Managing a case of trichotillomania with trichobezoar.

Sir,

Trichotillomania derives its meaning from the Greek: Trich (hair), till (en) (to pull) and mania ("an abnormal love for a specific object, place, or action").[1] It is a compulsive urge to pull out one's own hair leading to noticeable hair loss leading to social or functional impairment. Trichotillomania is often complicated by trichobezoar, resulting from trichophagia that consists of ingesting the pulled hairs. Associated medical complications, misconceptions and ignorance about the disorder make treatment difficult. Further, lack of co-ordination and clarity of management options between different treating departments delay the clinical care pathway for the patient. Here, we report various challenges encountered in the management of a case of trichobezoar with trichotillomania in a 9-year-old female child.

A 9-year-old Hindu girl, resident of a nuclear family of middle socio-economic status presented with the complaints of 2 years duration characterized by compulsive pulling of hair from the scalp and ingesting them [Figure 1]. She had consulted a pediatrician and a dermatologist previously and was treated as a case of alopecia areata as a mother would conceal history due to attached stigma. Due to severe pain abdomen after 2 years of onset of illness, she was referred to a surgeon where detailed investigations revealed trichobezoar and the child had to be operated [Figure 2]. After recovery, she was referred to the psychiatry department, was diagnosed with trichotillomania and treated with Cap. Fluoxetine 40 mg (selective serotonin reuptake inhibitor). An aggressive treatment plan comprising of pharmacological and psychotherapeutic interventions was initiated. Antipsychotic augmentation (risperidone 2 mg) was initiated after 12 weeks of treatment with inadequate response on the Massachusetts General Hospital hair-pulling scale.[2] Psychotherapeutic approaches (habit reversal training, social skills training, supportive psychotherapy, art therapy and play therapy) were also instituted alongside. The child was successfully managed and was followed-up for a period of 1 year. No recurrence occurred. The challenges encountered in the management were frequent breaks in compliance due to various psychosocial stressors (lack of social support, father's death and financial constraints), ignorance about psychiatric illnesses, rigid socio-cultural beliefs and intermittent consultation with faith healers.

Figure 1

Hair loss due to trichotillomania

Figure 2

Post-operative abdominal scar

Hair-pulling behaviors lie along a continuum. In severe form, it can lead to the formation of trichobezoar resulting from the ingestion of pulled hairs. The incidence of trichobezoar in trichotillomania is unclear, although it has ranged from none to as high as 37.5% of the patients.[34] These can be life-threatening by causing gastrointestinal tract obstruction with ulcerations and perforation. Given that endoscopic removal of trichobezoar is possible at times, an early diagnosis is advantageous. However, the diagnosis is often delayed due to misconceptions and ignorance about the disorder, lack of co-ordination and clarity of management options between different treating departments.

Given the limited available clinical research evidence, no formal treatment algorithm for trichotillomania can be formulated. Dual treatment, using pharmacotherapy (selective serotonin reuptake inhibitor or clomipramine) and psychotherapy (habit reversal training) is more effective than monotherapy.[5] Various psychosocial factors which precipitate and perpetuate the pathology of trichotillomania should be taken into consideration and dealt with appropriately. The importance and severity of the medical complications of trichotillomania should not be underestimated. Awareness of the disorder along with greater inter-departmental collaboration would help in early diagnosis and appropriate management.