Silent Hill 2's Pyramid Head design came to life from a painting in the game, not James's mind. This information came from a recent comment by art director Masahiro Ito.

So if I’m being honest, that’s one of the reasons I designed a creature with such a bizarre yet simply shaped head and a human silhouette. Masahiro Ito – Silent Hill 2 Concept Artist ...

Pyramid Head arrives as part of Dead by Daylight's upcoming Silent-Hill-themed DLC - which also includes a suitably sinister new map and familiar survivor - and marks the game's seventh licensed ...