Trichotillomania by proxy.

Trichotillomania is a disorder of an impulsive hair pulling that occurs in both adults and children alike. Trichotillomania is seen in children and often has other psychiatric comorbidity. Here, we present an interesting case of a mother who had trichotillomania and recovered with treatment following which she resorted to pulling hair of her child and brought her child for treatment saying that the child too had trichotillomania and that we should help the child recover like her. After interviewing the child, it was revealed that it was, in fact, the mother who used to pull the child's hair as a release for her hair-pulling urges.

INTRODUCTION

Trichotillomania is a common impulse control disorder seen in both children and adults characterized by the intense urge to pull out one's hair which then results in hair loss over the scalp, eyebrows, and/or pubic areas.[1] Pulling is often caused or preceded by stress and anxiety which is then relieved after the hair pulling process.[2] There is also a sense of guilt, ridicule, and shame associated with the disorder and patients do not often present on their own for treatment.[3] Sometimes, patients may have trichotillomania like symptoms that may extend to them pulling hair from sofa fibers, carpets, soft toys, and even pet animals though its documentation is not as common as the disorder itself.[4] Patients with trichotillomania often have insight that they have a disorder and may present to dermatological clinics seeking treatment for alopecia which is patchy and may appear to be alopecia areata. On close scrutiny, however, it may be detected that the alopecia is often due to trichotillomania rather than alopecia areata.[5] Here, we present a case of a patient who had trichotillomania and recovered well but then started pulling her child's hair and in fact brought the child for treatment claiming nonawareness with regards to the cause of the hair loss.

CASE REPORT

A 36-year-old woman presented to the psychiatry outpatient department with symptoms of hair pulling. She was brought by her husband who claimed that his wife used to pull her hair when anxious or worried. On questioning the patient, she revealed having an anxious nature and would worry unnecessarily about routine daily activities. When her worries would increase, she would develop an incessant urge to pull her hair and initially started pulling eyebrow hair, later moving to the scalp. She would have an intense urge that would make her do so, and she would experience a sense of relief after the act. She had similar hair pulling behavior when she was in school, and it would usually happen prior to either a stage performance or school examinations. It resurfaced in the past 6 months when her son who was in second grade had academic difficulties, and she would worry about his academics and education. She had good insight and realized that she has a problem that needed treatment and wanted a cure for her woes. She was started on Fluoxetine in the dose of 20 mg/day which was increased weekly by 20 mg and over a period of 3 weeks; we reached a dose of 60 mg/day. She was also psycho-educated about trichotillomania and was taught thought stopping and habit reversal to encounter her intense urges to pull hair. She responded well to the treatment and claimed nearly 100% improvement in a period of 4 weeks. She did not follow-up thereafter.

Within a period of 3 months post recovery, she brought her 8-year-old son to our outpatient department as a patient, claiming that he too exhibited trichotillomania and that he used to pull his eyebrow hair. She cited his poor performance in school academics as a reason for the same. The child was assessed and on repeated questioning vehemently denied hair pulling while his mother insisted on the same. The child's father was called upon in the absence of the mother and it was during the same session that the child tearfully told us that his own mother used to pull his hair from the eyebrows as a punishment for his bad performance in school. He said she used to do this whenever she felt like and it was only when his eyebrows look damaged and the school authorities complained about the same to her, that she brought him for treatment to us claiming that he was the patient as she needed documentation to the school that he was ill and was undergoing treatment. When we confronted the mother, in the presence of her husband threatening her police and legal action, in view of physically abusing her own child, she then broke down and admitted that she did pull her child's hair as she had intense hair pulling urges from time to time. She was then counseled and advised to restart the medication (fluoxetine). Supportive counseling was provided to the family, and the school authorities were briefed and asked to report to us if they suspected further hair loss in the child.

DISCUSSION

In child and adolescent psychiatry, we come across a condition called factitious disorder by proxy or Munchausen's disorder by proxy where a child may present to the medical or pediatric unit with medical conditions which may not have a cause and may, in fact, be due to the wrongdoing of a parent. These cases may often borderline on child physical and sexual abuse as well.[6] Here, we would like to use the term “trichotillomania by proxy” as a variant of Munchausen or factitious disorder by proxy where a parent pulls the child's hair as a means to satisfy her hair pulling urges and brings the child for treatment claiming that the child has trichotillomania. This is an important consideration for pediatricians, dermatologists, trichologists, and child psychiatrists when assessing childhood onset trichotillomania particularly when parents too have or admit to a history of trichotillomania. This case study brings to the fore an important yet rare presentation of trichotillomania that needs a detailed analysis.