The psychodynamic significance of trichotillomania: a case study

Il significato psicodinamico della tricotillomania: un caso clinico


1Cattedra di Psichiatria, Dipartimento di Medicina dei Sistemi, Università di Roma Tor Vergata

SUMMARY. In this paper we present a case of trichotillomania which lasted 33 years, starting with the patient’s menarche at 12 years old, and lasting until her first and only pregnancy at 45 years old. We explore the psychodynamic meaning of the hair pulling, both in light of the problems related to introjective and projective processes which, in the kleinian view, gives structure to the internal world and, according to Margaret Mahler, individuation-separation theory. The hypotheses on the significance of this symptom are discovered in part in light of the material which emerged from the patient’s intermittent participation in group psychotherapy for nearly five years prior to her pregnancy. Her pregnancy represents the transformational process of this symptom. Her feelings of desperation and anguish, and the rather dramatic expression of them, accompanied by constant suicidal ideas, reveal other conflicts in her primary relationships. The contact with these relational issues is accompanied by a progressive resolution of the trichotillomania. This also comes through in the significantly symbolic shift from the pulling of her own hair to the pulling of the hair from her wig.

KEY WORDS: trichotillomania, depression, psychodynamics, Klein, individuation-separation process.

RIASSUNTO. In questo lavoro presentiamo un caso di tricotillomania durato 33 anni, che si è manifestato dal menarca del paziente, a 12 anni, fino alla sua prima e unica gravidanza a 45 anni. Esploriamo il significato psicodinamico della tricotillomania, sia alla luce dei problemi connessi ai processi introiettivi e proiettivi che, in un’ottica kleiniana, determinano la struttura del mondo interno, sia secondo la teoria di Margaret Mahler sul processo di separazione-individuazione. Le ipotesi sul significato di questo sintomo emergono in parte alla luce del materiale raccolto dalla partecipazione intermittente del paziente alla psicoterapia di gruppo per quasi cinque anni prima della sua gravidanza, che rappresenta il processo di trasformazione di questo sintomo. I suoi sentimenti di disperazione e angoscia, e la loro espressione piuttosto drammatica, accompagnata da continue idee suicide, rivelano altri conflitti nelle sue relazioni primarie. Il contatto con questi problemi relazionali è accompagnato da una progressiva risoluzione della tricotillomania. Ciò avviene anche nel passaggio significativamente simbolico dal tirare i propri capelli al tirare i capelli dalla parrucca.

PAROLE CHIAVE: tricotillomania, depressione, psicodinamica, Klein, processo di separazione-individuazione.

