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Case Report

Case Report

Time to test trichotillomania terminology

Shyamanta Das,1 Uddip Talukdar2 Suresh Chakravarty, 3 Bornali Das,4 Maheshwar Nath Tripathi5

1Assistant Professor, 2Registrar, 3 Professor and Head,Department of Psychiatry, 4Assistant Professor, Department of Dermatology, Fakhruddin Ali Ahmed Medical College Hospital, Barpeta, Assam, India, 5Service Senior Resident, Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Abstract

Impulse control disorders have been broadly defined as harmful behaviours performed in response to irresistible impulses. Habit and impulse disorders include disorders such as pathological gambling, pyromania, kleptomania, trichotillomania, and intermittent explosive disorder. It should be noted that with mounting research, the impulse control disorders are increasingly viewed as complex conditions sharing, in addition to irresistible impulses to perform harmful behaviours, features of trait impulsivity, trait compulsivity, and mood dysregulation, as well as obsessive compulsive mood, and addictive disorders. A 40 years old Islam female hailing from lower middle socioeconomic status of rural background complained of creeping sensation of head leading to an irresistible urge for pulling hairs associated with immediate gratification resulting in hair loss over scalp for eight months. The typical subject was a 33-year-old woman who had completed one or more years of college and had been pulling her hair for 19 years. Although many case reports and open trials describe successful treatment of trichotillomania with various serotonin reuptake inhibitors, controlled studies have yielded mixed results. Some authorities have argued that both the DSM-IV and ICD-10 criteria for trichotillomania are too narrow and it should be grouped with other self-grooming behaviours that may become problematic (e.g. skin picking and nail biting) into a family of grooming disorders or body-focused impulse control disorders.

Keywords: Impulsive control disorder, Grooming disorder and obsessive compulsive spectrum

 

Introduction

Historically, impulse control disorders have been broadly defined as harmful behaviours performed in response to irresistible impulses.1 In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), an impulse control disorder is defined as the failure to resist an impulse, drive, or temptation to commit an act that is harmful to the individual or to others.2 In the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), these conditions are classified as habit and impulse disorders and defined as repeated acts that have no clear rational motivation, cannot be controlled, and that generally harm the patient’s own interests and those of other people.3

Habit and impulse disorders include disorders such as pathological gambling, pyromania, kleptomania, trichotillomania, and intermittent explosive disorder.4 The disorders in this heterogeneous group are characterised by impulsive behaviour which the patient cannot resist or control.4 There may be a feeling of release of tension by doing the act and a feeling of guilt after the act is over.4 It should be noted that with mounting research, the impulse control disorders are increasingly viewed as complex conditions sharing, in addition to irresistible impulses to perform harmful behaviours, features of trait impulsivity, trait compulsivity, and mood deregulation, as well as obsessive compulsive mood, and addictive disorders.1

Trichotillomania (compulsive hair-pulling) is characterised by noticeable hair loss caused by person’s persistent and recurrent failure to resist impulses to pullout hair.4 There is an intense urge to pull out hair with mounting tension before the act and a sense of relief afterwards.4 There is no pre-existent skin lesion or inflammation, and hair pulling is not secondary to any delusion or hallucination.4 The management of impulse control disorders consists of behavioural therapy (e.g. aversion therapy), cognitive behaviour therapy (CBT), individual psychotherapy, and occasionally pharmacotherapy (e.g. carbamazepine for intermittent explosive disorder; fluoxetine for trichotillomania).4

 Case

E:\Assistant Professor\Case Report\Trichotillomania\Trichotillomania2\2011-07-30 13.08.42.jpgB.K. was a 40 years old Islam female hailing from lower middle socioeconomic status of rural background. She came alone to the Psychiatry outdoor patients’ department (OPD), referred from the Dermatology OPD. She complained of creeping sensation of head leading to an irresistible urge for pulling hairs associated with immediate gratification resulting in hair loss over scalp for eight months. Sleep was increased, appetite was diminished, micturition was frequent, bowels were irregular, and there was weight loss. Stress was land dispute. There was a similar episode, three years back which subsided on treatment. There was no family history of psychiatric disorder. She was illiterate, homemaker, and married, mother of two daughters and one son, chewed tobacco. Her mood was depressed and anxious. There was helplessness and death wish. Concentration was not sustained. Insight was level three. Her diagnosis was trichotillomania and treatment started with fluoxetine.

