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January 1992, Volume 42, Issue 1

Case Reports

TRICHOTILLOMANIA

Shahin H. Hussain  ( Department of Psychiatry, Aga Khan Hospital, Karachi. )

INTRODUCTION

Makranis, inhabiting Makran coast near Karachi are reportedly African in origin. They arrived as slaves in India in 18th and 19th centuries. Some of the treaties prohibiting the slave trade in India are quoted as early as 18201. They belong to lower socio-economic group and are mostly employed as domestic servants or labourers2. Inspite of many inter-marriages, they retain some of their original cultural phenomena. Their festivities involve dancing on African drums. They are less sophisticated, rather aggressive by nature, often illiterate but with some religious education at home or in the local mosque. Wife-battering is common and the natives declare that they are as vengeful as camels2. Jewellery is regarded as a symbol of femininity and their females start wearing it from a very young age. A woman is considered to be worthless if she is sterile and this often forces the husband to seek for a new wife. Two case reports of trichotillomania in Makrani women are presented.

CASE 1
Trichotillomania associated with infertility
A 30 years old housewife was referred by a dermatologist to the psychiatric outpatient department of the Aga Khan University Hospital, with a 6 years history of pulling out scalp hair and symptoms of depressive illness like difficulty in sleeping, feeling run down, poor appetite and loss of interest in daily household chores. The habit of pulling hair from the scalp was preceded by a strange sensation in her head followed by a sense of relief. Initially this occurred when she was upset due to some reasons but later became a regular habit. She got worse after the death of her mother to whom she was very attached. She was the youngest of four sibs and her father died of congestive cardiac failure 10 years back. There was no family history of psychiatric illness. She had a happy childhood and had received only religious educa­tion at a local mosque. She got marned 10 years ago to a distant relative who was 20 years her senior. This was an arranged marriage and she was ill-treated, beaten and not provided any financial assistance. The husband did not have a regular job and indulged in dubious activities, at times not returning home for weeks. Even after getting married she had to live with her elder brother and his family who were not very supportive. She had consulted various gynaecologists for her childlessness and as no abnormality was detected in her therefore the doctor had suggested an examination of her husband to which he vehemently refused and accused the patient of being a sick and a useless creature. The examination of her hair which was covered by a big cloth revealed that it was only about 1/2” in length with small areas of bald patches. She appeared tense, dejected and tearful while talking about her husband’s behaviour and of her own childless state. She seemed to be engrossed in her illness stating that life seemed like a burden, but had no suicidal thoughts. She admitted to her hair-pulling. She was given supportive psychotherapy alongwith amitriptyline (75 mg/day) and was advised to keep herself busy with household chores. Seen 3 weeks later, she appeared relaxed and reported marked improve­ment in her distressing symptoms. She also appeared to be well motivated to overcome her hair-pulling problem. The bald patches on her scalp showed small hair follicles growing out. During her third follow-up appointment three weeks after the second one, she appeared normal and was managing to control the urge of pulling her hair. After her third visit she did not show up again.
CASE 2
Trichotillomania associated with loss of jewellery
A 28 years old housewife from Makran was referred by a dermatologist with a 3 year history of pulling out scalp hair. She was the eldest often siblings and reported congenial family atmosphere with no overt family history of psychiatric illness except for her mother who was described to be possessed by ghosts in the form of developing blisters over her face since the last 10 years which improved on their own without any treatment. She had a happy childhood and had received only religious education at home. She got married at the age of 16 years to a cousin who was five years older and employed as a cook in a restaurant with a meagre pay insufficient for the family of eight people including 6 children. Because of financial difficulties, the husband decided to go to Dubai for better prospects. He required a sum of Rs.24,000 (Rs.26 = 1 US$) for completing the visa and other formalities to an agent and she was forced to sell her jewellery for arranging this money. Later on the husband did not go abroad and instead gave the money to his mother for loaning it to her younger son who wanted to start a business. This money was never paid back to her which perturbed the patient and she also stopped attending any weddings for not having her jewellery to wear on. She also developed the habit of pulling out her scalp hair though she herself denied about doing so and was noted to be engrossed in her thoughts most of the time. Over the past 3 years her hair-pulling had become so severe that she started getting bald patches among normal hair. Her husband later on bought her some new jewellery worth only Rs.4,000 which she refused to wear. She being very irritable and moody over the last 2 years and the symptoms of feeling low, poor appetite, loss of interest in meeting people and difficulty in sleeping were suggestive of a depressive illness. She had been treated by various faith healers without any improvement, until she saw us. The examination of her scalp showed patchy areas of baldness with untidy short hair not more than one inch long. She also expressed excessive concern regarding her hair problem and loss of jewellery. She was reassured and Mianserin (60 mg/day) was prescribed. On her sub­sequent visit 4 weeks later, she seemed to have re sponded favourably to treatment and appeared less depressed. There was a decrease in the intensity of hair-pulling. When asked about her jewellery, she ap­peared content with the efforts of her husband who was trying his best to raise some money in order to buy her some expensive jewellery. She never reported back to the clinic after her second visit.

