DISCUSSION
Similar to our present study, TTM usually presents first during childhood or adolescence and has a chronic course, with a female predominance of over 4 times to that of males [10]. TTM typically manifests as isolated patches of hair loss, which are frequently observed over the scalp’s crown, occipital, and parietal areas. The eyelashes, brows, pubic or other body hair are other areas that are usually affected [11]. The involvement of scalp hair was seen in our patient with patches of baldness mainly over the crown region, which appears to be unique and correlates with the literature. Other than scalp hair, this behavior did not involve the eyebrows, armpits or pubic area.
According to the DSM-V, five outline criteria must be met for the diagnosis of TTM, which include [1,2]:
  1. Recurrent pulling out one’s hair resulting in noticeable loss of hair
  2. Increasing sudden feeling of tension before pulling hair out or while in attempt for resisting
  3. Sense of pleasure, rewarding, or relief after behavior
  4. The disturbance is neither accounted by another mental disorder nor due to other general medical condition
  5. Causing clinically significant distress or impairment in social, occupational, or other important areas of function.
Patients frequently have a history or concurrent diagnosis of other psychiatric conditions, including anxiety or depression, similar to OCD-related illnesses [12]. Although TTM and obsessive-compulsive disorder (OCD) share many characteristics, TTM is a distinct clinical condition with grave social repercussions and potentially fatal effects if there is also associated hair consumption. According to literature, eating disorders (EDs) should also be included in the spectrum of OCDs, just like TTM [13,14]. The existence of TTM usually indicates a more severe form of generalized impulse control disorder, which could involve various related conditions, including EDs. A subjective sense of compulsion and trouble controlling repetitive activities are two traits shared by OCD and EDs [6,15].
About 20% of chronic hair-pullers are found to have eating disorders [10]. Our case was identified to have intermittent binge eating attacks with compensatory behavior like excessive exercising along with TTM. In another study of smaller populations with trichotillomania, Houghton et al. reported a prevalence range of 2%-14% for bulimia nervosa [5]. TTM and EDs are both considered to belong to a limited subset of diseases that also exhibit impulsive and compulsive elements and have comparable pathophysiological causes, such as cortico-striatal dysfunction, in addition to having comparable phenomenology and functionality [14,16]. A recent study discovered that there is a 16-fold higher chance of developing bulimia nervosa in females than males with OCD, which is consistent with our patient’s findings [17].
Studying the comorbidity of EDs and TTM is crucial for developing new therapeutic techniques to complement existing treatments like CBT. Innovative approaches could focus on addressing shared underlying vulnerabilities such as impulsivity or difficulties with emotional regulation. 79% of those who had TTM also had one or more mental health comorbidities, with anxiety/depressive disorders, OCD, PTSD, and ADHD being the most prevalent [12]. ADHD in general, is one of the most prevalent neurodevelopmental diseases in children. Both TTM and ADHD are difficult to define as both disorders share some common symptoms, in which, people with TTM may have a hard time resisting the urge to pull their hair, fidget or squirm in their seats, while similarly, people with ADHD also have trouble focusing and easily distracted or impulsive. The dysfunction of the reward system has been suggested as a potential factor in hair-pulling behavior, with the dopaminergic system also implicated in the pathophysiology of TTM [18]. Bhanji and Margolese reported a case study in which TTM was effectively treated with the dopamine/norepinephrine reuptake inhibitor, bupropion [19]. Nevertheless, in our patient, bupropion was found to be ineffective.
The predominance of ADHD features in our patient mandated the management to mainly include stimulants such as Methylphenidate or Lisdexamfetamine. A study by Golubchik P et al. showed that Methylphenidate was effective in the management of 9 adolescents with trichotillomania and comorbid ADHD [20]. Methylphenidate showed improvement in ADHD features, but symptoms of trichotillomania were relatively resistant to management, which is consistent with the results of our present case.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used for the management of both TTM and EDs, with effective results in the reduction of the symptoms of TTM, as seen in various literatures [21–23]. Since our patient also had co-morbid MDD, it was apt to add Escitalopram to the management. Despite being the first-line treatment option, studies indicate that while antidepressants may help alleviate depression and anxiety symptoms associated with trichotillomania, they do not produce consistent positive outcomes for the condition itself [24]. A study that analyzed the effectiveness of SSRIs in treating trichotillomania using randomized controlled trials reported a moderate level of improvement for all antidepressants utilized in the treatment [22].
Furthermore, it was seen that our patient did have an improvement in the symptoms on this management for a few months but subsequently worsened due to exam stress for the last 2 months. This was consistent with the findings of Golubchik et al., who noted that exposure to stressful life events was one of the key factors contributing to treatment-resistant TTM [20]. Thus, it appears that certain factors, such as stressful life events like exams or conflicts between parents and children, may have a substantial impact on the effectiveness of treatment for TTM. However, the vast majority of evidence indicates that the management of TTM is most effectively achieved by combining pharmacologic and non-pharmacologic treatment with ongoing follow-up and monitoring [22].
Case reports available in literature on trichotillomania with comorbid eating disorders: