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A Case Report J Psychiatrists’ Association of Nepal Vol .4, No.1, 2015 CASE REPORT ARTICLE Childhood Trichotilomania with Atypical Treatment Response: A Case Report Das M1, Kaur A2 1. Assistant Professor, Department of Psychiatry, Government Medical College, Haldwani, Nainital (Uttarakhand) 2. Assistant Professor, Department of Community Medicine, Government Medical College, Haldwani, Nainital (Uttarakhand). E-mail *Corresponding author: [email protected] Abstract Trichotillomania once was considered as a rare disorder but now it is recognized as a psychiatric illness that is not as rare as previously thought. Standard treatment guideline of this disorder, especially for children is not available till the present date. In this report, a case of childhood trichotillomania, its various diagnostic possibilities and successful treatment with Risperidone in a child has been described. Keywords: Trichotillomania, Childhood Onset, Risperidone INTRODUCTION in infants though it is more often seen in the first French dermatologist, François Henri two decades of life, especially in female Hallopeau was the first to describe a case of self- adolescents. inflicted depilation of scalp and he coined the ICD 10 (International Classification of term Trichotillomania in 1989. This word is Diseases 10th revision) 5 has classified derived from Greek words: tricho- (hair), tillo trichotillomania in habit and impulse disorder (pull), and mania (madness). The term whereas DSM-V (Diagnostic and Statistical trichotillomania is misleading because the suffix Manual of Mental Disorders, Fifth Edition) 4 puts "mania" implies the presence of a serious it under obsessive compulsive and related psychiatric disorder. Even after 100 years of disorders. Meyer and Haag6 reported recognising the disease, etiology, natural history trichotillomania's association with stressful and treatment is not fully clear. However, it is situations. Major depression, dysthymia, anxiety, suggested that the adult type of trichotillomania borderline personality, psychosis, academic is associated with greater psychopathology than problems and over-concern with weight have that seen in childhood. 1, 2, 3 also been observed in association with According to the Diagnostic and trichotillomania.7 Hair pulling that occurs in Statistical Manual of mental disorders (fifth infancy and early childhood appears to be more edition) 4, in general population, the twelve likely to remit spontaneously or with minimal month prevalence of trichotillomania in treatment. 7 Oranje et al1, reported adolescents and adult is 1 – 2%. Trichotillomania trichotillomania in childhood starting as a "habit appears to be more frequent in females than in disorder". It is often seen in association with males, at a ratio of approximately 10:1. The thumb sucking, nail biting, and nose picking. female preponderance may be due to women’s No single modality has been established as greater willingness to seek treatment for cosmetic definitive effective treatment approach. Habit issue. Hair pulling is seen in all age groups, even reversal training (HRT) is a behaviourally based Das M & Kaur A. Childhood Trichotillomania….. 54 J Psychiatrists’ Association of Nepal Vol .4, No.1, 2015 treatment approach designed to treat further details were available. No history of trichotillomania. But its utility in early childhood discordance among the family members was is limited. Many drugs has been reported to be present. effective in this condition, commonly Physical examination of the patient antidepressant, combination of antidepressant revealed an area of baldness over the left fronto- and antipsychotics, even hormonal treatment has parieto-temporal region. In rest of the scalp, hairs been reported in cases, depending upon the were very short (trimmed). General and systemic associated co-morbid illnesses.7 examinations did not show any pathology. Her psychomotor activities were increased. There CASE HISTORY was no evidence of hallucination or delusion. Patient had no insight into her problems. A 44 months old girl was referred from On routine examination, haemogram, Paediatrics OPD (outpatient department) to the liver function tests, kidney function tests and Psychiatry OPD with complain of hair loss in the electrocardiography were normal. Thyroid left fronto-parieto-temporal region around 4cm x function tests (TFT) showed increased thyroid 4 cm area. Parents reported that they had noticed stimulating hormone (TSH) (5.61µIU) with gradual loss of hair on the said area for about 6 normal T3 & T4 levels. Paediatrician’s opinion months; on vigilance they found that the child was taken for deranged TFT but no active would pull hair from that site. On being asked the intervention was advised as it was subclinical child could not give any explanation and could hypothyroidism. Patient was referred to only say that she would experience ‘uneasiness’ Dermatologist, who too did not advise any before pulling hair. treatment after examining the patient and Parents also reported that for last one referred her back to Psychiatry OPD. month the frequency of hair pulling had Patient was treated with 0.25 mg of increased significantly to the extent that the area Risperidone and dietary modifications were had become totally hairless and ugly looking. advised for constipation. After one week of This made parents more concerned about the follow up parents reported some improvement in child. her over-activity, sleep disturbance, irritability, On being asked, parents reported that fidgeting and also improvement in frequency of there was change in the child’s behavior for last hair pulling. The dose of Risperidone was one month. She was more active as compared to increased to 0.5 mg. In the follow-up her previous self. She would not sit quietly while examinations over the next three months there studying or watching TV unlike her previous self, was significant improvement - the bald area was and was easily irritable and fidgety. Though covered by small hair. there were frequent breaks in her sleep at night, she would not feel sleepy during day time. DISCUSSION Though she would take food routinely, the intake The present case – 44months old girl was decreased. Parents reported that there was child presenting with history of hair pulling and no significant weight loss in the child, but they bald patch – responded well to Risperidone. The gave history of constipation for last 10 days. The relationship between anxiety and hair pulling is patient never made an attempt to eat the pulled difficult to establish in this patient. However, in out hair. this reported case there is some evidence of The patient belongs to nuclear family of anxiety characterised by patient’s complain of lower middle socio-economic status. She is some “uneasy feeling” before the hair pulling. It younger among two siblings. She was born may be possible that because of age factor, the normally at full term with uneventful antenatal patient could not properly describe anxiety period, had achieved normal mile-stones of symptoms. Also, hyperactivity, easy irritability, development and had no history of neurotic traits fidgeting may be manifestations of her anxiety.8 initially. No history of nail biting and thumb These symptoms might also lead us to think of sucking was present. Family history of hair the diagnosis of Mania or ADHD. pulling from head and eye brow to that extent of Therefore, clinical features of reported baldness was present in her cousin sister – no patient do not categorically fit for Das M & Kaur A. Childhood Trichotillomania….. 55 J Psychiatrists’ Association of Nepal Vol .4, No.1, 2015 trichotillomania or mania or Attention Deficit Hyperactivity Disorder. Also, no definite REFERENCE: guideline for the management of trichotillomania 1. Oranje, AP, Peere-Wynia, JD, DeRaeymaker, in early childhood is available till date. DM: Trichotillomania in Childhood. J Am Acad Considering that both of manic symptoms and Dermatol 15: 614-619, 1986. 2. Hautmann G, Hercogova J, Lotti T. ADHD would respond to antipsychotics, Trichotillomania. J Am Acad Dermatol Risperidone was started followed up with 2002;46:807–821. significant improvement in the condition. 3. Byrd MR, Richards DF, Hove G et al. Treatment Subclinical hypothyroidism might have of early onset hair pulling as a simple habit. been an associated co-morbid illness in this Behav Modif 2002;26:400–411. patient, but hypothyroidism is associated with 4. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric passive loss of hair not with active pulling of Association; 2013. p.251. 9 hair. Also, in this case the thyroid status 5. The ICD-10 Classification of Mental and remained same after two months on repeat Behavioural Disorders: Clinical Descriptions and examination though there was improvement in Diagnostic Guidelines. World Health pulling of hair. Thus, thyroid disorder as a cause Organisation; 1992. p. 167. for hair loss in this patient was ruled out. 6. Meyer, AE, Haag, A.: Psychosomatics of There is evidence for a genetic Trichotillomania and Related States or Disorders. Psychother Psychosom 42: 119 – 123, 1984. vulnerability to trichotillomania and more 7. Koran LM. Obsessive-Compulsive and Related common in individual with Obsessive Disorders in Adults: A Comprehensive Clinical Compulsive Spectrum Disorder and their first Guide. Cambridge: Cambridge University Press; degree relatives.7, 10 In this case one of paternal 1999. cousin sister, aged 12 years, has features 8. (Adam BS, Kashani JH. Trichotillomania
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