DISCUSSION

Both these patients though unrelated came from the same area and cultural background. Though most cases start in adolescence3,4.  but these females had a slightly late onset. Hair is regarded as a symbol of beauty, strength and femininity in many cultures. The first lady, who could not conceive, was called a useless creature by her husband as, not only in Makran but in most primitive and unsophisticated cultures, the prime function of a female is to produce children; fertility represents femininity. Therefore hair-pulling in this depressed female who felt worthless and deprived of femininity was possibly a symbolic expression of her feelings. Trichotillomania has also been regarded as an expression of giving up of the feminine part of the self5.. Long hair and jewellery in some cultures represent femininity and perhaps this might explain the reason for pulling the scalp hair in the second patient who, deprived of her jewellery, felt worthless and de pressed. The hair-pulling is often denied by the patient4.. Here the first patient admitted to it but the second one totally denied it. Both these patients failed to keep their subsequent follow-up appointments which could be due to financial or social reasons. Both were clinically depressed. Greenberg and Sarner6.  reported nine teen patients most of whom had the onset in adolescence and 68% were suffering from depression which were often masked by denial, hypochondriacal ruminations and rationalizations. Majority (84%) of the cases in their series were females. The prognosis of trichotillomania is not known3.  and appears to be guarded inspite of the fact that many approaches including psychotherapy7.. psychoanalysis5., behavioural methods2.  and treatment with chlorpromazine8.  had been tried. There are encouraging re ports about the use of Clomipramine9,10.. Zaidens12.  reported a poor prognosis in cases of trichotillomania of the scalp but a more favourable one in cases involving the eyebrows, eyelashes or pubic hair.

REFERENCES

1. Aitchison, CU. A collection of treaties, engagementsand sun nuds relating to Indiaand neighbouring countries. Cukutta, Culcutta Military Orphan Press, 1865, Vol.7, p. 147, 227,251.
2. Burton, RY. Sirsdh and the races that inhabit the valley of the Indus. Oxford, Oxford University Press, 1973, p.253.257.
3. Gelder, M., Gath, D. and Mayou, R. Oxford textbook of psychiatry. Oxford, Oxford University Press, 1983, p. 384.
4. Gelder, M., Oath, D., Mayou, R. Oxford textbook of psychiatry. 2nd ed. Oxford University Press, 1989, p.458-459.
5. Sperling. M. The use of hair as a bisexual symbol Psychoanal. Rev., 1954; 41:363.365.
6. Greenberg. H.R. and Sarner, C.A. Trichotillomania symptom and syndrome. Arch. Geri. Psychiatry, 1965; 12:482- 489.
7. Stockmann, F. Trichotillomania. . Astudyof child psychiatry. Prax. Kinderpsychol., 1962;11:281-290
8. Childers, R.T. Jr. Report of two cases of trichotillomania of long standing duration and their response to chlorpromazine. J. Clin. Exp. Psychopathol., 1958; 19:141 - 144.
9. Swedo, S.&, Leonard, H.L, Rapoport, J.L, Lenane, M.C., Gold berger, E.L and Cheslow, D.L A double-blind comparison of clomipremine and desipramine in the treatment of trichotillomania (hair pulling). N. Engl. 3. Med., 1989; 321:497-501.
10. Pollard, CA., lbe, 1.0., Krojanker, D.N., Kitchen, AD., Bron son, S.S. and Flynn, TM. Clomipramine treatment of trichotillo mania, a follow-up report on four cases. J. Clin. Psychiatry, 1991; 52:128-130.
11. Zaidens, S.H. Self-inflicted dermatoses and their psychodynamics. 3. Nerv. Ment. Dis., 1951; 113:395-402.

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