Trichotillomania in a case of vascular dementia.

Trichotillomania is a complex psychiatric disorder and occurs along with a large number of comorbidity. We report a case of trichotillomania associated with vascular dementia. Trichotillomania in our case did not resolve using mirtazapine or conventional medications. Trichotillomania in dementia seems to have a neurobiological origin that needs to be elucidated.

INTRODUCTION

Trichotillomania is a disorder characterized by repetitive hair pulling, leading to noticeable hair loss and functional impairment.[1] It has been classified as an impulse control disorder and its neurobiological basis is not fully understood.[2] Whole-brain trichotillomania neuroimaging studies are lacking as well as treatment guidelines are unclear.[3] Although, several studies have revealed the role of impulsivity in mental disorders, its role in dementia is far from understood.[4] Impulsivity is defined as the failure to resist a drive or stimulus, or in a personality dimension as the inability to resist the desire to carry out a particular act.[5] It can be a psychopathological structural part of many mental disorders and it is mentioned as a diagnostic criterion in several mental disorders such as impulse control disorders such as trichotillomania and neurological disorders with behavioral disinhibition.[6] In the present report, we discuss a case of hair pulling associated with dementia and discuss the clinical issues related to the same.

CASE REPORT

A 79-year-old right-handed Hindu Indian male retired engineer was referred by his family physician to the psychiatry outpatient division of our private clinic. He presented with progressive cognitive and mental deterioration, involving memory impairment and executive dysfunction (difficulties in planning, sequencing, abstraction, and goal-directed behavior). This was coupled with behavioral and personality changes that began 3 years prior to the memory impairments and cognitive deterioration. His wife (main caregiver) reported deterioration in personal hygiene, an abandonment of personal interests and apathy with a lack of will to do anything. The patient just lay in bed all day long, locked up in his room. His magnetic resonance imaging brain revealed multiple infarcts in subcortical and cortical areas of the brain. The patient was diagnosed as having vascular dementia. The patient was started on Donepezil 10 mg per day and multivitamins were prescribed, with a 20% improvement in cognitive symptoms over a 4 week period. During the 3rd week of treatment he began pulling out his scalp hair throughout the day and multiple times. The patient gave no explanation for this act, and denied any feeling of tension prior to the act or deriving any pleasure from the act. He reported no pain, and had no insight regarding its compulsive nature or the potential harmful consequences to his skin. There was no evidence of any delusional beliefs or psychotic features related to his hair-pulling behavior. No history of similar symptoms, obsessive compulsive disorder or dementia in the family was present. The trichotillomania persisted despite treatment with several selective serotonin reuptake inhibitors (SSRIs) like Sertraline, Fluoxetine, Escitalopram, and Fluvoxamine (all separately in divided doses) and Mirtazapine with no improvement with any of the drugs. The patient had a mini mental status examination score of 16. The patient's informal neuropsychological exam showed marked memory deficits, executive dysfunction, and apraxia. No language deficits were noted except slowness in speech. A metabolic workup for treatable causes of dementia revealed no abnormalities that could contribute to his cognitive deficits. The patient followed-up for a few months and did not follow-up thereafter.

DISCUSSION

Trichotillomania is a complex disorder of multifaceted pathology, which often requires an interdisciplinary approach for management.[7] It is rare in dementia patients and has been reported however, in frontal lobe dementia.[8] In the present case, the symptom appeared with dementia progression. Trichotillomania includes (a) recurrent pulling out of one's hair resulting in noticeable hair loss; (b) an increasing sense of tension immediately before pulling out hair or when attempting to resist the behavior; (c) pleasure, gratification, or relief when pulling out hair; (d) the disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition); (e) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.[9] Our case fulfilled all these criteria, except for relief of tension when pulling out his hair, which proves hard to verify because of the difficulty in communication and understanding dementia patients. In fact, many patients with trichotillomania do not manifest the full criteria or do so intermittently.[10] In our dementia case, the patient had a loss of insight of the behavior, thus, indicating probable frontal lobe dysfunction.

The neurobiology of trichotillomania is a poorly understood phenomenon.[11] Our patient had multiple infarcts in the white matter and various areas of his brain. Reduced basal ganglia volumes,[12] cerebellar volumes[12] and increased grey matter densities in the left striatum, left amygdalo-hippocampal formation, and in multiple cortical regions bilaterally (including cingulate, supplementary motor, and frontal) have been reported in cases of trichotillomania.[12] This shows that trichotillomania was probably associated with structural grey matter changes in neural circuitry implicated in habit learning, cognition and affect regulation. Further studies are necessary to confirm an association between trichotillomania and structural brain changes in dementia. Our report suggests that trichotillomania in dementia does not resolve when treated with mirtazapine or routine SSRI medication probably due to an organic basis rather than a serotonergic basis. Thus it is prudent that the phenomena of trichotillomania in dementia be further studied and more cases reported and understood.