Hair-pulling disorder (trichotillomania) is included in the DSM-5 as an obsessive-compulsive disorder1. Christenson et al.2 conducted a study with a large sample of university students, which estimated a lifetime prevalence of 0.6%. The incidence was 1.5% in men and 3.4% in women. There is frequent co-morbidity with anxiety disorders and depressive disorders3. In the DSM-5 trichotillomania is described as a disorder characterized by the recurrent pulling out of one’s hair, repeated attempts to decrease or stop hair pulling, and significant distress or impairment in social, occupational or other important areas of functioning due to the related hair loss. In this paper we report the case of a patient with trichotillomania whose disorder began during menarche and resolved itself with her first and only pregnancy.
M, the first of two daughters, was admitted to our facility when she was 40 years old. She was diagnosed as having a major depressive disorder as well as trichotillomania. M was prescribed medicines and assigned group psychodynamic orientation psychotherapy sessions. As her depressive symptoms improved, her dosages were lowered and eventually eliminated. However, her trichotillomania persisted. When she became pregnant at 45 years old, her anxiety and depression returned and her symptoms were particularly accentuated. After several hospitalizations, she undertook individual psychotherapy sessions, although her attendance was sporadic. The initial phase of the psychotherapeutic path highlighted how, in this patient, the pattern of object relations appeared significantly permeated by the split, the projection, and projective identification.
There were many contrasts in M’s perceptions of objects. On one hand, M remembers her mother as haughty, distant and unreachable. She remembers running enthusiastically to her mother, upon her mother’s return from work, but that her mother would stand back claiming to be tired. This created a strong feeling of disappointment leading to a general sense of abandonment. On the other hand, she saw her mother as extremely beautiful, perfect, and omnipotent.
Her father, whose mother died when he was 8 years old, appears to try to rebuild with his daughters the mothering he tragically lost in his childhood. It is interesting to note that, according to the literature, patients with trichotillomania often have parents who were orphaned at a young age4,5. After his mother’s death, M’s father, was neglected and subjected to humiliation by his father and his father’s new partner. Moreover, as a young man he was forced to abandon his dreams of becoming a tenor singer by a case of debilitating tuberculosis. M’s father took care of her and her sister more than their mother did. He was extremely strict about schoolwork and sports and their lifestyle was very sober. For example, the girls were not allowed to eat sweets except at Christmas, and even then they were allowed to buy only one Christmas brioche ( panettone). This style of increasing sobriety can also be seen when her father decided to purchase a beautiful villa in the countryside. He seemed to want from his daughters, and his country house, a compensation for his suffering through a kind of idealized perfection. M’s mother was dominated by M’s father and his needs, which probably contributed to her taking a step back in her relationship with her daughters. M’s childhood seemed to be characterized by her mother’s detached care and her father’s intrusive care, with little remaining space for individuality.
M’s desires and feminine identification were blocked on the one hand by a strong, projective paternal identification, and on the other hand, by an artificial and fragile imitative identification with her mother. M’s father’s intense need for redemption from his childhood of losses and humiliations unconsciously pushed M into the impossible task of trying to resolve her father’s problems. The internal paternal object appeared to be at the same time devouring and devoured6. It’s interesting to note that, after seeing a movie which featured a woman who was bald due to chemotherapy, M felt a panicked anxiety that her father could die.
M’s mother’s introjective process seemed to have been lacking. She was a distant mother, blocked both on a conscious and unconscious level from the possibility of entry into her daughter’s life. She became, for her daughter, more of a land to conquer and control with powerful projections, than a useable object. Her mother’s lacking introjection seemed to determine an absent maternal object. In this context M’s father also seemed to feel the need to play the role of a maternal surrogate.
M remembers living in constant anguish and guilt which resulted in a prohibition to success. M’s need for atonement seemed to manifest both in the trichotillomania and in a more general moral masochism.
M’s use of the split was evident in psychotherapy. On the one hand, there was a relay of persecutors that, from session to session, were M’s husband, father, sister, or State. On the other hand, the idealized mother towered, enjoying of a sort of immunity.
Even in the transference, there was the split and a powerful projective identification that sometimes placed the therapists in a location of idealized objects and sometimes seen as completely inept objects, useless and to be abandoned. There were several periods in which M disappeared, which left the therapists with the feeling of complete impotence as well as with the concern that something serious could have happened.
In line with trichotillomania’s frequent onset in puberty, M’s began at menarche. Menstruation seems to mark the identification of an autonomous femininity. The procreative capacity poses a separative problem with respect to her imitative identity of daughter-in-standby7. In childhood, M hoped that “her breasts would forget to grow”. This is almost repeated in her decision, prior to pregnancy, not to breast feed any eventual child.
The trichotillomania appears to represent the failure of the internalization of the good maternal object. The compulsive hair-pulling seems to represent aggression towards the maternal object and self. “Ruthless love” saves the object but at the same time it continuously destroys it so that it can always be rediscovered8. This could also represent the failure of the symbiotic phase in relation with her mother. The compulsive hair pulling seems to represent her mother’s abandonment. This appears to follow the fantasy of the symbiotic relation associated with the desire for her hair’s re-growth. In fact, Greenberg and Sarner discuss Hair Pulling Symbiosis5.
Over the course of years of daily hair-pulling, the areas of alopecia became increasingly extended to the point that M needed to wear a wig, which she would remove only inside her house. The trichotillomania appears to represent these two opposing internal objects: the alopecia as a sign of destruction of femininity, corollary of the maternal abandonment, and the wig as an idealized object. Interesting in this regard is a photograph of her father, young and handsome, with a costume wig which he wore in a theatrical scene when he was studying to become a tenor.
Klein, in 19529, observes that babies often reassure themselves of the good relationship with their mother by playing with her hair before feeding. In this light, perhaps, a symbolic shift could be proposed from the breast to the hair.
Pulling out her hair seems to represent, for M, at the same time an attack on her mother and a disintegration of her own ego. J. Riviere (1952)[10] highlights the infantile desire to disfigure the breasts of the mother (connecting it to envy in women). This hair-pulling compulsion mimics the impression of having received and incorporated the nipple and the breast into small pieces. Perhaps the hair may also represent the prolongation of vicious, aggressive thoughts to be eradicated.
M often associated the impulse to pull out her hair with feelings of loss and abandonment which recalls the lack of playful contact with the mother’s hair. Her bald scalp seemed to represent, at the same time, her monstrosity in relation to her mother’s abandonment of her, with the consequent aggression and the unconscious fantasy of taking control of her abandonment4.
After a long period of psychotherapy, M remembers her desperation at seeing her light brown hair in contrast with her mother’s idealized pale blond hair. The painful emphasis on the gap between the nuances of color catalyzes her anguish because of the difficulty of completing the introjective process of her own mother and the subsequent failure of the attempt at imitative identification. We could perhaps consider hair as an imperfect gift from mother to daughter. The relationship with her mother seemed to be the basis of the feelings of depression and loneliness and of the sense of solitude often present in M.
Moreover, both Ferenczi (1921)11 and Klein (1925)12 noticed a strong tendency to imitate in patients affected by tics. While we cannot fully assimilate this compulsion to tic we can find similarities. For Klein12 the tic contains the early object relationship conflicts of sadistic-anal and genital types. The tic is also considered both by Ferenczi11 and Klein12 as a masturbatory equivalent. The total absence of masturbation during M’s childhood and adolescence is interesting in this view.
Klein13 points out the role of projection in object relations. Having the positive aspects of the self projected onto the mother is fundamental to the development of good object relations. However, excessive projection onto the mother depletes the Ego, depriving it of its own value and life, leaving it almost a shell of the internal object from which it depends. The extension to other people leads to a very strong dependence on new external representatives of the positive aspects.
The common idea of death, and its extreme auto-devaluation, could read as a corollary of the projection of positive aspects of the mother with the consequent fear of never being able to find them in one’s self because they are buried in the object.
M’s poor self esteem, despite her obvious intellectual capacity, corresponds to her unconditional and unrealistic trust in the doctors (including colleagues who had met her only once in emergency situations, and whose expressed opinions became like the stone tablets of Moses to M’s mind). As her mother, they have the status of custodians of M’s projection of her reparative ability.
During her 33 years of trichotillomania, her wig seemed to be representative of an unreachable maternal world and possibly also the ideal of the paternal Ego (the father as a tenor). Her wig’s color is very pale, in homage to the hair that M’s mother had during M’s childhood. M was scrupulous about bringing the wig to special centers for cleaning and maintenance and often received compliments for her hair (the wig) from people ignorant of her actual alopecia.
The fullness of her wig and the baldness of her head represent the two extreme poles of the split between idealization and the monstrosity of abandonment. This extreme dichotomy between bad objects and idealized objects did not allow the use of transitional objects in M’s childhood. According to the literature4, the absence of a transitional object seems to represent a common denominator in patients suffering from trichotillomania.
M had a strong feeling of shame which accompanied her trichotillomania. She kept it secret for years from the psychoanalytic group and she declared during her pregnancy that, if her child were to see her bald, she would kill herself. This feeling seemed to connote the revelation of the shame of an unacceptable Self and of an internal mother forever torn apart by her own destructivity and by an extremely impoverished Ego, lacking the ability to repair herself. Moreover, the beautiful and well cared-for wig seemed an exhibit of an idealized, maternal and paternal object, lifeless and inanimate.
Every event which separated her from her mother caused a painful nostalgia. M remembers the seven years which she spent exclusively with her mother as a honeymoon period. This period came about following the Involuntary Psychiatric Treatment of her sister. A psychiatrist who treated her sister in an emergency, advised the separation of M and her sister. It was advised that M stay with their mother and her sister stay with their father.
M’s pregnancy, although wanted, was a true trauma for M. The entire duration of her pregnancy was characterized by constant episodes of anguish and crying fits, with thoughts of suicide and abortion. M seemed to consider her maternity as an unhealthy renouncement of any possible introjections with her own mother and an unmistakable rupture of the symbiosis. By the end of her pregnancy, M was terrorized by the idea that her child would see her bald, as a monster abandoned by her own mother.
Pregnancy marked a persecutory intrusion of a third element in her body along with the symptom (trichotillomania) which was defensively kept as a fragile, but violent, link with her mother. In fact, M’s anguish and despair were similar, even in their expression, to those of a small child abandoned by its mother.
The real, live fetus, created by her and growing within herself was inserted in the context of the strong split between the dying internal object and the external idealized object. The anguish of a mortal contamination which destroys life, renders the statement “if the baby were to see me bald, I would kill myself” more understandable. She seemed to feel as if the contact between the monstrous aspect, which contains at the same time dependence and destruction, would ruin her life forever. In this light, you can perhaps understand M’s impulse to throw herself out the window on the day of her delivery.
Towards the end of her pregnancy, M began pulling out the hairs of her wig instead of pulling out her own hair. As M was about to become a mother herself, the wig seemed to have passed from a static, idealized fetish to an extremely fragile sketch of a transitional object.
M delegated the care of her son to her mother from the time of his birth and throughout his infancy. Meanwhile, M recovered in a psychiatric ward for a month following delivery. The symbolic significance of her recovery, while her mother cared for her son, mimicked maternal care and reassured M with respect to the possibility of having a mother.
In this context, M passed from pulling out the hair from her wig, to stopping altogether to pull out hair, in homage to the tormented attempt at a new possibility of a mother with hair with which one may play.
This case appears to support the hypothesis that trichotillomania symbolizes the failure of the introjective process in the primary relationship with the corollary of the split and of the projective identification13. In parallel, this disorder seems be a consequence of the failure of the process of separation and individualization. M’s pregnancy revealed her repressed anguish and sense of solitude from her abandonment which we plan to explore in depth in ongoing psychotherapy. The transformation of the trichotillomania into a strong abandonment anguish shows the primary relational meaning of the symptom14.

Conflict of interests: the authors have no conflict of interests to declare.
 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-5. Washington: American Psychiatric Publishing, 2013.
 2. MChristenson GA, Pyle RL, Mitchell JE. Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry 1991; 52: 415-7.
 3. Grant JE, Redden SA, Leppink EW, Chamberlain SR. Trichotillomania and co-occurring anxiety. Compr Psychiatry 2017; 72: 1-5.
 4. Galski T. Hair Pulling (Trichotillomania). Psychoanal Rev 1983; 70: 331-45.
 5. Greenberg HR, Sarner CA. Trichotillomania: symptoms and syndrome. Arch Gen Psychiat 1965; 12: 482-9.
 6. Klein M [1948]. Sulla teoria dell’angoscia e del senso di colpa. In: Scritti 1921-1958. Torino: Bollati Boringhieri, 1978.
 7. Mahler MS. On Human symbiosis and the vicissitudes of individuation. New York: International Universities Press, 1968.
 8. Winnicott DW [1950]. Dalla pediatria alla psicoanalisi. Firenze: Martinelli, 1975.
 9. Klein M [1952]. Sull’osservazione del comportamento dei bambini nel primo anno di vita. In: Scritti 1921-1958. Torino: Bollati Boringhieri, 1978.
10. Riviere J (ed). Developments in psycho-analysis. London: The Hogarth Press, 1952.
11. Ferenczi S [1921]. Osservazioni psicoanalitiche sul tic. In: Fondamenti di Psicoanalisi. Rimini: Guaraldi, 1974.
12. Klein M [1925]. Contributo alla psicogenesi dei tic. In: Scritti 1921-1958. Torino: Bollati Boringhieri, 1978.
13. Klein M [1946]. Note su alcuni meccanismi schizoidi. In: Scritti 1921-1958. Torino: Bollati Boringhieri, 1978.
14. Freud S [1925]. Inibizione, sintomo, angoscia. O.S.F., 10. Torino: Bollati Boringheri, 1984.