1. Introduction
Trichotillomania (TTM) is a type of chronic impulse control disorder, characterized by the recurrent pulling of hair that appears on a person,s head (1). This process can cause pleasure and relief of pressure in the patient (2), although, it may be associated with skin disease, infection and injury at the site of the hair pulling (3). The cause is unknown, but there are a few suggestions that there is a genetic source, because trichotillomania may be more likely in children of families with a previous history of trichotillomania and in twins (4). The prevalence of hair-pulling in childhood period and adolescents is below 1% (5). Some patients eat the hair after pulling, which can cause masses, called trichobezoar (6, 7). The procedures for treatment of trichotillomania are different in children and adults and include psychotherapy and pharmacotherapy (8).
2. Case Presentation
The case is a 4.5-year-old girl who was referred to a psychiatrist because of obsession and compulsion to tweeze. The child was belong to a family from a middle socioeconomic class. There was a history of psychiatric disorder in the parents, but her mother separated from her hausband because of her father was dependent to crystal. Her mother was anxious with obsessive-compulsive traits. There was a history of separation anxiety disorder about her. The patient was taken to the nursery at age four, when for the first time she encountered separation anxiety and obsessive hair pulling. Her mother shaved her hair as a first line treatment. Once again, the child was taken into the nursery, but was ridiculed by her peers about whether she was a boy or a girl. Then, the child generally refrained from going to kindergarten, was isolated, a loner and refused to eat. The child did not tend to play with the other children. When her short hair grew again she began hair pulling more vigorously. The child had noted that if I dont it, Im offend and when I do it therefore, I will be better, and her peers thought her hair was more important to her. Behavioral therapy was provided for her including mindfulness training, awarding of prizes, positive encouragement and attempts by the parents to create a low stress, calm and supportive home environment. The patient showed significant improvement with this treatment and gradually was able to go to kindergarten.
3. Discussion
Psychiatric disorders in children, and their diagnosis and treatment, are always challenging. Especially when there are multiple comorbid disorders, treatment and how to deal with the disorder are faced with challenges. Separation anxiety normally occurs between the ages of 18 months and 3 years, with the peak age at 12 to 24 months and gradual reduction after 24 months. The child in this case had stress and anxiety, and felt forced to pull hair, because when she did this she felt relaxed. The sense of relief was temporary and later replaced by shame, fear and discomfort. Tweezing led to some parts of the head being bald, which created unpleasant appearance. The child performed the behavior secretly, not in front of others, and separation anxiety could have intensified it.
A study of 133 patients aged 10-17 years old with compulsive hair pulling found that in many cases anxiety and depression, as well as school problems, were more prevalent, and also that comorbidities have importance (9).
Trichotillomania in childhood is rare and is seen in girls more than boys and can be associated with an emotional deprivation in relation to the mother (10). Trichotillomania is usually seen in children aged 10 - 13 years, but in this case occurred at the age of 4.5 years, which required timely supportive measures by the parents (11). These measures are very important, particularly for children at an early age, to prevent consequences. Especially, this is of high priority when the child is sent to kindergarten, and hence, faces separation anxiety (12). The separation anxiety could lead to obsessive-compulsive disorder. These disorders can occur simultaneously. The hair shaving treatment done by the parent not only did not improve the disorder, but the child was isolated and a loner because of peer ridicule and an unpleasant appearance, which increased the severity of the disease and hair pulling after the hair re-growth. The full-head shaving made those around her say she was a boy (4). This caused the issue of gender conflict and was extremely upsetting to her (13). Families should be educated about proper treatments and not using unscientific and incorrect therapies that are recommended to them. In this case, using an unusual treatment exacerbated the patient’s problems.
Most people with trichotillomania are referred to dermatologists and treated for a long period of time, but because the origin of the problem is not a skin problem, no improvement in their condition is seen (14). In fact, the first line treatment of this disorder is psychotherapy and pharmacotherapy, followed by skin treatment. This means the patient should be referred to a psychologist and/or psychiatrist first, and then a dermatologist can help to improve hair re-growth (15).
Trichotillomania can be seen at the preschool age and is associated with separation anxiety disorder. Improper and delayed treatments can be associated with a worsening of the disorder.
