Clinical case rounds in child and adolescent psychiatry: trichotillomania-by-proxy: a possible cause of childhood alopecia.

Introduction Trichotillomania (TTM) is a common psychiatric disorder that presents in both children and adults (Reeve & Keuthen, 1998). Cases have also been reported in children who are toddleraged (Homes & Wright, 2003). TTM is characterized by the presence and subsequent inability to resist an urge to pull one’s own hair, which results in noticeable hair loss. Pulling is often preceded by a sensory or environmental trigger and is followed by tension reduction or pleasurable sensations. TTM sufferers frequently pull hair from the scalp, eyelashes, eyebrows and pubic regions, and keep this behavior hidden due to an associated sense of shame. Individuals with TTM have also reported the tendency to pull fibers from carpets and fur from stuffed toys and family pets in response to their urges (Tay, Levy, & Metry, 2004). Alopecia is a medical condition that is also defined by noticeable regions of hair loss, for which TTM is a potential cause. Childhood alopecia has a broad differential diagnosis including infectious and environmental etiologies. A potential cause that has not been reported in the literature to date is alopecia secondary to hair pulling by a TTM-affected parent. The following case series reports on two individuals diagnosed with TTM who reluctantly disclosed their behavior of pulling their children’s hair.