The psychiatric literature is rather scanty on the subject of trichotillomania though the French dermatologist Hallopeau1 first introduced this term, as early as 1889, to describe an “irresistible urge to pull one’s hair”, mainly from the scalp area but which can also involve eyebrows, eyelashes, pubic hair and beard. Hair may be pulled out in tufts or one by one. In some cases the hair, after being pulled out, is swallowed (trichophagy) with subsequent formation of hair ball in the stomach or intestinal obstruction. Most cases start in adolescence and there appears to be a female preponderance2. It is not a common occurrence in children3 where usually emotional deprivation in the maternal relationship during the early years appears to contribute significantly to the development of the symptom4,5. It might occur as an isolated symptom which sometimes responds to behavioral treatment6. Trichotillomania is a rare presentation in a psychiatric clinic and is usually brought into the knowledge of psychiatrists by dermatologists. Some cases start at a time of stress and last only a few months, others continue for years2. Trichotillomania seems to have a diverse psychopathology though even at the time of Samson and Delilah, the genital significance of hair had been stressed and it was regarded to be an expression of strength. Berg7 suggested that hair behaviour in general is a symptom reflecting the conflict between sexual impulses at the genital level and the repressing forces of the super-ego or the ego and concerns about hair becoming thin, falling out, etc. were seen as displacement of castration anxiety. Brahal8, like Berg, also interpreted hair as a phallic symbol and indicated that hair pulling may appear in any type of sexual maladjustment, regardless of the outward emotional display. Sperling9, from her analysis of seven cases, observed preoccupation with hair to be a symbol for the expression of unconscious bisexual conflicts and in certain cases it even expressed giving up of the feminine part of the self. Monroe and Abse10 also stressed sexual conflict as being an aetiological feature and viewed tnchotillomania as a manifestation of self-castration or masturbatory impulses. According to Brahal8 and Leache11 it was also found out that hair symbolized strength, beauty, mourning, castration complex and played a major role in myths and customs of many cultures. Zaidens12 viewed trichotillomania as a self-inflicted dermatosis and considered the hair pulling of scalp area as a more serious disorder which, in four cases of women he studied, represented an attempt to escape from unbearable sexual situation presented by marriage. Hair-pulling of eyebrows, eyelashes and pubes was seen to occur as a mild neurotic symptom, a mechanism for release of nervous tension and as a masturbatory substitute. Ilan and Alex ander13 suggested that the trichotillomania of the scalp indicated pre-genital disturbances, involving deep regression. English14 regarded hair-pulling as a perverse means of gratification and Wilson15 also considered it as a practice giving gratification which, if prevented, evoked annoyance. Kanner16 defined it as a habitual manipulation of the body alongwith thumb-sucking, nose- picking and nail-biting as observed in two mentally retarded children. Irwin17 referred to hair pulling as an aggressive reaction with the emotions of grief and rage associated with it while Gelder2 regarded it as a tension reducing habit. Psychopathology in marital relationship had also been speculated. Zaidens18 cases were all unhappily married to inadequate dependent men whom the patient wanted “out of their hair”. Monroe and Abse\\\'a10 patient wed a primitive, sadistic individual. Trichotillomania is also seen in a variety of psychiatric disorders, e.g., in depression19, in mental retardation20, as an obsessive-compulsive disorder21, as fetishism22 and even as masochistic behaviour23. Bartsch24 raised the possibility of organic aetiology resulting from motor discharges originating in subcortical regions. Two case studies of Makrani females are presented in this issue of the Journal who fulfilled the diagnostic criteria of trichotillomania25 as described in Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) 26, i.e., recurrent failure to resist impulses to pull out one’s own hair, resulting in noticeable hair loss, increasing sense of tension immediately before pulling out the hair, gratification or a sense of relief when pulling out the hair, no association with a preexisting inflammation of the skin and not a response to a delusion or hallucination.
1. Hallopeau, X. Alopecia par grottage (trichomania ou trichotillo mania). Ann. Dermatol. Syphilis, 1889; 10:440.
2. Gdder, M., Gath, D. and Mayou, R. Oxford textbook of psychiatry. Oxford, Oxford University Press, 1983, p. 384.
3. Mannino, F.V. and Delgado, R.A. Trichotillomania in children. A review. Am. J. Psychiatry, 1969; 126:505 .511.
4. Langford, W.S. Disturbance in mother-infant relationship leading to apathy, extra nutritional sucking and hair ball, in emotional problems of early childhood. Edited byG. Caplan. New York, Basic Books, 1955, p. 57-76.
5. Stockmann, F. Trichotillomania . a study in child psychiatry. Prax. Kinderpsychol., 1962; 11:281-290
6. Gelder, M., Gath, D. and Mayou, R. Oxford textbook of psychiatry. 2nd ed. Oxford, Oxford University Press, 1989, p. 458.459.
7. Berg. C.The unconscious significance of hair. London, George Allen and Unwin, 1951.
8. Barahal, H.S. The psychopathology of hair plucking. Psychoanal. Rev., 1940, 27:291-310.
9. Sperling, M. The use of hair as a bisexual symbol. Psychoanal, Rev., 1954; 41:363-365.
10. Monroe, J.T. Jr. and Absc, D.W. The psychopathology of trichotil lomania and trichophagy, Psychiatry, 1963; 26:95 - 103.
11. Leache, ER. Magical hair. 3. Royal Anthropological Institute, 1958; 88:147- 164.
12. Zaidens, S. Self-inflicted dermatoses and their psychodynamics. j. Nerv. Mental Dis., 1951; 113:400--02.
13. Ilan, F.. and Alexander, E. Eyelash and eyebrow pulling (tricho tillomania). Treatment of two adolescent girls. Isr. Ann. Psy chiatcy Related Dis., 1965; 3:267 - 281.
14. English, OS. The role of emotion in disorders of the skin. Arch. Dermat. Syph., 1949;60:1063 -1076.
15. Wilson, S.A. Neurology. London, Arnold, 1944, p. 1632.
16. Kanner. L Child psychiatry. 4th ed. Springfield, Ill., Thomas, 1972, p 532.
17. Irwin, D. Alopecia, in emotional factors in skin disease. Edited by B.G. Russel and ED. Wittkower. New York, Paul Hoeber, 1953, P. 179.
18. Zaidens, S. Skin, psychodynamic and psychopathologic concepts. 3. Nerv. Merit. Dis., 1941; 113:388-394.
19. Greenber, HR. and Sarner, C.A. Trichotillomania symptom and syndrome. Arch. Gen. Psychiatry, 1965; 12:482-489.
20. Kaplan, H.L and Sadock, B.J. Comprehensive textbook of psychia try. 5th ed. Baltimore, Williams and Wilkins, 1989,vol. 2 p.1150.
21. Philippopoulos, G.S. Acase of tricbotillomania (hair pulling). Acta Psychotherapeutics (Basel), 1961; 9:304 -312.
22. Buxbaum, E. Hair pulling and fetishism. Psychonal. Study Child., 1960 15:243 - 260.
23. Oguchi, T. and Miura, S. Trichotillomania: Its psychopathological aspect. Compr. Psychiatry, 1977; 18:177-182.
24. Bartsch, E. Contribution towards the aetiology of trichotilloma nia in infancy. Psychiatry, Neurol. Med. Psychology, 1956; 8:173 -182.
25. Hussain, S. Trichotillomania - two case report from a similar cultural background. JPMA., 1992; 42.:,
26. Diagnostic and statisstical manual of mental disorders: DSM-III-R 3rd ed. rev. Washington, American Psychiatric Associatioon, 1989, p.326-328.