Trichotillomania Associated with Bipolar Disorder and Obsessive Compulsive Disorder: Pathoplasty or Comorbidity?

Sir,

Trichotillomania (TTM), a disorder of compulsive self-directed hair pulling that often results in focal alopecia, is an impulse control disorder that occurs in a chronic course, with functional and organic potential etiologies.[1,2] It is often associated with psychiatric comorbidity, such as depression or anxiety disorders. The nosological status of TTM remains in debate, since it can presents as an independent entity ("primary" TTM) or as a syndrome accompanying and straight related to a major nocological category such as an affective disorder or an organic brain disease ("secondary" TTM).[2] The relationship between bipolar disorder (BD) and TTM also remains unclear.[1,3] Pathoplastic presentation of a disease refers to the ability of a disorder in mimicking clinical features of another known disorder.

We report a 38-year-old white male, married, unemployed, seeking psychiatric assistance because of “anxiety and plucking hair.” He had a history of bipolar disorder Type I (BDI) beginning in adolescence, two suicide attempts and three psychiatric hospitalizations. Obsessive compulsive disorder (OCD) had begun 2 years after BDI onset. He started plucking hair with 24-year-old, and it worsened 3 years later (head, beard, and pubic areas), in the occasion of his father's death. TTM and OCD symptoms appear when humor is impaired and wax and wane according to humor shifts. The patient's mother had BDI, and his father had alcohol dependence. At first, patient's scores were 20 for Young Mania Rating Scale (YMRS), 17 for TTM Symptom Severity Scale (TTMS) and 20 for Yale-Brown Obsessive Compulsive Scale (YBOCS). The treatment included: Divalproex sodium 2,000 mg and quetiapine 800 mg/day. Six months after treatment and patient performed much better scores: Five for YMRS, six for TTMS and seven for YBOCS. Previous antidepressant trials failed to improve TTM and even worse OCD. During follow-up, 1 year after beginning treatment of BDI, TTM completely disappeared [Figure 1].

Figure 1.

Improvement of plucked hair in two different sites (head and pubic areas) after 6 months of mood stabilizer plus antipsychotic therapy

There are some features in our case that points to TTM as a syndrome or pathoplasty of a major psychiatric category (BDI) to the detriment of a separate nosological entity. First, TTM in our case began in adulthood, instead of childhood or adolescence when is classically described the onset of TTM as a primary disorder. Second, our patient showed amelioration of all clinical pictures (BDI, OCD and TTM) with mood stabilizer therapy, but not with antidepressant, unlike that is described in the literature about primary TTM.[4] Third, TTM and OCD symptoms appear when humor is impaired and wax and wane according to humor shifts, instead of presenting an independent course as is the case in primary OCD and TTM. Fourth, during follow-up, TTM completely disappeared, while literature about primary TTM argues that it is a very pervasive and chronic disorder, even with adequate pharmacological and psychotherapeutic treatments.[5] Due to these arguments, the most probable explanation would be based on the concept of OCD and TTM as pathoplastic presentation of BD instead of the comorbidity between them.