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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 1  |  Issue : 1  |  Page : 47-48

Pubic hair trichotillomania in an adolescent with autism


Consultant Psychiatrist and Founder Trustee Desousa Foundation, Mumbai, Maharashtra, India

Date of Web Publication19-Jun-2017

Correspondence Address:
Avinash De Sousa
Carmel, 18, St. Francis Avenue, Off S.V. Road, Santacruz (W), Mumbai - 400 054, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_1_17

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  Abstract 


Trichotillomania is a compulsive disorder of recurrent hair-pulling that may be seen in children and adolescents in the setting of obsessive-compulsive disorder, psychosis, and mental retardation or other developmental disabilities. Child and adolescent trichotillomania has been understudied in India and studies on its features and management from India are rare. We report here a case of pubic hair trichotillomania in an adolescent with autism that responded successfully to fluvoxamine.

Keywords: Autism, fluvoxamine, pubic, trichotillomania


How to cite this article:
De Sousa A. Pubic hair trichotillomania in an adolescent with autism. Ann Indian Psychiatry 2017;1:47-8

How to cite this URL:
De Sousa A. Pubic hair trichotillomania in an adolescent with autism. Ann Indian Psychiatry [serial online] 2017 [cited 2019 Jan 22];1:47-8. Available from: http://www.anip.co.in/text.asp?2017/1/1/47/208330


  Introduction Top


Trichotillomania is defined as an impulse control disorder characterized by the recurrent failure to resist impulses to pull out one's own hair and intense anxiety when unable to do so as an intense urge persists.[1] The diagnosis is not made if hair pulling is associated with inflammation or is in response to a delusion or hallucination.[2] Hair may be pulled from the scalp through sites such as the eyebrows, eyelashes, armpits, thighs, and pubic hair have also been reported to be involved.[3] Recent research into the neurobiology of the disorder has implicated the role of serotonin in the genesis and maintenance of the disorder.[4] Few case reports have reported trichotillomania in autism and mental retardation.[5],[6] In the present case report, we describe a case of a 15-year-old adolescent boy with autism where pubic hair trichotillomania responded to fluvoxamine.


  Case Report Top


A 15-year-old adolescent diagnosed with autistic spectrum disorder was brought by his parents to a private psychiatric clinic with chief complaints of pulling hair from the pubic regions which led to bleeding and wounds over the area. His IQ was 71 which indicated borderline intellectual functioning. The hair pulling was occurring for the past 6 months and throughout the day. It did not have any precipitating events or factors and would randomly happen. There was no history or clinical evidence of hair pulling from the scalp or eyebrows or other sites such as armpits. His pubic area on examination revealed numerous patches of hair loss and wounds with bleeding due to hair pulling. He also had a history of hand writhing movements and would do so many times a day. He had poor eye contact and was socially aloof he spoke in monosyllables with incomplete 2–3-word sentences and had poor speech since the age of 9 years. He also made grunting sounds and indulged in teeth grinding at night. He did not tolerate loud sounds or loud music and did not like bright lights. He preferred crunchy and salty food and had poor appetite which would improve off and on. He was born after a full-term normal delivery. He had a history of very high fever (102-103° F) at the age of 2½ years for which he was admitted to a local nursing home and this resulted in an intensive care admission where he was diagnosed as a case of probable viral encephalitis (as per papers) ensuing which he developed signs and symptoms of autism spectrum disorder. After the fever, he showed social aloofness and detested from being touched or cuddled. He showed a lot of hyperactivity that increased over the next 3–4 years till the age of 6 years. He was admitted to a special school setting for autistic children where he was studying till the present time. He was in a classroom of 8 children though he always needed one to one interaction. His hair pulling had started 6 months from the time of presentation as parents observed him doing so. Initially, they thought that it would subside on its own but when the habit increased they decided to seek medical help. He did not show any behavior where he would eat the hair that was plucked. Various behavior modification techniques such as habit reversal, applying Vaseline to the area and positive reinforcement were tried. Behavior modification was unsuccessful, and he was put on haloperidol 2 mg/day in divided doses by a pediatrician who saw him, but it was of little help. At the time of the referral, he was medication free for 3 months. He made poor eye contact during the interview. Based on the history and examination, a diagnosis of autistic spectrum disorder with borderline intellectual functioning and trichotillomania was made. He was started on oral fluvoxamine 50 mg at night which was increased on weekly evaluations to 150 mg/day in divided doses. Two weeks after reaching a dose of 150 mg, the parents reported that the hair pulling had reduced by 80%. After 4 weeks on 150 mg/day of fluvoxamine, there was a total stoppage of hair pulling behavior. He is presently maintained on 150 mg of fluvoxamine per day, and the parents also reported that even his hand movements have reduced.


