Some reflections on infancy-onset trichotillomania

Whether infancy-onset trichotillomania is best regarded as a habit, an early sign of obsessive compulsive disorder, a symptom of anxiety, or a sign of severe deprivation has been a topic of continuous debate. In this paper, we describe our clinical experience with nine consecutive cases of infancy-onset trichotillomania and detail the evaluation process and treatment course in one case. A distinct psychosocial stressor was identified in all cases, often accompanied by loss in the parents' histories. Most of the children had no transitional object. In six infants, the symptom resolved after treatment and did not recur, while in three others improvement was partial. Length of treatment varied from four to twenty-one sessions and outcome was unrelated to treatment duration. In all cases, mother-child interactions were characterized by a lack of maternal physical contact and warmth, sharp maternal transitions between under-involvement and intrusiveness, lack of mutual engagement, and no elaboration of symbolic play. The infant's behavior during play was marked by anxiety, irritability, and momentary withdrawal from the interaction. Our cases reveal an impaired affective interpersonal communication between mother and child, often masked by a fair overallfamily instrumental functioning. It is tenta- tively suggested that infancy-onset trichotillomania represents an end-point symptom of several factors, such as a disturbed parent-infant relationship, a low pain threshold in the infant, and a parental hypersensitivity to overt expressions of aggressive impulses and negative affects. Issues related to treatment modalities are also addressed. Discussion focused on our experience that early-onset cases of trichotillomania are often not benign or homogenous in terms of etiology, course, or response to treatment and require much further study.