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Childhood Trichotillomania

Successful Treatment With Fluoxetine Following an SSRI Failure

Received April 15, 1999; accepted May 6, 1999. From University of Oklahoma-Tulsa, Department of Psychiatry, 2808 S. Sheridan Rd., Tulsa, OK 74129; e-mail: william-yates{at}ouhsc.edu Address correspondence and reprint requests to Dr. Yates at the same address.

Key Words: Trichotillomania • Fluoxetine • Obsessive-Compulsive Disorder • Case Report

Trichotillomania is a behavioral disorder characterized by repetitive hair-pulling resulting in noticable alopecia. DSM-IV categorizes trichotillomania as an impulse control disorder, and requires the presence of "an increasing sense of tension immediately before pulling out the hair followed by pleasure, gratification, or relief when pulling out the hair."¹ King et al. found that "as a group, hairpulling subjects have substantial comorbid psychopathology, and a parent history of tics, habits, or obsessive-compulsive symptoms was common."² The researchers also assert that rising tension followed by relief may not be an appropriate criterion for diagnosis, especially in children, because 4 of their 15 subjects denied tension followed by relief.² There is also controversy over whether trichotillomania is a variant of obsessive-compulsive disorder(OCD), an OCD-spectrum disorder, or a separate clinical entity.³

To the authors' knowledge, there are neither published clinical trials of pharmacologic treatments for trichotillomania in childhood nor established guidelines. Clomipramine has been proven superior to desipramine in the treatment of trichotillomania in adults.⁴ Results are inconclusive on the use of fluoxetine for trichotillomania in adults.^5,6 A randomized, placebo-controlled, double-blind study by Riddle et al. suggests that fluoxetine is safe and effective in the treatment of children with OCD.⁷ DeVane and Sallee summarize the published clinical experience with selective serotonin reuptake inhibitors (SSRIs) in children and adolescents for several disorders, including OCD, Tourette's syndrome, and trichotillomania.⁸

The case we present provides information in two areas: 1) successful treatment of trichotillomania with fluoxetine after failure with another SSRI, fluvoxamine; and 2) trichotillomania as the initial symptom in a possible case of emerging OCD.

Case Report

S. was a 7-year-old white female child when she and her grandmother presented to her family practice doctor with her first complaint of hair-pulling of the scalp. Conservative treatment was recommended. The patient returned 6 months later with continued hair-pulling resulting in patchy alopecia with broken shafts. The patient was started on fluvoxamine (25 mg/day). Three weeks later, the patient's family reported decreased hair-pulling, except when asleep, with alopecia unchanged. Fluvoxamine was increased to 50 mg/day. Four weeks later, the patient presented with increased hair-pulling associated with a stressor involving the destruction of her uncle's trailer by fire. There were also two nights of enuresis following this event.

A consultation from the Psychiatric Consult Service was obtained 8 weeks after starting fluvoxamine at a dose of 50 mg/day. It was learned that S. pulled her hair throughout the day and while asleep. She pulled both intentionally and absentmindedly. Her family reported that she would experience discomfort if they prevented her from pulling. The family deny trichophagia and rituals involved with pulling. The family report that S. has always been a light sleeper and eater, but they deny depressive symptoms. S. described herself as very happy and reported functioning very well academically, with "straight A's." She reported no difficulty making or keeping friends at school, but she reported appropriate sadness when peers would tease her and steal her hat.

Past history was negative for anxiety or depression. She had a normal development. She had no academic or behavioral problems at school. The patient's family reported two episodes of head lice several months before the onset of trichotillomania. The patient's family reported good physical health throughout her life, and denied any infectious history.

The family history was significant for several psychiatric illnesses. The patient's father was reported to have severe alcoholism and schizophrenia, although he refuses to take psychiatric medications. The patient's paternal grandmother reported that the patient's father has pulled his hair since early childhood and currently has a habit of "playing with" his hair but does not pull it out. The patient's mother reported she has mitral valve prolapse and "a problem with her nerves," for which she has taken benzodiazepines and antidepressants. The patient's 12-year-old brother attends special education classes and has been diagnosed with atttention-deficity hyperactivity disorder.

Physical examination showed a cheerful child wearing a colorful hat to cover her head. When the hat was removed, there was severe hair loss to the frontal, occipital, and parietal areas, but no scarring of the scalp. There was fine, short hair on the top of the head. Eyebrows and eyelashes were within normal limits. Mental status exam showed bright affect and excellent eye contact. The patient answered questions appropriately, with good vocabulary. There was no evidence of thought disorder, including no mention of obsessions. She reported she "didn't know" why she pulled her hair. The patient denied worrying excessively but reported that she was very upset when her uncle's trailor burned down, although no one was hurt.

At the time of psychiatric consult, fluvoxamine was discontinued and fluoxetine 10 mg/day was started. At an 8-week follow-up with the family practice physician, the patient showed remarkable improvement. Hair-pulling behavior had dramatically decreased, resulting in significant regrowth to the scalp. The patient's family reported no adverse side effects, and also noticed the patient had been sleeping longer and more soundly on the fluoxetine.

At 15 weeks after starting fluoxetine, the family reported excellent control of the child's trichotillomania. However, S. had recently begun to ask to take several baths per day, and they said that she would take baths hourly if they would allow her. She also had begun insisting on using a fresh towel after each bath. Despite this new development, the family was very pleased with the fluoxetine and desired to continue the dose at 10 mg/day.

Discussion

This patient's case is interesting in light of her success on fluoxetine after failure on fluvoxamine. Because there are no established clinical guidelines on treatment of trichotillomania, one may consider using the practice parameters for treatment of OCD in children and adolescents, which recommends clomipramine, fluvoxamine, and sertraline as first-line agents.⁹ Approved usages for the SSRIs are shown in Table 1.

Failure to respond to 50 mg of fluvoxamine was considered an adequate dose in this child. Based on weight, 50 mg for the patient was equivalent to a 150-mg dose in an adult. Some studies of fluvoxamine have suggested doses up to 150 mg/day for the childhood and adolescent ages. We cannot rule out that the patient might have responded to a higher dose of fluvoxamine.

In failure of one SSRI, a trial with another SSRI could prove successful, as shown in the case we presented. Studies in depression have confirmed that a failure with one SSRI does not mean failure for all SSRI compounds. Naylor and Grossman presented a case of trichotillomania with comorbid depression in a 16-year-old person in which the depression responded to fluoxetine, but the trichotillomania did not. The trichotillomania improved greatly, however, when the fluoxetine was discontinued and clomipramine started.¹¹

Another approach in treatment failures is augmentation therapy. Consistent with the findings that dopamine may play a role in OCD and related disorders, atypical neuroleptics have been used with moderate success in patients with OCD, trichotillomania, and Tourette's syndrome that was refractive to monotherapy.¹² Potenza and colleagues presented a case of trichotillomania in a 22-year-old person in which the patient had a significant decrease in hair-pulling on risperdone augmentation of fluvoxamine, but who developed hyperprolactinemia and elected to discontinue the risperdone. Olanzapine (10 mg/day) was added to a 15-week trial of fluoxetine monotherapy, with significant decrease in trichotillomania symptoms.¹³ Clonazepam, haloperidol, and risperdone have been proven to be superior to placebo in studies in adults,⁹ but caution should be used in prescribing neuroleptics in children because of side effects. Finally, naltrexone augmentation of fluoxetine achieved moderate improvement in symptoms in an adult with trichotillomania and depression.¹⁴

The role of behavioral therapy cannot be ignored in cases of trichotillomania that is refractory to pharmacologic treatment. We support a trial of a second SSRI following failure of a first-line trial of SSRI and believe that more studies of treatment strategies are necessary. Furthermore, the development of bath-taking compulsions on fluoxetine supports the correlation of trichotillomania and OCD.

ACKNOWLEDGMENTS

Dr. Yates received research grant support from Eli Lilly and Co., the makers of fluoxetine (Prozac).

View this table: [in this window] [in a new window]

TABLE 1. Food and Drug Administration package insert information for selective serotonin reuptake inhibitors

REFERENCES

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, p. 621
2. King RA, Scahill L, Vitulano LA, et al: Childhood trichotillomania: clinical phenomenology, comorbidity, and family genetics. J Am Acad Child Adolesc Psychiatry 1995; 34:1451–1459
3. Keuthen NJ, O'Sullivan RL, Sprich-Buckminster S: Trichotillomania: current issues in conceptualization and treatment. Psychother Psychosom 1998; 67:202–213[Medline]
4. Swedo SE, Leonard HL, Rapoport JL, et al: A double-blind comparison of clomipramine and desipramine in the treatment of trichotillomania. N Engl J Med 1989; 321:497–501[Abstract]
5. Streichwein SM, Thornby JI: A long-term, double-blind, placebo-controlled crossover trial of the efficacy of fluoxetine for trichotillomania. Am J Psychiatry 1997; 152:1192–1196
6. Christenson GA, MacKenzie TB, Mitchell JE, et al: A placebo-controlled double-blinded crossover study of fluoxetine in trichotillomania. Am J Psychiatry 1991; 148:1566–1571
7. Riddle MA, Scahill L, King RA, et al: Double-blind, crossover trial of fluoxetine and placebo in children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 1993; 31:1062–1069
8. DeVane CL, Sallee FR: Serotonin selective reuptake inhibitors in child and adolescent psychopharmacology: a review of published experience. J Clin Psychiatry 1996; 57:55–66[Medline]
9. King RA, Leonard H, March J: Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 1998; 37(10 suppl):27S–44S
10. Medical Economics Company, Inc: Physicians' Desk Reference. Montvale, NJ, 1999
11. Naylor MW, Grossman M: Trichotillomania and depression (letter). J Am Acad Child Adolesc Psychiatry 1991; 30:155–156
12. Stein DJ, Bouwen C, Hawkridge S, et al: Risperdone augmentation of serotonin reuptake inhibitors on obsessive-compulsive and related disorders. J Clin Psychiatry 1997; 58:119–122[Medline]
13. Potenza MN, Wasylink S, Epperson CN: Olanzepine augmentation of fluoxetine in the treatment of trichotillomania. Am J Psychiatry 1998; 155:1299–1300
14. Carrion VG: Naltrexone for the treatment of trichitillomania: a case report (letter). J Clin Psychopharm 1995; 15:444–445[Medline]

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