  Discussion Top


A variety of psychopharmacological approaches has been tried for the management of trichotillomania.[7] Trichotillomania may be an impulse control and obsessive-compulsive spectrum disorder.[8] Selective serotonin reuptake inhibitors (SSRIs) have been the mainstay for the treatment of trichotillomania [9] though drugs like naltrexone have been tried in some cases.[10] The response to fluvoxamine probably suggests an underlying serotonergic neurobiology in hair pulling in this case. We aim to continue medication for 18 months before thinking of reduction in medication and looking for a recurrence of behavior. It is prudent to state that when trichotillomania occurs in the setting of autism spectrum disorders in the absence of other major psychiatric disorders, SSRIs may be the mainstay in treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Franklin ME, Flessner CA, Woods DW, Keuthen NJ, Piacentini JC, Moore P, et al. The child and adolescent trichotillomania impact project: Descriptive psychopathology, comorbidity, functional impairment, and treatment utilization. J Dev Behav Pediatr 2008;29:493-500.  Back to cited text no. 1
    
2.
Duke DC, Keeley ML, Geffken GR, Storch EA. Trichotillomania: A current review. Clin Psychol Rev 2010;30:181-93.  Back to cited text no. 2
    
3.
Bloch MH, Landeros-Weisenberger A, Dombrowski P, Kelmendi B, Wegner R, Nudel J, et al. Systematic review: Pharmacological and behavioral treatment for trichotillomania. Biol Psychiatry 2007;62:839-46.  Back to cited text no. 3
    
4.
Chamberlain SR, Odlaug BL, Boulougouris V, Fineberg NA, Grant JE. Trichotillomania: Neurobiology and treatment. Neurosci Biobehav Rev 2009;33:831-42.  Back to cited text no. 4
    
5.
Mancini C, Van Ameringen M, Patterson B, Simpson W, Truong C. Trichotillomania in youth: A retrospective case series. Depress Anxiety 2009;26:661-5.  Back to cited text no. 5
    
6.
Woods DW, Flessner CA, Franklin ME, Keuthen NJ, Goodwin RD, Stein DJ, et al. The Trichotillomania Impact Project (TIP): Exploring phenomenology, functional impairment, and treatment utilization. J Clin Psychiatry 2006;67:1877-88.  Back to cited text no. 6
    
7.
Woods DW, Flessner C, Franklin ME, Wetterneck CT, Walther MR, Anderson ER, et al. Understanding and treating trichotillomania: What we know and what we don't know. Psychiatr Clin North Am 2006;29:487-501, ix.  Back to cited text no. 7
    
8.
Bloch MH. Trichotillomania across the life span. J Am Acad Child Adolesc Psychiatry 2009;48:879-83.  Back to cited text no. 8
    
9.
Kaur H, Chavan BS, Raj L. Management of trichotillomania. Indian J Psychiatry 2005;47:235-7.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
De Sousa A. An open-label pilot study of naltrexone in childhood-onset trichotillomania. J Child Adolesc Psychopharmacol 2008;18:30-3.  Back to cited text no. 10
    




 

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