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]:
- Recurrent pulling out one’s hair resulting in noticeable loss of hair
- Increasing sudden feeling of tension before pulling hair out or while
in attempt for resisting
- Sense of pleasure, rewarding, or relief after behavior
- The disturbance is neither accounted by another mental disorder nor
due to other general medical condition
- 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: