The E m o t i o n a l Areata,
Disturbance Underlying Alopecia Alopecia Totalis and Trichotillomania
Charles Toback, PhD and Solomon Rajkumar, MD Kings County Hospital, Brooklyn, N Y
ABSTRACT." A psychological study on fifteen children with diverse etiologies of hair loss, viz.,
alopecia areata, alopecia totalis and trichotillomania was conducted in order to assess the degree of underlying psychodynamics in children with hair loss. The results confirm the relationship of the underlying emotional disturbance to the hair loss. Further, it appears that the nmre severe the psychopathology of the individual, the greater is the hair loss and/or the clinical manifestation of trichotillomania.
Children with alopecia or trichotillomania are referred to psychiatry, rarely if ever to psychology, mainly because of their adjustment problems. Mostly through the psychiatric evaluation of these patients, the underlying relationship between the psychoanalytic dynamics and the physiologic correlate of baldness was inferred. Since previous studies (Mehlman and Greismar [1], Cohen and Lichtenberg [2], Bassef et al. [3], Asam and Trager [4] and Campbell and Hirsch [5] have suggested such a relationship, a psychological study would be of great interest to assess the degree of the underlying psychodynamics in children with hair loss.
Subjects Fifteen cases referred to the child psychologist from the Pediatric Ambulatory Service of the Kings County Hospital-Dov,aastate Medical Center, Brooklyn, NY, comprised the study group. The study period extended from January 1974 to November 1976. There were nine males and six females. The mean age of the children was nine years with a range of Drs. Toback and Rajkumar are Senior Clinical Child Psychologist and Clinical A~sistant Professor, respectively, Department of Pediatrics, Kings County Hospital-Downstate Medical Center, 451 Clarkson Avenue, Brooklyn, N.Y. 11203. Requests for reprints should be directed to Dr. Toback.
114
Child Psychiatry and Human Development, ~,bl. 10(2), Winter 1979
0009-398X/79/1690-0114 $00.95 C 1979HumanSciencesPress
Toback and Rajkumar
115
three years, six months to 12 years, 11 months. A medical diagnosis of alopecia areata, alopecia totalis or trichotillomania were made by the referring primary pediatrician. T h e r e were eight children with alopecia areata, five with trichotillomania and two with alopecia totalis.
Method All children were interviewed with the parent or guardian and a detailed family history was elicited. An inquiry was made as to whether a psychiatric evaluation was done. Each child was given individual psychological tests. A full psychological examination was administered whenever possible. The tests administered included the Wechsler Intelligence Scale for Children, the Geometric Forms test, the Goodenough draw-a-man test, the BenderGestalt test and the Picture Vocabulary test. The emotional disturbance was defined as poor adjustment at home, in school or both as well as parental complaints and analysis by the author. T h e degree of emotional disturbance was graded mild, moderate and severe.
Results Of the 15 cases referred for psychological evaluations, eight were administered full psychological tests and seven partial tests which excluded a standardized IQ test, because of failure to keep appointments. Majority of children ranged from dull normal to average intelligence; one case was estimated to be mentally retarded and another being in the superior range (Table 1). A close clinical observation of all cases revealed that there were some obselwable behavior which could be described as atypical, immature or of questionable adjustment. Poor relationship with the maternal figure specifically was a crucial factor in addition to the basic chaotic unstable home environment. In all fifteen cases of this report, the detailed family history revealed that emotional problems definitely existed. For example, in the case of a ten year girl who was an habitual nail biter and poor eater, significant adjustment problems in school was noted. Also, the darkened a n d marginally copied B e n d e r - G e s t a l t r e p r o d u c t i o n s suggested m a r k e d tension. Her drawing of a person was tiny, not well coordinated and suggested of a less socially mature child. Although her IQ was within average limits, her drawing was grossly abnormal with two arms protruding
116
Child Psychiatlw and Human Development
Table 1
No.
