;15:777–791.
12. Winchel RM. Trichotillomania: presentation and treatment. Psychiatr Ann.
1992;22:84–89.
13. Mansueto CS. Typography and phenomenology of trichotillomania. Paper presented
at: Annual Convention of the Association for the Advancement of Behaviour
Therapy; November 6–9, 1990; San Francisco,CA.
14. Schlosser S, Black DW, Blum N, Goldstein RB. The demography, phenomenology,
and family history of 22 persons with compulsive hair pulling. Ann Clin Psychiatry.
1994;6:147–152.
15. Vaughan ED Jr, Sawyers JL, Scott HW Jr. The Rapunzel syndrome. An unusual
complication of intestinal bezoar. Surgery. 1968;63:339–343.
16. Hautmann G, Hercogova J, Lotti T. Trichotillomania. J Am AcadDermatol.
2002;46:807–821.
17. Swedo SE, Leonard HL, Rapoport JL, Lenane MC, Goldberger EL, Cheslow DL. A
double-blind comparison of clomipramine and desipramine in the treatment of
trichotillomania (hair pulling). N Engl J Med.1989;321:497–501.
18. Stein DJ, Bouwer C, Maud CM. Use of the selective serotonin reuptake inhibitor
citalopram in treatment of trichotillomania. Eur Arch Psychiatry
ClinNeurosci. 1997;247:234–236.
19. Franklin ME, Tolin, DF. Treating Trichotillomania: Cognitive Behavioural Therapy
for Hair Pulling and Related Problems. Springer Science and Business Media; NY,
USA: 2007.
20. Christenson GA, Crow SJ. The characterization and treatment of trichotillomania. J
Clin Psychiatry. 1996;57(suppl 8):42–49.
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