 

Discussion

The typical subject was a 33-year-old woman who had completed one or more years of college and had been pulling her hair for 19 years.5 Nearly two-thirds met the criteria for a major mental disorder (particularly anxiety and mood disorders), and more than one-half met the criteria for a personality disorder.5 Nearly three-quarters of first-degree relatives were reported to have a psychiatric disorder, and about five percent were reported to be hair pullers.5

Clinical studies indicate trichotillomania is more common in females than in males; may begin in childhood, adolescence, or adulthood; and may have an episodic or chronic course.6,7 Trichotillomania often co-occurs with mood, anxiety, eating, substance use, and other impulse control disorders in clinical samples of adults.6,7 Neuropsychological abnormalities found in trichotillomania patients have included increased error rates in spatial processing, divided attention, nonverbal memory, and executive functioning.6,8

Although many case reports and open trials describe successful treatment of trichotillomania with various serotonin reuptake inhibitors, controlled studies have yielded mixed results.6,7,9 Two small (N=13 and N=12) double-blind, crossover trials found clomipramine was superior to desipramine and equivalent to fluoxetine (which had beneficial effects), respectively, in reducing hair-pulling symptoms.10 In contrast, two slightly larger (N=21 and N=23) placebo-controlled, double-blind crossover studies of fluoxetine (both up to 80 mg/day) in adult chronic hair pullers found fluoxetine was not superior to placebo in suppressing hair-pulling symptoms.6,7,9

Some authorities have argued that both the DSM-IV and ICD-10 criteria for trichotillomania are too narrow, noting that patients with distressing hair pulling behaviour, especially children, may not always experience impulses and/or tension before hair pulling or relief with or after hair pulling.5-7 Indeed, for some persons, the hair pulling may be automatic or habit-like and not associated with urges, tension, or relief.10 In addition, the hair loss may not be noticeable.10 For this reason and because hair pulling is a self-grooming behaviour, some authorities have argued that trichotillomania should be grouped with other self-grooming behaviours that may become problematic (e.g. skin picking and nail biting) into a family of grooming disorders or body-focused impulse control disorders.6,7,11

The familial relationship between obsessive-compulsive disorder (OCD) and “obsessive-compulsive spectrum” disorders is unclear. Bienvenu et al.11 investigates the relationship of obsessive-compulsive disorder (OCD) to somatoform disorders (body dysmorphic disorder [BDD] and hypochondriasis), eating disorders (e.g. anorexia nervosa and bulimia nervosa), pathologic “grooming” conditions (e.g. nail biting, skin picking, trichotillomania), and other impulse control disorders (e.g. kleptomania, pathologic gambling, pyromania) using blinded family study methodology. Eighty case and 73 control probands, as well as 343 case and 300 control first-degree relatives, were examined using the Schedule for Affective Disorders and Schizophrenia-Lifetime Anxiety version and final consensus diagnoses were made using DSM-IV criteria. BDD, hypochondriasis, any eating disorder, and any grooming condition occurred more frequently in case probands. In addition, BDD, either somatoform disorder, or any grooming condition occurred more frequently in case relatives, whether or not case probands also had the same diagnosis. These findings indicate that certain somatoform and pathologic grooming conditions are part of the familial OCD spectrum. Though other “spectrum” conditions may resemble OCD, they do not appear to be important parts of the familial spectrum.

 

References

1.        Hollander E, Stein DJ, editors. Clinical manual of impulse control disorders. Arlington, VA: American Psychiatric Publishing; 2006.

2.        American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

3.        World Health Organization. International statistical classification of diseases and related health problems. 10th rev. Geneva: World Health Organization; 1992.

4.        Ahuja N. A short textbook of psychiatry. 7th ed. New Delhi: Jaypee Brothers Medical Publishers; 2011. p. 119.

5.        Schlosser S, Black DW, Blum N, Goldstein RB. The demography, phenomenology, and family history of 22 persons with compulsive hair pulling. Ann Clin Psychiatry. 1994;6:147-52.

6.        Franklin ME, Tolin DF, Diefenbach GJ. Trichotillomania. In: Hollander E, Stein DJ, editors. Clinical manual of impulse control disorders. Arlington, VA: American Psychiatric Publishing; 2006. p. 1149-73.

7.        Woods DW, Flessner C, Franklin ME, Wetterneck CT, Walther MR, Anderson ER, et al. Understanding and treating trichotillomania: what we know and what we don't know. Psychiatr Clin North Am. 2006;29:487-501, ix.

8.        Keuthen NJ, Makris N, Schlerf JE, Martis B, Savage CR, McMullin K, et al. Evidence for reduced cerebellar volumes in trichotillomania. Biol Psychiatry. 2007;61:374-81.

9.        McElroy SL, Keck PE Jr. Impulse control disorders. In: Gabbard GO, editor. Gabbard’s treatments of psychiatric disorders. 4th ed. Arlington, VA: American Psychiatric Publishing; 2007. p. 877-88.

10.     McElroy SL, Keck PE Jr. Habit and impulse control disorder. In: Gelder MG, Andreasen NC, Lpez-Ibor JJ Jr, Geddes JR, editors. New oxford textbook of psychiatry. 2nd ed. Oxford: Oxford University Press; 2009. p. 911-9.

11.     Bienvenu OJ, Samuels JF, Riddle MA, Hoehn-Saric R, Liang KY, Cullen BA, et al. The relationship of obsessive-compulsive disorder to possible spectrum disorders: results from a family study. Biol Psychiatry. 2000;48:287-93