Age
Sex
1 2 3 4 5 6 7 8 9 I0 II 12 13 14 15
8-7 5-I 12-11 4-7 10-2 3~ 5-6 8-g 8-4 10-4 9-11 3-6 8-1 10-6 10-8
M
M F M M M M M F F M F M F F
Diagnosis
Psychological Evaluation
Intelligence
Trichotillomania Trichotillomania Trichotillomania Trichotillomania Trichotillomania Alopecia Totalis A1opecia ~otalis Alopecia Areata Alopecia Areata Alopecia Areata Alopecia Areata Alopecia Areata Alopecia Areata Alovecia Areata Alopecia Areata
Dull Normal Dull Normal Average* ~ n t a l Retard.* Average* ~ I I Normal Dull Normal Average Average Average* Average Average* Average Superior* Average
Full Full Partial Partial Partial Partial Full Full Full Partial Full Partial Full Partial Full
Psychiatric Evaluation
Emotional Disturbance
None None Yes Yes Yes None None Yes Yes None None None None None None
Severe Severe Severe Severe Severe Severe Nod~rate ~derate Mild Moderate Mild Moderate Mild Mild Mild
*Es timated
from the head, indicating the extent of the psychopathology involved. A possible correlation of a strong emotional overlay of children with alopecia and trichotillomania was also observed in this study. The emotional disturbance was found to be severe in six children, moderate in four and mild in five. The six children with severe emotional disturbance included all the trichotillomania cases and one of alopecia totalis. The four children with moderate disturbance included one case of alopecia totalis and three of alopecia areata. All five children with mild disturbance belonged to alopecia areata group. N o n e of the eight alopecia areata cases were found to have severe emotional disturbance; five had moderate disturbance and three others were mildly disturbed (Table 2). As the emotional pathology got severe the hair loss was greater as evidenced in the two cases of alopecia totalis which began as alopecia areata cases progressed to total baldness as the psychopathology worsened. Among the five cases seen by the psychiatrists as well, three had trichotillomania out of a total of six and two had alopecia areata out of a total of eight, further suggesting a greater n e e d for psychiatric evaluation in trichotillomania than alopecia. It appears that the severity of the emotional disturbance was significantly greater in cases of trichotillomania than in cases of alopecia. Table 2
Emotional Disturbance Mi Id Moderate Severe
Trichotillomania 0 0 5
Alopecia Totalis 0 1 I
Alopecia Areata 5 3 0
Tobaek and Rajkumar
117
Discussion A c o m p u t e r search of the literature revealed not only paucity of reports but also failed to reveal any controlled studies of alopecia or trichotillomania. In the r e p o r t e d cases, the underlying behavior dynamics and family social relationships were a s s e s s e d individually by a psychiatrist. Asam and T r a g e r [4] found that "early disturbance of m o t h e r child relations are seen as causes of trichotillomania". Campbell and Hirsch [5] o b s e r v e d in one of two brothers who had trichotillomania later also developed suicidal preoccupation. T h e act of hair pulling was viewed as part of a psychotic manifestation of an emotionally disturbed schizophrenic boy. T h e other b r o t h e r who developed alopecia areata was described as labile, hyperactive with an IQ of 94. In addition he was not b l a d d e r trained and had minimal abnormality in E E G . However, he p r o g r e s s e d in school satisfactorily. Children with trichotillomania also suffered from self-mutilating activities such as head banging, biting, hitting and scratching. Thus, evidence from literature suggests that trichotillomania cases showed more serious emotional disturbance and psychopathology than cases of alopecia areata. Conclusions T h e results of the present psychological study confirms the clinical psychiatric inferences of the relationship of alopecia and trichotillomania with emotional disturbance. This suggests an underlying emotional disturbance as a basis for a sudden hair loss in m a n y children without any identifiable dermatological etiology. T h e more severe the psychopathology of the individual, the greater is the hair loss and/or the clinical manifestation of trichotillomania.
References 1. MehlmanRD, Greismar RD: Alopecia areata in the very young. Am JPsych 125:605-614, 1968. 2. Cohen IH, Lichtenberg JD: Alopecia areata. Arch Gen Ps)vh 17:608-614, 1967. 3. Bassef et ah Some considerations concerning the psychosomatic study of alopecia. Ann Medico-Psychologiques 2:283,1969. 4. Asam U, Trager SE: Contribution to the etiology and pathogenesis of trichotillomania with special consideration of mother-child relations. Praxis der Kinderpsychol und Kinderpsychiatrie 22:283-290, 1973. 5. Campbell M, Hirsch SP: Observations on the vicissitudes of aggression in two siblings. J Aut Child Schizo 1:398-410, 1971.
