H12: ‘Keep your hair on!’ A historical narration of trichotillomania

S. Gupta,¹ V. Loniker,² S. Mazzon¹ and A. De³

¹Hertford County Hospital, East and North Hertfordshire Trust, Hertford North, UK; ²NMC Speciality Hospital, Abu Dhabi, UAE; and ³Calcutta National Medical College, Kolkata, India

‘Keep your hair on’ is used colloquially to ask somebody to not pull their hair out, figuratively, in stress. Given a medical connotation, it aptly describes trichotillomania, an impulse-control disorder of repetitive hair pulling in response to stress. Ancient literature describes ‘hair pulling’ across societies, where it was not only acceptable, but even encouraged: Greeks laid torn-out scalp hair on funeral pyres; Jains in India plucked hair to denote detachment; and African Ila tribe brides plucked their husbands’ pubic and chin hair following the consummation of marriage. The first documented account was by Aristotle in the fourth-century bc, in his renowned work ‘Nicomachean Ethic’, which had references to plucking hair and gnawing nails. Biblical citations include Prophet Ezra’s hair pulling (Ezra 9 : 3) and Prophet Nehemiah using it as punishment (Nehemiah 13 : 25). Other literary references include Greek philosopher Epictetus expressing that ‘men who plucked hair for fashion/vanity reasons fell into habitual behavior’ in his book The Discourses (101 ad); Greek poet Homer, in The Iliad (c.750 bc) and several of Shakespeare’s plays, including The Rape of Lucrece (1594), Much Ado About Nothing (1599) and even Romeo and Juliet, where he used it to emphasize Romeo’s deep exasperation: ‘Then mightst thou speak, then mightst thou tear they hair…’ (Kim WB. On trichotillomania and its hairy history. JAMA Dermatol 2014; 150: 1179). Hair pulling also finds a place in historical art, the most notable being ‘The Women from the Mad House’ – a life-size statue of a woman tearing her hair out by Artus Quellinus de Oude (1600s). Thomas Rowlandson and August Pugin’s drawing of St. Luke’s Asylum, London (1809), showed a patient with hands full of locks (1985). The 2015 documentary ‘Trichster’ described trichotillomania as ‘the most common disorder you’ve never heard of!’ In the medical literature, the earliest case report was by Hippocrates in the fifth century bc, in Epidemics I and III, of Delearces’s wife who ‘groped about, scratching and plucking out hair’ making such an impact that Hippocrates suggested physicians assess hair pulling routinely. The term trichotillomania was coined much later, in 1889, by French Dermatologist Francois Henry Hallopeau. The American Psychiatric Association first recognized trichotillomania as a mental disorder in 1987 and r-classified it in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an ‘obsessive-compulsive and related disorder’ in 2013. The rich history spanning not only medical, but also cultural, artistic and literary realms thus makes for an intriguing narration the next time somebody asks you to ‘keep your hair on!’.