Hair pulling (trichotillomania).

Based on the findings in this case and common elements reported in other articles on trichotillomania, there seems to be evidence that the "irresistible urge" to pull out the hair has its beginnings in the early years of a child's life. The nature of the parent-child relationships appears to be especially important in establishing psychological antecedents for the later development of trichotillomania. Specifically, the trichotillomanic's mother sets the stage for the emergence of this symptom by extending the child's dependence upon her as the primary need-gratifier beyond early childhood into latency, adolescence, and adulthood. As a result the child is not gradually propelled to participate in newer and more complex learning experiences that ultimately lead to a sense of mastery and independent functioning in the environment. Important developmental stimuli are not presented at the appropriate times and the child is not exposed to certain types of interactions at the optimal times so that some very important ego functions do not develop, or develop minimally, or in a distorted manner. Simply, the mother cannot "let go" of her child, apparently deriving gratification of her own needs through infantilization of the child; as a result the child develops a limited or illusory sense of self sufficiency. Continuation of such an unhealthy symbiotic relationship, however, is found in many forms of psychopathology and the fact that it also underlies trichotillomania may partially account for hair pulling as a symptom associated with such a wide range of nosological categories. It is the main contention of this study, however, that the quality of the parent-child relationships impairs the ego development and causes failure of the trichotillomanic patient to establish object constancy. Without the establishment of object constancy an individual requires visible evidence that the object/person capable of gratifying basic security needs is present or available. In trichotillomania the hair seems to symbolize the need-gratifying object/person who is lost when the hair is pulled out and, more importantly, regained when it is eaten or restored. It appears to be this latter component of trichotillomania, i.e., reincorporation of the need-gratifying object/person, which reassures the patient that infantile needs can be gratified and security can be reestablished. Unfortunately, the trichotillomanic is driven to repeatedly and compulsively remove hair so that it can be regained temporarily since object constancy is never really established.