Psychosomatics 43:429-430, October 2002
© 2002 The Academy of Psychosomatic Medicine
Resistant Trichotillomania and Risperidone
Vesile  entürk, M.D., and
Nilgün Tanr verdi, M.D., Ankara, Turkey
TO THE EDITOR: Trichotillomania is a disorder characterized by chronic hair pulling and is categorized as an impulse-control disorder not otherwise specified in DSM-IV. The most common site of hair pulling is the scalp, followed by the eyelashes, eyebrows, and pubic hair.1 We present the case of a treatment-resistant trichotillomania patient who was treated successfully with risperidone alone after unsuccessful treatment attempts with various drugs and cognitive behavior therapy.
Case Report
Ms. A, a 22-year-old Caucasian woman, was seen for pulling out her hair. A physical examination revealed a short haircut and many 5-by-10-cm areas of her scalp that were lacking hair. Her psychiatric evaluation did not reveal any major psychiatric disorder (in DSM-IV) except hair pulling.
She started pulling her hair out during her high school years. She pulled her hair whenever she got angry with her friends; the hair pulling got more intense when she was stressed. Ms. A reported feeling mounting tension before an incidence of hair pulling; the tension vanished when she pulled the hair out. Ms. A was able to control herself whenever she promised not to pull her hair.
She liked pulling her hair out at night when she was alone in her room listening to the radio, watching TV, or smoking. She pulled out the hair on her scalp as well as her arms, legs, and back. She would pull out 250–350 hairs in 1 to 2 hours, usually resulting in a patch of alopecia about 5 cm in diameter. After pulling hairs out, Ms. A would throw them on the rug to be cleaned up later.
While walking on the sidewalk, she tried not to step on the lines, and she counted stairs as she climbed. She felt social alienation, shame, and embarrassment and used scarves or a hat to disguise her hair loss when she was outdoors. She had impulsively attempted suicide four times. Her father was dependent on alcohol, and he physically abused her during childhood. Her family disliked her.
The results of a MMPI revealed antisocial personality traits. After a consultation with a dermatologist, Ms. A was diagnosed with trichotillomania. Previous unsuccessful treatment attempts included clomipramine, venlafaxine, pimozide, fluoxetine, and cognitive behavior psychotherapy. Risperidone was initiated at 2 mg/day. A slight decrease in hair pulling was reported 4 weeks later, and Ms. A's dose of risperidone was increased to 4 mg/day. Ms. A reported that she felt more "emotionally stable and enthusiastic" than she had for a long time. Her sleeping habits returned to normal, and she did not have as much time for pulling hair out at night. Subsequently, Ms. A was maintained with risperidone, 4 mg/day, for 8 months, and she totally stopped pulling her hair out and even had her hair cut. The symptoms of trichotillomania reappeared when she discontinued her medication at 8 months. She began taking risperidone, 4 mg/day, again, and her symptoms had been gone for the last 3 months when this report was written.
Discussion
The phenomenology of trichotillomania is variable across patients, but some common elements have been documented. Negative affective states and sedentary or contemplative activities are cues that often prompt or exacerbate hair pulling.2 Trichotillomania also appears closely related to Gilles de la Tourette's syndrome. Hair pulling and tics are both involuntary repetitive behaviors that reduce discomfort and tension. Both have impulsive as well as compulsive elements, and neither occurs in response to obsessive thoughts.3 Trichotillomania and Tourette's syndrome are disorders that possibly fall on a spectrum of obsessive-compulsive-related disorders.4 This spectrum of disorders is characterized by similar phenomenological presentations, comorbidity of the disorders, and neurobiological underpinnings. Recent evidence suggests that trichotillomania may respond better to treatment for Tourette's syndrome than it does to treatment for obsessive-compulsive disorder.5 Neuroleptic medications, such as haloperidol, pimozide, and risperidone, have proven to be effective either alone or in augmentation of selective serotonin reuptake inhibitors (SSRIs) in the treatment of trichotillomania.
The case presented here indicates that risperidone alone may be used effectively in the treatment of trichotillomania. Recently, Gabriel6 successfully treated a patient with resistant trichotillomania with fluvoxamine plus risperidone. In that case, risperidone was added to the treatment regimen when the patient got worse taking fluvoxamine alone. Epperson et al.7 treated three patients successfully by adding risperidone to treatment for trichotillomania that was refractory to SSRIs. Stein8 has achieved clinically effective results with risperidone augmentation in trichotillomania patients whose condition was refractory to SSRIs.
Conclusions drawn from this report must take into account the limitations of a case report. Despite this caveat, we believe that there are grounds for cautious optimism about the efficacy of risperidone in the treatment of trichotillomania. Newer atypical neuroleptic agents such as risperidone deserve further research for the pharmacological management of trichotillomania.
REFERENCES
- Schlosser S, Black BW, Blum N, Goldstein RB: The demography, phenomenology, and family history of 22 persons with compulsive hairpulling. Ann Clin Psychiatry 1994; 6:147-152[Medline]
- Christenson GA, Ristvedt SL, Mackenzie TB: Identification of trichotillomania cue profiles. Behav Res Ther 1993; 31:315-320[Medline]
- Hollander E, Liebowitz MR, DeCaria CM: Conceptual and methodological issues in studies of obsessive-compulsive and Tourette's disorders. Psychiatr Dev 1989; 7:267-296[Medline]
- Jenike MA: Obsessive-compulsive and related disorders: a hidden epidemic. N Engl J Med 1989; 321:539-541[Medline]
- Van Ameringen M, Mancini C, Oakman JM, Farvolden P: The potential role of haloperidol in the treatment of trichotillomania. J Affect Disord 1999; 56:219-226[Medline]
- Gabriel A: A case of resistant trichotillomania treated with risperidone-augmented fluvoxamine (letter). Can J Psychiatry 2001; 46:285-286
- Epperson CN, Fasula D, Wasylink S, Price LH, McDougle CJ: Risperidone addition in serotonin reuptake inhibitor-resistant trichotillomania: three cases. J Child Adolesc Psychopharmacol 1999; 9:43-49[Medline]
- Stein DJ, Bouwer C, Hawkridge S, Emsley RA: Risperidone augmentation of serotonin reuptake inhibitors in obsessive-compulsive and related disorders. J Clin Psychiatry 1997; 58:119-122[Medline]
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