Disturbance Underlying Alopecia Alopecia Totalis and Trichotillomania
Charles Toback, PhD and Solomon Rajkumar, MD Kings County Hospital, Brooklyn, N Y
ABSTRACT." A psychological study on fifteen children with diverse etiologies of hair loss, viz.,
alopecia areata, alopecia totalis and trichotillomania was conducted in order to assess the degree of underlying psychodynamics in children with hair loss. The results confirm the relationship of the underlying emotional disturbance to the hair loss. Further, it appears that the nmre severe the psychopathology of the individual, the greater is the hair loss and/or the clinical manifestation of trichotillomania.
Children with alopecia or trichotillomania are referred to psychiatry, rarely if ever to psychology, mainly because of their adjustment problems. Mostly through the psychiatric evaluation of these patients, the underlying relationship between the psychoanalytic dynamics and the physiologic correlate of baldness was inferred. Since previous studies (Mehlman and Greismar [1], Cohen and Lichtenberg [2], Bassef et al. [3], Asam and Trager [4] and Campbell and Hirsch [5] have suggested such a relationship, a psychological study would be of great interest to assess the degree of the underlying psychodynamics in children with hair loss.
Subjects Fifteen cases referred to the child psychologist from the Pediatric Ambulatory Service of the Kings County Hospital-Dov,aastate Medical Center, Brooklyn, NY, comprised the study group. The study period extended from January 1974 to November 1976. There were nine males and six females. The mean age of the children was nine years with a range of Drs. Toback and Rajkumar are Senior Clinical Child Psychologist and Clinical A~sistant Professor, respectively, Department of Pediatrics, Kings County Hospital-Downstate Medical Center, 451 Clarkson Avenue, Brooklyn, N.Y. 11203. Requests for reprints should be directed to Dr. Toback.
114
Child Psychiatry and Human Development, ~,bl. 10(2), Winter 1979
0009-398X/79/1690-0114 $00.95 C 1979HumanSciencesPress
Toback and Rajkumar
115
three years, six months to 12 years, 11 months. A medical diagnosis of alopecia areata, alopecia totalis or trichotillomania were made by the referring primary pediatrician. T h e r e were eight children with alopecia areata, five with trichotillomania and two with alopecia totalis.
Method All children were interviewed with the parent or guardian and a detailed family history was elicited. An inquiry was made as to whether a psychiatric evaluation was done. Each child was given individual psychological tests. A full psychological examination was administered whenever possible. The tests administered included the Wechsler Intelligence Scale for Children, the Geometric Forms test, the Goodenough draw-a-man test, the BenderGestalt test and the Picture Vocabulary test. The emotional disturbance was defined as poor adjustment at home, in school or both as well as parental complaints and analysis by the author. T h e degree of emotional disturbance was graded mild, moderate and severe.
Results Of the 15 cases referred for psychological evaluations, eight were administered full psychological tests and seven partial tests which excluded a standardized IQ test, because of failure to keep appointments. Majority of children ranged from dull normal to average intelligence; one case was estimated to be mentally retarded and another being in the superior range (Table 1). A close clinical observation of all cases revealed that there were some obselwable behavior which could be described as atypical, immature or of questionable adjustment. Poor relationship with the maternal figure specifically was a crucial factor in addition to the basic chaotic unstable home environment. In all fifteen cases of this report, the detailed family history revealed that emotional problems definitely existed. For example, in the case of a ten year girl who was an habitual nail biter and poor eater, significant adjustment problems in school was noted. Also, the darkened a n d marginally copied B e n d e r - G e s t a l t r e p r o d u c t i o n s suggested m a r k e d tension. Her drawing of a person was tiny, not well coordinated and suggested of a less socially mature child. Although her IQ was within average limits, her drawing was grossly abnormal with two arms protruding
116
Child Psychiatlw and Human Development
Table 1
No.
