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TRICHOBEZOARS IN TRICHOTILLOMANI

TRICHOBEZOARS IN TRICHOTILLOMANIA: A CASE REPORT

1 Abhishek Pathak,2  JS Yadav, 3 Sameeksha Kaur,4 Shweta Singh

Senior Resident,Dept of Psychiatry IMS BHU,Varanasi.1 Assistant Prof. AIIMS, New Delhi,2 Psychologist SRLN hospital Varanasi,3Junior resident, Dept of Anatomy, IMS, BHU Varanasi4

 

Abstract

Background: The term trichotillomania refers to recurrent pulling out of one's own hair. Trichotillomania is currently classified as an impulse control disorder. Trichotillomania occurs more commonly in females than males, and there is high incidence of obsessive-compulsive disorder (OCD) in patients with trichotillomania (1,2). The prevalence of Trichotillomania is around 1% - 4% and is often associated with psychiatric and medical morbidity

Aim:  There is relatively little description of trichobezoars in psychiatric literature. This study aims to focus on trichobezoars in a patient of trichotillomania.

Methodology: We present a case of a patient with trichotillomania and a trichobezoar, including psychiatric management.

Results: Hair-pulling significantly improved in response to treatment with the selective serotonin reuptake inhibitor fluoxetine and supportive psychotherapy.

Conclusions: The medical and psychiatric sequelae of trichotillomania should not be underestimated. Pharmacotherapy may be playing a useful role in some patients with this disorder.

Key words: trichotillomania, trichobezoars, hair pulling, serotonin reuptake inhibitor.

Introduction


The term trichotillomania refers to recurrent pulling out of one's own hair. Trichotillomania is currently classified as an impulse control disorder. Trichotillomania occurs more commonly in females than males, and there is high incidence of obsessive-compulsive disorder (OCD) in patients with trichotillomania (1,2). The prevalence of Trichotillomania is around 1% - 4% and is often associated with psychiatric and medical morbidity (1,2). The most notorious of the medical sequelae of trichotillomania is trichobezoar—the formation of a hair ball after trichophagia. DeBakey and Ochsner (3) noted that trichobezoars may present with abdominal pain, nausea and vomiting, weakness, and loss of weight; may be diagnosed by a characteristic abdominal mass, hair in the stool, or radiolog ical findings; and may be complicated by obstruction, ulceration, perforation, and peritonitis. In this report, we describe a trichotillomania patient who presented with the uncommon complication of acute appendicitis secondary to a trichobezoar.

Case Report

Ms. F. is a 21-year-old Woman who presented with symptoms of Major depressive disorder. On further questioning she admitted to a history of hair pulling since the age of 10. Hair pulling was predominantly from the scalp, but she also pulled hairs from eyebrows, eyelashes, abdomen, limbs, and pubic area.  She also use to swallow the pulled hair. When interviewed with the Structured Clinical Interview for the diagnosis of Axis I disorder her current symptoms of depression met criteria for a major depressive episode. There was no family history of hair-pulling . However, the patient's mother had apparently suffered from major depression in the past. There was no significant medical history in the past. Patient was finally admitted in the ward. However, after 2 days of admission patient reported abdominal pain, nausea and vomiting for which she was referred to surgical emergency. Examination revealed tenderness in the right iliac fossa. Ultrasonography showed free fluid in the lower abdomen. The results of laboratory examination were with in normal limits. A decision was made to operate for suspected acute appendicitis. At surgery, the appendix was filled with hair. Around one month after surgery patient was readmitted in the psychiatry ward. The patient was treated with 40 mg of fluoxetine daily and supportive psychotherapy. She had significant improvement in mood and reduction in hair-pulling (Clinical Global Impression change score = 1 or very much improved), which was maintained for the duration of the subsequent year.

Discussion

Medical complications of trichotillomania may be dermatological (eg, scalp infection, lack of hair regrowth, color and textural changes (2)), orthopedic (e.g., carpal tunnel syndrome, and dental (e.g., gingivitis (2), trichobezoar is undoubtedly the most worrisome. Without surgical intervention, mortality figures were noted to be more than 70% (3). Bhatia et al. (4) reported that 37.5% of 24 young patients with trichotillomania had bezoars (25% trichobezoar, 12.5% trichophytobezoar). Trichobezoars are usually found in the stomach (3), but may also be found in the duodenum (3). Appendicitis secondary to trichobezoar has been described only rarely (5). Trichobezoars may result in a range of gastrointestinal symptoms or may be asymptomatic (3,4). On physical examination, there may a characteristic abdominal mass (3,6). Laboratory investigation may show anemia (4) and, although iron deficiency has been suggested to be a cause of trichophagy (7), normal iron levels in most patients with trichotillomania (8) suggest that this is rather a consequence. Radiological examination with barium swallow (3), ultrasonography (9), or computerized tomography (10) may show a characteristic appearance. In summary, the importance and severity of the medical complications of trichotillomania (and of other disorders with compulsive symptoms) should not be underestimated. Although studies of the pharmacotherapy of trichotillomania remain inconsistent, some patients, like the one described here, do seem to respond to fluoxetine or other serotonin reuptake inhibitors (8). Increased awareness of these disorders at a primary health care level should be encouraged.

References

1. Christenson GA, Mackenzie TB, Mitchell JE: Characteristics of 60 adult chronic hair pullers. Am J Psychiatry 148:365-370, 1991

2. Christenson GA, Mansueto CS: Descriptive characteristics and phenomenology of trichotillomania. In Stein DJ, Christenson GA, Hollander E (eds), Trichotillomania: Current Concepts. Washington, DC, American Psychiatric Press, in press

3. DeBakey M, Ochsner W: Bezoars and concretions: A comprehensive review of the literature with an analysis of 303 collected cases and a presentation of 8 additional cases. Surgery 4:934-

963, 1938; and Surgery 5:132-160, 1939

4. Bhatia MS, Singhal PK, Rastogi V, et al: Clinical profile of trichotillomania. J Indian Med Assoc 89:137-139, 1991

5. Smith DA: Gangrenous appendicitis associated with an appendiceal trichobezoar. Lancet 1:1390, 1983

6. Lamerton AJ: Trichobezoar: Two case reports—a new physical sign. Am J Gastroenterol 79:354-356, 1984?

7. McGehee FT, Buchanan GR: Trichophagia and trichobezoar: Etiological role of iron deficiency. J Pediatr 97:946-948, 1980

8. Swedo SE, Leonard HL, Rapoport JL, et al: A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania (hair pulling). N Engl J Med 321:497-501, 1989

9. Malpani A, Ramani SK, Wolverson MK: Role of sonography in trichobezoars. J Ultrasound Med 7:661-663, 1988

10. Tamminen J, Rosenfield D: CT diagnosis of a gastric trichobezoar. Comput Med Imaging Graph 12:339-341, 1988