Trichotemnomania in a family

Abstract

A 10-year-old school-going boy was brought to the dermatology department by his anxious parents for complaints of loss of hair over scalp, eyebrows, and eyelashes during the previous week.The onset of hair loss was sudden and not associated with any other local or systemic symptoms. The shed hair was found in clusters on the floor of the house and on the child's clothing. On further enquiry, the child's grandmother, aged 55 years, was also found to have lost her braid overnight. The child and his parents denied any self-manipulation.On examination, there was multifocal hair loss in a linear bizarre pattern over the vertex, eyebrows, and eyelashes ( Fig. 1). Trichoscopic evaluation carried out using a hand-held Dermlite II hybrid M dermatoscope at 109 magnification in polarized mode showed clean sharply cut ends, which were of equal length of around 5-6 mm from the scalp surface. Similar findings were noted over the eyebrows and eyelashes (Fig. 2).In addition, superficial abrasion suggestive of micro trauma was noted over the eyelid (Fig. 2). Hair pull test was negative, and nails were normal. By clinical and trichoscopic correlation, a diagnosis of trichotemnomania was established.On further probing by a psychiatrist, the child was found to be pressured at school by peers and teachers on his scholastic performance. Being the only child at home, he was frequently compared by his mother with brilliant students in the neighborhood. For the last few months, he would find excuses to miss school and use to spend more time with his grandmother, with whom the index patient shared a common bedroom. During this time, the grandmother's braid was 'found to be cut' overnight. This event drew a lot of attention and was widely propagated in both conventional and social media as a "demonic act of Satan." In a couple of weeks, a lot of similar cases were reported from various parts of northwestern India. 1 Media reports attributed this to some unexplained evil spirit, and the same reason was given by the grandmother. Common people and masses at large attributed it to some supernatural event due to cultural beliefs in the concept of ghosts, spirits, and supernatural prevalent from ages in this part of the world. However, later it was found to be a voluntary act. Thus symptom production in the form of braid cutting in the grandmother was a deliberate production of symptoms for unconscious gain, anxiety reduction, and a cry for help.Encouraged by the "sympathetic attention" drawn by the grandmother, the same was modeled by the index patient, wherein the child started cutting his own hairs. The child's parents stopped sending him to school thereafter. The symptom production provided an unconscious gain to the child in the form of escape from his stressful situation at home and school. These symptoms were unconsciously modeled as they had acceptance in the community.