Age
Sex
1 2 3 4 5 6 7 8 9 I0 II 12 13 14 15
8-7 5-I 12-11 4-7 10-2 3~ 5-6 8-g 8-4 10-4 9-11 3-6 8-1 10-6 10-8
M
M F M M M M M F F M F M F F
Diagnosis
Psychological Evaluation
Intelligence
Trichotillomania Trichotillomania Trichotillomania Trichotillomania Trichotillomania Alopecia Totalis A1opecia ~otalis Alopecia Areata Alopecia Areata Alopecia Areata Alopecia Areata Alopecia Areata Alopecia Areata Alovecia Areata Alopecia Areata
Dull Normal Dull Normal Average* ~ n t a l Retard.* Average* ~ I I Normal Dull Normal Average Average Average* Average Average* Average Superior* Average
Full Full Partial Partial Partial Partial Full Full Full Partial Full Partial Full Partial Full
Psychiatric Evaluation
Emotional Disturbance
None None Yes Yes Yes None None Yes Yes None None None None None None
Severe Severe Severe Severe Severe Severe Nod~rate ~derate Mild Moderate Mild Moderate Mild Mild Mild
*Es timated
from the head, indicating the extent of the psychopathology involved. A possible correlation of a strong emotional overlay of children with alopecia and trichotillomania was also observed in this study. The emotional disturbance was found to be severe in six children, moderate in four and mild in five. The six children with severe emotional disturbance included all the trichotillomania cases and one of alopecia totalis. The four children with moderate disturbance included one case of alopecia totalis and three of alopecia areata. All five children with mild disturbance belonged to alopecia areata group. N o n e of the eight alopecia areata cases were found to have severe emotional disturbance; five had moderate disturbance and three others were mildly disturbed (Table 2). As the emotional pathology got severe the hair loss was greater as evidenced in the two cases of alopecia totalis which began as alopecia areata cases progressed to total baldness as the psychopathology worsened. Among the five cases seen by the psychiatrists as well, three had trichotillomania out of a total of six and two had alopecia areata out of a total of eight, further suggesting a greater n e e d for psychiatric evaluation in trichotillomania than alopecia. It appears that the severity of the emotional disturbance was significantly greater in cases of trichotillomania than in cases of alopecia. Table 2
Emotional Disturbance Mi Id Moderate Severe
Trichotillomania 0 0 5
Alopecia Totalis 0 1 I
Alopecia Areata 5 3 0
Tobaek and Rajkumar
117
Discussion A c o m p u t e r search of the literature revealed not only paucity of reports but also failed to reveal any controlled studies of alopecia or trichotillomania. In the r e p o r t e d cases, the underlying behavior dynamics and family social relationships were a s s e s s e d individually by a psychiatrist. Asam and T r a g e r [4] found that "early disturbance of m o t h e r child relations are seen as causes of trichotillomania". Campbell and Hirsch [5] o b s e r v e d in one of two brothers who had trichotillomania later also developed suicidal preoccupation. T h e act of hair pulling was viewed as part of a psychotic manifestation of an emotionally disturbed schizophrenic boy. T h e other b r o t h e r who developed alopecia areata was described as labile, hyperactive with an IQ of 94. In addition he was not b l a d d e r trained and had minimal abnormality in E E G . However, he p r o g r e s s e d in school satisfactorily. Children with trichotillomania also suffered from self-mutilating activities such as head banging, biting, hitting and scratching. Thus, evidence from literature suggests that trichotillomania cases showed more serious emotional disturbance and psychopathology than cases of alopecia areata. Conclusions T h e results of the present psychological study confirms the clinical psychiatric inferences of the relationship of alopecia and trichotillomania with emotional disturbance. This suggests an underlying emotional disturbance as a basis for a sudden hair loss in m a n y children without any identifiable dermatological etiology. T h e more severe the psychopathology of the individual, the greater is the hair loss and/or the clinical manifestation of trichotillomania.
References 1. MehlmanRD, Greismar RD: Alopecia areata in the very young. Am JPsych 125:605-614, 1968. 2. Cohen IH, Lichtenberg JD: Alopecia areata. Arch Gen Ps)vh 17:608-614, 1967. 3. Bassef et ah Some considerations concerning the psychosomatic study of alopecia. Ann Medico-Psychologiques 2:283,1969. 4. Asam U, Trager SE: Contribution to the etiology and pathogenesis of trichotillomania with special consideration of mother-child relations. Praxis der Kinderpsychol und Kinderpsychiatrie 22:283-290, 1973. 5. Campbell M, Hirsch SP: Observations on the vicissitudes of aggression in two siblings. J Aut Child Schizo 1:398-410, 1971.
