Address for Correspondence: Dr.
Aswathi Krishna, Department of Psychiatry, MES Medical
College, Perinthalmanna, Kerala, India. Email:
aswathi.raveendran05@gmail.com
Abstract
Trichotillomania is a chronic psychiatric disorder
characterized by pulling out one's own hair, which results in
an obvious loss of hair. Hair pulling was first described in
Henri Allopeau in 1889. The term "trichotillomania" comes from
the Greek words "thrix" - hair, "tillein" - to pull and
"Mania" madness or frenzy. 30 year old man presented with
complaints of hairpulling behavior and associated erectile
dysfunction. His hairpulling behavior improved on treating his
sexual dysfunction.
Key Words: Trichotillomania
Introduction
Trichotillomania (TTM) is a chronic psychiatric disorder
characterized by pulling out one's own hair, which results in
an obvious loss of hair. Hair pulling was first described in
Henri Allopeau in 1889. The term "trichotillomania" comes from
the Greek words "thrix"- hair , "tillein"- to pull and
"Mania" madness or frenzy [1,2].
TTM is classified by the International classification of
diseases (ICD 10) as habit and impulse disorder under
disorders of adult personality and behavior. The hair pulling
is usually preceded by anxiety and is followed by a sense of
relief [3].
Lifetime prevalence seems to be in the range of 0.6-3.4%
in the general population and about 1% in children. It is
reported to be more common among girls [4]. Co-morbid
psychiatric problems are common in children and adults with
trichotillomania. Trichotillomania is reported to occur among
patients with obsessive compulsive disorder (OCD),
schizophrenia, depression, borderline personality disorder as
well as mental retardation [2,3,5]. Trichotillomania co-morbid
with sexual dysfunction is rarely described in literature.
Here we report a case of trichotillomania in a 30 year old
male with sexual dysfunction.
Case Report
A 30 year old male presented with history of frequent pulling
of hair since childhood, difficulty in having sexual
relationship and worsening of hair pulling behavior and
excessive anger outbursts. In his childhood, he used to pluck
his scalp hair whenever he was tensed. The behavior continued
with each setback in his life. He was reporting a feeling of
urge before pulling his hair and he would feel relaxed after
plucking a few scalp hairs. It was not associated with any
repeated thoughts. He never mouths the plucked hair or its
root. Only scalp hair was being plucked. His erectile problem
led to divorce within one month of his first marriage. He
became anxious; his hair pulling behavior worsened leaving his
head almost bald. He had a remission after moving away
for work, only to relapse after remarriage. He had significant
hair loss from the front and vertex, amounting to baldness. He
had no history of repeated thoughts, images or repetitive,
ritualistic behaviour. He had no features of impulse control
like stealing, gambling, or acts of self mutilation. No
history of any depressive symptoms. No history of any
delusions, hallucinations or substance use. He has no past or
family history of psychiatric illness. He had pre-morbid
anxious traits.
On examination the patient was well kempt and rapport was
established. His psychomotor activity and talk was normal. He
was anxious and preoccupied with worries of not having proper
sex. Once tension builds up, he would start plucking hair
which gives him some gratification. Physical examination
showed patchy hair loss from front and vertex of scalp. No
area of inflammation of scalp.
A diagnosis of Trichotillomania, and Failure of genital
response; Male erectile disorder-were made as per ICD 10. His
lab investigations were normal. He was psycho-educated
regarding his problems and started on clonazepam to reduce his
anxiety. He was taught relaxation techniques. Sensate focus
therapy based on Masters and Johnson was discussed with the
couple. Patient was given Tadalafil for his erectile
dysfunction. He was able to achieve good sexual function with
treatment. His hair pulling behavior started decreasing along
with improvement in anxiety symptoms. On follow up his scalp
hair has increased and they started having satisfactory sexual
life and were able to continue functioning even after the
drugs were stopped. He was kept on follow up and given
cognitive interventions.
Discussion
Though trichotillomania was reported to occur with many
psychiatric disorders including OCD, depression,
schizophrenia, borderline personality disorder and mental
retardation, the co-morbidity with sexual disorders has not
been reported. Other co morbid conditions reported include
dissociative experiences, dementia, and Parkinson's disease
[5].
The treatment modalities focus on pharmaco-therapeutic and
psychotherapeutic approaches. The selective serotonin reuptake
inhibitors remain the mainstay of pharmacologic treatment.
Other drugs include clomipramine, venlafaxine, risperidone and
benzodiazepines [5,6]. Psychotherapy focuses on relaxation,
cognitive behaviour therapy, family therapy and hypnotherapy
[5]. In our case the trichotillomania appeared secondary to
his erectile dysfunction and the condition improved once the
primary disorder was treated. So the management of
trichotillomania is based on the co-morbidities and may not
necessitate pharmacotherapy in all cases.
References
1. Krishnan KR, Davidson JR, Guajardo C. Trichotillomania - a
review. Comp Psychiatry 1985; 26:123-8.
2. Greenberg HR, Sarner CA. Trichotillomania. Arch Gen
Psychiatry 1965;12:482-9
3. Kumar PNS, Rajmohan V. Trichotillomania with
trichorhizophagia in a schizophrenic patient: Case report and
review of literature. Indian J Psychiatry. 2012; 54(2):
196-197.
4. Christenson GA, Pyle RL, Mitchell JE. Estimated lifetime
prevalence of trichotillomania in college students. J
Clin Psychiatry. 1991; 52:415-417.
5. Rajmohan V. Trichotillomania in Schizophrenia. Ker Med
Jour; 3 (2): 52- 56.
6. Franklin ME, Zagrabbe K, Benavides KL.
Trichotillomania and its treatment: a review and
recommendations Expert Rev Neurother. 2011; 11(8): 1165-1174.