Some Reflections on Infancy-Onset Trichotillomania

Clinical Characteristics, Sleep, and Temperament in Infants and Young Children with Problematic Hair Pulling and Skin Picking

Background

This study examined clinical characteristics of problematic hair pulling (HP) and skin picking (SP) in infants and young children and their association with self-soothing, sleep, and temperament.

Methods

An internet survey of parents/caregivers of 0-5-year-olds (n = 384 with data analyzed, of whom 26 experienced HP, 62 experienced SP, and 302 were controls free of HP and SP) assessed demographics and medical history, HP and SP characteristics, contextual factors, self-soothing, sleep patterns, and temperament. Participants were recruited through both HP and SP advocacy and support webpages and general webpages (e.g., parenting groups). Descriptive statistics, chi-square tests of independence, independent samples t-test clinically characterized HP, SP, and control groups. Logistic regression and one-way analysis of covariance controlled for sex and age in analyses.

Results

HP and SP rates were 6.1% (n = 26) and 14.5% (n = 62), respectively. SP presented in 23.1% of children with HP, and HP presented in 9.7% of children with SP. Mean HP and SP onset occurred at 12.2 (SD = 11.2) and 24.1 (SD = 15.8) months, respectively. Contextual factors, including boredom, upset, and awake-in-bed were common in HP and SP. Common caregiver responses included distracting the child, moving the hand away, and telling the child to stop. Few caregivers sought professional help for the child. Children with HP engaged in more hair twirling than controls, and children with SP engaged in more nail biting than controls. Children with HP, but not SP, had more sleep disturbance than controls. In terms of temperament, children with HP displayed sensitivity to stimuli, children with SP exhibited low persistence, and both HP and SP groups displayed serious, observant mood relative to controls.

Conclusions

Findings expand clinical understanding of HP and SP in children aged 0-5 and provide targets (contextual factors, sleep, sensory sensitivity, persistence, and mood) for behavioral interventions. Low rates of treatment seeking highlight the need for expansion of clinical guidelines for HP and SP in this age range.

Gastric Perforation With Peritonitis Secondary to a Trichobezoar: A Literature Review and Report of a Rare Presentation

Trichobezoar, a rare disorder commonly seen in psychiatric patients having a habit of plucking and eating their own hair, is a ball of hair admixed with gastro-intestinal secretions that leads to the blocking of the passage of food particles. Presentation of the disease is variable, ranging from asymptomatic to severe complications including obstruction and perforation. We report a case of a 27-year-old female patient who presented with an acute abdomen and on laparotomy, gastric perforation secondary to large gastric trichobezoar was found. The patient was treated with en bloc removal of the trichobezoar.

A case of trichotillomania and trichophagy: Fantasies of cannibalism

Cannibalistic fantasies underlie some core mechanisms in psychoanalysis: identification, incorporation, introjection, and internalization. Freud (1917) saw melancholia as an incorporation of the object by devouring it, and Julia Kristeva (1989) takes the melancholic cannibalistic imagination to be a repudiation of loss, a destruction in order to possess the object. The author argues that cannibalism is a useful concept for understanding the double dynamics of trichotillomania and trichophagy - as destructive disconnection followed by incorporation of the hair; both suggest a magical reconnection with what was disconnected in order to establish a bond with the mother/analyst. The paradoxical passion of consuming the object of desire, symbolized here by the hair (resembling an umbilical cord and connection to the maternal object) captures the cannibalistic fantasy of never losing the object by destroying it.

Hair loss in an infant presenting with failure to thrive

An 11-month-old male child with a complex past medical history presented for admission due to failure to thrive. He had hair loss throughout his scalp, and his abdomen was distended. There was parental report of hair pulling and hair in his stool. An upper gastrointestinal (GI) radiograph with fluoroscopy was performed and showed a filling defect in the gastric lumen. On endoscopy, he was found to have a gastric bezoar consisting of hair, nail, and food material. The trichobezoar was removed, and he began to tolerate feeds and showed consistent weight gain. There were no recurrence of symptoms 8 months following removal. While inadequate caloric intake is a common reason for failure to thrive, mechanical obstruction from a trichobezoar as a cause is rare and to our knowledge has not been reported in a child this young.

The function of language in parent-infant psychotherapy

Parent-infant psychotherapy, a rather new field in psychoanalysis, raises questions of how to conceptualize the clinical process. Previous publications have used semiotic concepts to account for the therapist's non-verbal communication and investigated the countertransference, including what the baby might grasp of its variations. The present paper focuses on another argument for using verbal interventions to a baby in therapy; they present him with a symbolic order that differs from that of the parent. The qualitative difference between the parent's and the analyst's address is conceptualized by Dolto's term parler vrai. The therapeutic leverage is not the analytic interventions' lexical content but their message that words can be used to expose conflicts. Thereby, one can transform warded-off desires into demands that can be negotiated with one's objects. The reasons why this address catches the baby's attention are discussed. A prerequisite for such attention is that the infant brain is prewired for perceiving words as a special communicative mode. Relevant neuroscientific research is reviewed in regard to this question. The presentation relies on concepts by Dolto, Lacan and Winnicott and findings from neuroscience and developmental psychology. It also briefly discusses Chomsky's linguistic concepts in relation to these therapies.

Age of onset of trichotillomania symptoms: investigating clinical correlates

Pathological hair-pulling with onset in very early childhood is thought to represent a different disorder from that with later onset. We examined whether there are differences between adult hair-pullers with very early onset (VEO, i.e., <6 years), early onset (EO, i.e., 6 years to <18 years), and late onset (LO, i.e., ≥18 years) trichotillomania symptomatology. Participants with VEO (n = 76; 5%), EO (n = 1280; 80%), and LO (n = 248; 15%) symptoms of trichotillomania did not differ significantly from one another in terms of hair-pulling phenomenologies, comorbidity, functional impact, and perceived treatment response. However, hair-pulling sites varied across the groups; the VEO and EO groups were significantly more likely to pull eyelashes whereas the EO group was more likely to pull pubic hair. Study subjects had current hair-pulling, so biasing the sample to those with more enduring symptoms, despite differences in age of onset of initial pulling. The lack of significant differences found here does not support subtyping hair-pulling by age of onset in patients who present in adulthood.